Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Synthesize the key components of a biopsychosocial assessment into the plan of care for an older client.

Question 14

Type: MCSA

Which of the following signs would lead the nurse to suspect elder abuse is occurring?

1. Leaving a competent elder at the doctors office to wait for an appointment

2. Leaving a confused elder at home alone

3. Complaints of a person poisoning their food or robbing them

4. Skin tears on the arms and hands

Correct Answer: 2

Rationale 1: Leaving a confused elder unattended for long periods of time is a form of mistreatment. However, leaving a competent elder at the doctors office to await an appointment is not neglect or abandonment. Abrasions, sprains, and dislocations can be signs of coercion; however, most elders skin is very friable and skin tears are often the result of unintentionally hitting a sharp object. Suspiciousness or persecutory complaints may be a sign of dementia or delusions and should be further investigated if dementia or delusions are ruled out; but are not automatic signs of elder abuse.

Rationale 2: Leaving a confused elder unattended for long periods of time is a form of mistreatment. However, leaving a competent elder at the doctors office to await an appointment is not neglect or abandonment. Abrasions, sprains, and dislocations can be signs of coercion; however, most elders skin is very friable and skin tears are often the result of unintentionally hitting a sharp object. Suspiciousness or persecutory complaints may be a sign of dementia or delusions and should be further investigated if dementia or delusions are ruled out; but are not automatic signs of elder abuse.

Rationale 3: Leaving a confused elder unattended for long periods of time is a form of mistreatment. However, leaving a competent elder at the doctors office to await an appointment is not neglect or abandonment. Abrasions, sprains, and dislocations can be signs of coercion; however, most elders skin is very friable and skin tears are often the result of unintentionally hitting a sharp object. Suspiciousness or persecutory complaints may be a sign of dementia or delusions and should be further investigated if dementia or delusions are ruled out; but are not automatic signs of elder abuse.

Rationale 4: Leaving a confused elder unattended for long periods of time is a form of mistreatment. However, leaving a competent elder at the doctors office to await an appointment is not neglect or abandonment. Abrasions, sprains, and dislocations can be signs of coercion; however, most elders skin is very friable and skin tears are often the result of unintentionally hitting a sharp object. Suspiciousness or persecutory complaints may be a sign of dementia or delusions and should be further investigated if dementia or delusions are ruled out; but are not automatic signs of elder abuse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Synthesize the key components of a biopsychosocial assessment into the plan of care for an older client.

Question 15

Type: MCSA

An elderly client has presented to the clinic with multiple physical complaints. Biologic assessment information must be obtained before any physical illnesses can be ruled out. Which of the following objective measurements would be most helpful?

1. Electroencephalogram (EEG)

2. Standard diagnostic laboratory analyses

3. Lumbar puncture

4. Drug toxicology screening

Correct Answer: 2

Rationale 1: Standard diagnostic laboratory analyses including: complete blood chemistry, electrolytes, glucose tolerance, CBC, urinalysis, thyroid levels, BUN, creatinine, and liver function tests would provide the most useful information regarding possible disease processes. A lumbar puncture, drug toxicology screening, and an EEG would not be performed unless standard diagnostic laboratory analyses revealed specific abnormalities warranting these tests.

Rationale 2: Standard diagnostic laboratory analyses including: complete blood chemistry, electrolytes, glucose tolerance, CBC, urinalysis, thyroid levels, BUN, creatinine, and liver function tests would provide the most useful information regarding possible disease processes. A lumbar puncture, drug toxicology screening, and an EEG would not be performed unless standard diagnostic laboratory analyses revealed specific abnormalities warranting these tests.

Rationale 3: Standard diagnostic laboratory analyses including: complete blood chemistry, electrolytes, glucose tolerance, CBC, urinalysis, thyroid levels, BUN, creatinine, and liver function tests would provide the most useful information regarding possible disease processes. A lumbar puncture, drug toxicology screening, and an EEG would not be performed unless standard diagnostic laboratory analyses revealed specific abnormalities warranting these tests.

Rationale 4: Standard diagnostic laboratory analyses including: complete blood chemistry, electrolytes, glucose tolerance, CBC, urinalysis, thyroid levels, BUN, creatinine, and liver function tests would provide the most useful information regarding possible disease processes. A lumbar puncture, drug toxicology screening, and an EEG would not be performed unless standard diagnostic laboratory analyses revealed specific abnormalities warranting these tests.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Synthesize the key components of a biopsychosocial assessment into the plan of care for an older client.

Question 16

Type: MCSA

Which of the following nursing diagnoses would be most appropriate for an older adult who recently lost his wife of 50 years after a long history of breast cancer?

1. Activity Intolerance

2. Ineffective Role Performance

3. Feeding Self-Care Deficit

4. Risk for Other-Directed Violence

Correct Answer: 2

Rationale 1: The recent loss of his wife will almost certainly lead to ineffective role performance due to a change in social interaction and ability to manage on his own after 50 years of marriage. Social withdrawal, loneliness, and mental status changes can also occur due to lack of social stimulation. A risk for self-directed violence or suicide attempt would be a greater concern than violence directed toward others. A deficit in self-care activities and intolerance for activity are remote possibilities if the client loses interest in performing self care activities or withdraws completely.

Rationale 2: The recent loss of his wife will almost certainly lead to ineffective role performance due to a change in social interaction and ability to manage on his own after 50 years of marriage. Social withdrawal, loneliness, and mental status changes can also occur due to lack of social stimulation. A risk for self-directed violence or suicide attempt would be a greater concern than violence directed toward others. A deficit in self-care activities and intolerance for activity are remote possibilities if the client loses interest in performing self care activities or withdraws completely.

Rationale 3: The recent loss of his wife will almost certainly lead to ineffective role performance due to a change in social interaction and ability to manage on his own after 50 years of marriage. Social withdrawal, loneliness, and mental status changes can also occur due to lack of social stimulation. A risk for self-directed violence or suicide attempt would be a greater concern than violence directed toward others. A deficit in self-care activities and intolerance for activity are remote possibilities if the client loses interest in performing self care activities or withdraws completely.

Rationale 4: The recent loss of his wife will almost certainly lead to ineffective role performance due to a change in social interaction and ability to manage on his own after 50 years of marriage. Social withdrawal, loneliness, and mental status changes can also occur due to lack of social stimulation. A risk for self-directed violence or suicide attempt would be a greater concern than violence directed toward others. A deficit in self-care activities and intolerance for activity are remote possibilities if the client loses interest in performing self care activities or withdraws completely.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Synthesize the key components of a biopsychosocial assessment into the plan of care for an older client.

Question 17

Type: MCSA

Which of the following outcomes would be the most important for an older adult who recently lost his wife of 50 years after a long history of breast cancer?

1. Ability to recognize behaviors that reduce feelings of hopelessness

2. Ability to focus on specific stimuli

3. Ability to acquire, organize, and use information

4. Ability to dress self and maintain own hygiene

Correct Answer: 1

Rationale 1: Depression, loneliness, and hopelessness are common reactions to loss; therefore, the ability to identify ways to reduce hopelessness would be the most important outcome for this client. Altered thought processes and self-care deficits would not be expected in this situation; therefore, the ability to process information or attend to stimuli would not be appropriate. Neither would the ability to dress or perform other self-care activities.

Rationale 2: Depression, loneliness, and hopelessness are common reactions to loss; therefore, the ability to identify ways to reduce hopelessness would be the most important outcome for this client. Altered thought processes and self-care deficits would not be expected in this situation; therefore, the ability to process information or attend to stimuli would not be appropriate. Neither would the ability to dress or perform other self-care activities.

Rationale 3: Depression, loneliness, and hopelessness are common reactions to loss; therefore, the ability to identify ways to reduce hopelessness would be the most important outcome for this client. Altered thought processes and self-care deficits would not be expected in this situation; therefore, the ability to process information or attend to stimuli would not be appropriate. Neither would the ability to dress or perform other self-care activities.

Rationale 4: Depression, loneliness, and hopelessness are common reactions to loss; therefore, the ability to identify ways to reduce hopelessness would be the most important outcome for this client. Altered thought processes and self-care deficits would not be expected in this situation; therefore, the ability to process information or attend to stimuli would not be appropriate. Neither would the ability to dress or perform other self-care activities.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Synthesize the key components of a biopsychosocial assessment into the plan of care for an older client.

Question 18

Type: MCSA

The nurse plans to implement health promotion activities at the local senior citizen center. Which one of the following strategies should the nurse include to meet the goal of promoting relaxation and restoring balance?

1. Pet therapy

2. Tai Chi exercises

3. Social support groups

4. Reality orientation

Correct Answer: 2

Rationale 1: Exercise and movement therapies such as Tai Chi can help induce relaxation, maintain flexibility, and restore balance in older clients. Pet therapy and social support groups are more commonly used with older adults who lack social supports or effective coping skills and do not restore balance. Older adults living in the community tend to have higher functional ability, greater social interaction, and cognitive abilities than older adults in long-term care facilities and are less likely to require reality orientation.

Rationale 2: Exercise and movement therapies such as Tai Chi can help induce relaxation, maintain flexibility, and restore balance in older clients. Pet therapy and social support groups are more commonly used with older adults who lack social supports or effective coping skills and do not restore balance. Older adults living in the community tend to have higher functional ability, greater social interaction, and cognitive abilities than older adults in long-term care facilities and are less likely to require reality orientation.

Rationale 3: Exercise and movement therapies such as Tai Chi can help induce relaxation, maintain flexibility, and restore balance in older clients. Pet therapy and social support groups are more commonly used with older adults who lack social supports or effective coping skills and do not restore balance. Older adults living in the community tend to have higher functional ability, greater social interaction, and cognitive abilities than older adults in long-term care facilities and are less likely to require reality orientation.

Rationale 4: Exercise and movement therapies such as Tai Chi can help induce relaxation, maintain flexibility, and restore balance in older clients. Pet therapy and social support groups are more commonly used with older adults who lack social supports or effective coping skills and do not restore balance. Older adults living in the community tend to have higher functional ability, greater social interaction, and cognitive abilities than older adults in long-term care facilities and are less likely to require reality orientation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity