MUSCULOSKELETAL  Determine the training heart rate and evaluate heart rate

-Physical activity aids respiratory, circulatory, digestive, excretory, during exercise to ensure that the rate stays within a safe
and musculoskeletal functions. Mental acuity and mood are range.
enhanced by the physiological effects of exercise. Physical activity  To determine an age-adjusted training heart rate,
can be a means to engage in social activity; a physically fit state subtract the person’s age from 220 and multiply that
supports older adults in participating in social events. Multiple answer by 70% (Centers for Disease Control and
health problems, such as atherosclerosis, obesity, joint immobility, Prevention, 2011). This calculates the maximum rate that
pneumonia, constipation, pressure ulcers, depression, and will provide vascular and other benefits without causing
insomnia, can be avoided when an active state is maintained. deleterious effects. The resting heart rate can serve as
the lower level and the training heart rate as the upper
EFFECTS OF AGING ON MUSCULOSKELETAL FUNCTION: level for a safe heart rate range during exercise.
 Monitor pulse during exercise and reduce intensity and
-An increasing challenge associated with the decreased muscle length of exercise if heart rate is more than 10 beats
mass and/or function facing individuals as they age is above the target heart rate.
sarcopenia—a decline in walking speed or grip strength. It can be  Consult the physician as to the appropriateness of the
caused by disease, immobility, decreased caloric intake, poor exercise program for persons who have a resting heart
blood flow to muscle, mitochondrial dysfunction, a decline in rate exceeding 100 beats per minute.
anabolic hormones, and an increase in proinflammatory cytokines  Advise the older adult to wear proper-fitting shock-
(Morley, Anker, & von Haehling, 2014). absorbing shoes with traction soles.
 Encourage warm-up exercises (e.g., gentle stretching and
-When added to the impaired capacity for muscle regeneration
flexing) for at least 10 minutes before the person
that occurs in late life, this can lead to disability, particularly in
engages in the full exercise program.
patients with diseases or organ impairment. In addition to the
effects of aging and disease, activity can be impacted by  Provide for a period of cooling down after exercises.
psychosocial factors. The loss of one’s spouse and/or friends can  Begin with a conservative exercise program and
limit the older adult’s participation in social and recreational gradually increase activity. Monitor vital signs and
activities, thereby reducing opportunities for physical activity. symptoms at various activity levels. Note arrhythmias,
Retirement is often accompanied by reduced activity as one no significant changes in blood pressure, dyspnea,
longer has to prepare for, travel to, and engage in work; social and shortness of breath, fatigue, angina, and intermittent
recreational activities that could offer opportunities for some claudication.
exercise may be restricted due to financial limitations or poor
health. The relocation from the house in which the older person
raised his or her family to a smaller home, apartment, or COMMUNICATION TIP: When discussing exercise with older
retirement community reduces housekeeping and maintenance adults, better results may be achieved if a plan is built on
functions that provided some opportunity for movement. individual interests and needs rather than a standardized exercise
program. Instead of offering literature about exercises or
-Educating and encouraging persons of all ages to exercise presenting recommendations to older adults, ask if they have a
regularly is an important way that gerontological nurses can history of exercising and what they think the likelihood of their
influence the health of today’s and future generations of older adhering to an exercise plan is. If they acknowledge that they don’t
people. All exercise programs should address: like or adhere to exercise plans, review their interests and
activities to explore how these can be used to promote physical
 Cardiovascular endurance. The ability of the heart, lungs, activity. Engage older adults in designing exercise plans, ask their
and blood vessels to deliver oxygen to all body cells is reaction to the plans, and aid them in exploring options to
enhanced by aerobic training. Aerobic exercises include overcome obstacles. Plans that are realistic and acceptable to
walking, jogging, cycling, swimming, rowing, tennis, and older individuals are more likely to be implemented and sustained
aerobic dancing than ideal exercise recommendations prescribed by their
 Flexibility. The ability to freely move muscles and joints providers that are inconsistent with individuals’ interests and
through their range of motion is another part of physical preferences.
fitness. Gentle stretching exercises help maintain
flexibility of joints and muscles; stretching exercises for -Some older individuals may be unable to participate in formal
about 5 to 10 minutes before and after other exercises exercise programs. For these persons, it can be beneficial to build
can reduce muscle soreness. less aggressive exercises into their daily activities and promote
maximum activity during routine care activities. For example:
 Strength training. Strength and endurance are enhanced
by exercises that challenge muscles. Key elements of
 Suggest that the patient do foot, leg, shoulder, and arm
strength training are resistance and progression.
circling while watching television.
Resistance is achieved by lifting weights and the use of
weight machines; isometric exercises or the use of one’s  Instruct the patient to do deep-breathing and limb
own body weight through calisthenics, such as push-ups exercises in the period between awakening and rising
and pull-ups, are also good means of strength training. from bed.
 Encourage the patient to wash dishes or light laundry by
hand to exercise the fingers with the benefit of warm
Guidelines for Exercise Programs for Older Adults: water.
 When greeting a patient in the hall, ask the person to
 Ensure that a recent physical examination has been done raise both arms as high as possible and wave.
to detect conditions that could affect or be affected by  When giving a medication, ask the patient to bend each
an exercise program (e.g., heart disease and diabetes). If extremity several times.
health conditions are present, consult with the physician  During bathing activities, ask the patient to flex and
as to restrictions or modifications to the exercise extend all body parts.
program.
 Assess the older adult’s current activity level, range of
motion, muscle strength and tone, and response to -People who are unable to participate in an aggressive exercise
physical activity. In collaboration with the patient, develop program can stretch and exaggerate movements during routine
an exercise program that recognizes interests, capacities, activities to promote joint mobility and circulation.
limitations, and realistic potential.
 Emphasize exercises that focus on good speed and -The nurse or other caregivers will find it useful to remember the
rhythm (e.g., low weights and high repetitions). Keep following points:
resistance exercises at a low level and avoid isometric
exercises.  Exercise all body joints through their normal range of
 motion at least three times daily. complications is high among older adults, the
 Support the joint and distal limb during the exercise. gerontological nurse must aim toward prevention,
 Do not force the joint past the point of resistance. drawing on the effectiveness of basic common
sense measures.
-The absence of typical signs of fracture does not guarantee that
-Prevention of Inactivity: a bone is not broken; therefore, close nursing observation is
essential whenever a bone has been subjected to trauma.
For a person of any age, maintaining an active state can be
challenging. For older adults, age-related changes in muscle o Fractures heal more slowly in older adults, and the
strength and endurance, reduced opportunities for activity, and risk of complications is greater. Pneumonia,
fatigue, pain, dizziness, dyspnea, and other symptoms associated thrombus formation, pressure ulcers, renal calculi,
with health problems prevalent in later life can further reduce fecal impaction, and contractures are among the
activity levels. complications that special nursing attention can help
prevent.
 Deleterious Effects of Inactivity: o Activity within the limits determined by the physician
o Changes in physiologic function should be promoted, including deep-breathing and
o Reduced pulse rate Increased cardiac workload coughing exercises, isometric and range-of-motion
o Decreased aerobic capacity exercises, and frequent turning and position changes.
o Decreased chest expansion and ventilation o Fluids should be encouraged and the characteristics
o Reduced muscle strength, tone, and endurance of urine output noted.
o Demineralization of bones, increased ease of fractures o Good nutrition will facilitate healing, increase
o Slower gastrointestinal motility resistance to infection, and decrease the likelihood
o Slower metabolism and lymphatic circulation Increased of other complications. Joint exercise and proper
risk of complications positioning can prevent contractures.
o Postural hypotension o Correct body alignment can be maintained with the
o Hypostatic pneumonia use of foot boards, trochanter rolls, and sandbags.
o Pressure ulcers o Keeping the skin dry and clean, preventing pressure,
o Poor appetite stimulating circulation through massage, and
o Obesity frequently turning the patient may reduce the risk of
o Constipation decubiti.
o Fecal impaction o Sheepskin, water beds, and alternating pressure
o Incontinence mattresses are beneficial, but they are not
o Renal stone formation substitutes for good skin care and frequent position
o Urinary tract infection changes.
o Joint stiffness, limited range of motion o The patient should be mobilized as early as possible.
o Changes in mood and self-concept Increased feelings of
helplessness, depression
o Perception of self as incapable, frail Increased  Osteoarthritis
dependency o is the progressive deterioration and abrasion of joint
o Reduced opportunities for socialization cartilage, with the formation of new bone at the joint
-Those caring for older people can enhance motivation by surfaces. This problem occurs increasingly with
demonstrating a sincere interest in their activities, for example, advanced age and affects most persons over age 55
asking how they spent their day, admiring crafts they made, or to some extent. It occurs in women more than in
listening to the details of a trip. men and is the leading cause of physical disability in
older adults.
-Recognizing housekeeping efforts, using their handmade gifts, o Disequilibrium between destructive (matrix
and commenting on a well-groomed appearance are small but metalloproteinase enzymes) and synthetic (tissue
meaningful ways to reinforce the older person’s efforts to be inhibitors of matrix metalloproteinase) elements
active. Nurses can inform older adults about local resources that leads to a lack of homeostasis necessary to
can promote activity, such as senior centers, exercise classes, maintain cartilage, causing the joint changes.
educational and recreational programs at local schools or o Excessive use of the joint, trauma, obesity, low
colleges, volunteer opportunities, and local clubs. In addition, they vitamin D and C levels, and genetic factors may also
can promote activity by arranging transportation for older adults predispose an individual to this problem. Patients
to and from activities. with acromegaly have a high incidence of
osteoarthritis. Usually, osteoarthritis affects several
joints rather than a single one.
o Weight-bearing joints are most affected, the
SELECTED MUSCULOSKELETAL CONDITIONS: common sites being the knees, hips, vertebrae, and
fingers.
 Fractures o Crepitation on joint motion may be noted, and the
o Trauma, cancer metastasis to the bone, distal joints may develop bony nodules (i.e.,
osteoporosis, and other skeletal diseases contribute Heberden nodes).
to fractures in older persons. The neck of the femur o The patient may notice that the joints are more
is a common site for fractures in older people, uncomfortable during damp weather and periods of
especially in older women, and most of these extended use.
fractures result from falls. Colles’ fracture (break at o Isometrics and mild exercises are beneficial,
the distal radius) is one of the most frequent upper excessive exercise will cause more pain and
extremity fractures and often occurs when degeneration.
attempting to stop a fall with an outstretched hand. o Acetaminophen is the first drug of choice because
Older adults are also at risk for compression of its safety over nonsteroidal anti-inflammatory
fractures of the vertebrae, resulting from falls or drugs.
lifting heavy objects. The more brittle bones of older o Rest, heat or ice, t’ai chi, aquatherapy, ultrasound,
persons not only fracture more easily but also heal and gentle massage help relieve joint aches.
at a slower rate than in younger persons, potentially o Acupuncture has been shown to bring about
predisposing older adults to the many complications shortterm relief. Splints, braces, and canes provide
associated with immobility. support and rest to the joints.
o Knowing that the risk of fracture and its multiple o The nurse should emphasize the importance of
 maintaining proper body alignment and using good  Cigarette smoking
body mechanics when educating the patient.  High alcohol consumption
o Cold water fish and other foods high in the essential  Prolonged immobility
fatty acids have anti-inflammatory effects and  Diseases or chronic use of drugs that
should be abundant in the diet. increase bone loss (e.g.,
o Vitamins A, B, B6 , C, and E and zinc, selenium, corticosteroids, thyroid hormones, and
niacinamide, calcium, and magnesium are among anticonvulsants)
the nutritional supplements that could prove useful  Family history of osteoporosis
in controlling symptoms. o Many of the following potential causes are problems
o Arthroplasty, or joint replacement, can be done to commonly found among older persons:
restore joint motion, improve function, and reduce - Inactivity or immobility. A lack of muscle pull on the
pain. bone can lead to a loss of minerals, especially
calcium and phosphorus. This particularly may be a
problem for limbs in a cast.
 Rheumatoid Arthritis - Diseases. Cushing’s syndrome, an excessive
o affects many persons, particularly those aged 20 to production of glucocorticosteroids by the adrenal
40 years; it is a major cause of arthritic disability in gland, is believed to inhibit the formation of bone
later life as a result. Fortunately, the incidence matrix. The increased metabolic activity of
decreases after 65 years of age; most older patients hyperthyroidism causes more rapid bone turnover,
with this disease developed it earlier in life. and the faster rate of bone resorption to bone
Specifically, the deformities and disability associated formation causes osteoporosis.
with this disease primarily begin during early - Reduction in anabolic sex hormones. Decreased
adulthood and peak during middle age; in old age, production or loss of estrogens and androgens may
greater systemic involvement occurs. This disease be responsible for insufficient bone calcium;
occurs more frequently in women and in persons therefore, postmenopausal women are at high risk.
with a family history of the problem. - Diet. An insufficient amount of calcium, vitamin D,
o In rheumatoid arthritis, the synovium becomes vitamin C, protein, and other nutrients in the diet can
hypertrophied and edematous with projections of cause osteoporosis. Excessive consumption of
synovial tissue protruding into the joint cavity. The caffeine or alcohol decreases the body’s absorption
affected joints are extremely painful, stiff, swollen, and retention of calcium
red, and warm to the touch. Joint pain is present - Drugs. Heparin, furosemide, thyroid supplements,
during rest and activity. Subcutaneous nodules over corticosteroids, tetracycline, and magnesium-and
bony prominences and bursae may be present, as aluminum-based antacids can lead to osteoporosis.
may deforming flexion contractures. Systemic
symptoms include fatigue, malaise, weakness,
weight loss, wasting, fever, and anemia.  Gout
o Encouraging patients to rest and providing support o is a metabolic disorder in which excess uric acid
to the affected limbs are helpful measures. accumulates in the blood. As a result, uric acid
o Limb support should be such that pressure ulcers crystals are deposited in and around the joints,
and contractures are prevented. causing severe pain and tenderness of the joint and
o Splints are commonly made for the patient in an warmth, redness, and swelling of the surrounding
effort to prevent deformities. tissue.
o Range-of-motion exercises are vital to maintain o During an acute attack, the pain can be quite severe;
musculoskeletal function; the nurse may have to the person may not be able to bear weight or have a
assist the patient with active exercises. blanket or clothing rest on the affected joint. Attacks
o Physical and occupational therapists can provide can last from weeks to months, with long remissions
assistive devices to promote independence in self- between attacks possible.
care activities, and heat, gentle massage, and o Treatment aims to reduce sodium urate through a
analgesics can help control pain. low-purine diet (e.g., avoidance of bacon, turkey, veal,
o Patients with rheumatoid arthritis may be prescribed liver, kidney, brain, anchovies, sardines, herring,
anti-inflammatory agents, disease-modifying smelt, mackerel, salmon, and legumes) and the
antirheumatic drugs (e.g., methotrexate), administration of drugs.
corticosteroids, and immunosuppressive drugs. o Alcohol should also be avoided because it increases
o The nurse should be familiar with the many toxic uric acid production and reduces uric acid excretion.
effects of these drugs and detect them early if they Colchicine or phenylbutazone can be used to
occur. If function becomes significantly impaired or manage acute attacks; long-term management could
pain severe, joint replacement surgery may be include colchicine, allopurinol, probenecid, or
recommended. indomethacin.
 Osteoporosis o Gout attacks can be precipitated by the
o Demineralization of the bone occurs, evidenced by a administration of thiazide diuretics, which raise the
decrease in the mass and density of the skeleton. uric acid level of the blood. Vitamin E, folic acid, and
Any health problem associated with inadequate eicosapentaenoic acid can be useful dietary
calcium intake, excessive calcium loss, or poor supplements. Herbs such as yucca and devil’s claw
calcium absorption can cause osteoporosis. reduce symptoms in some persons.
o Risk Factors for Osteoporosis o Nurses should monitor pain and encourage a good
 Advanced age (women over 65 years, fluid intake to prevent the formation of renal stones.
men over 80 years)
 Ethnicity White women with a
northwestern  Podiatric Conditions
 European or British Isles background o Calluses -(plantar keratoses) are caused by friction
 Asian women and irritation on the feet that create layers of
 Calcium deficiency thickened skin. Reduced fat padding of the foot,
 Vitamin D deficiency dryness of the skin, decreased toe function, and poor
 Small-framed, thin women fitting shoes contribute to callus formation. They
 History of early menopause usually appear on the heels and soles and, although
 Estrogen deficiency not painful, can be unsightly. There is the risk that
people will attempt to shave or cut off calluses from
 History of multiple pregnancies
 their feet and risk injuring their skin. Massaging the podiatrist can correct this problem by removing
feet with lotions and oils can aid in preventing the ingrown portion and cleaning the area.
calluses.
o Corns- are cone-shaped layers of thick, dry skin that
form over a bony prominence. Pressure on the area GENERAL NURSING CONSIDERATIONS FOR MUSCULOSKELETAL
causes discomfort as the tip of the cone presses CONDITIONS
into the tissue. Additional pressure increases the
size of the corn and, consequently, the pain. U-  Managing Pain
shaped corn pads and loosely wrapping the toe in o Pain relief is essential in promoting optimal physical,
lamb’s wool are superior to oval or round corn pads, mental, and social function. Unrelieved pain can
which can restrict circulation. As with calluses, interfere with older persons’ abilities to engage in
patients should be advised not to attempt to remove self-care, manage their households, and maintain
corns on their own. social contact.
o Bunions (Hallux Valgus) A bunion or bursa is a bony o To enrich the quality of life, every effort should be
prominence over the first metatarsal head . made to minimize or eliminate pain.
 There is a medial deviation of the first o Heat relieves muscle spasms; a warm bath at
metatarsal with abduction of the great toe in bedtime and keeping the extremities warm with
relation to that metatarsal. Bunions occur more blankets and clothing can reduce spasms and
often in women—not surprising considering cramps throughout the night and promote
women’s shoe styles that commonly have tight uninterrupted sleep. Because older adults are at high
toe fit and the tight hosiery that pull toes risk for burns, care must be taken to avoid injury if
together. heat applications or soaks are used.
 Some bunions are hereditary in nature. The o Passive stretching of the extremity can be helpful in
increased width of the foot caused by the controlling muscle cramps.
bunion can cause difficulty in finding properly o Excessive exercise and musculoskeletal stress
fitting shoes. Shoe repair shops can stretch should be avoided, as well as situations known to
shoes to accommodate bunions; custom-made cause pain, such as heavy lifting or damp weather
shoes are also beneficial. Surgery may be o Back rubs using slow, long, rhythmic strokes can
indicated for some cases. promote relaxation and comfort
o Hammer Toe - (Digiti Flexus) is a hyperextension at o Pain in the weight-bearing joints can be alleviated by
the metatarsophalangeal joint with flexion and often resting those joints, supporting painful joints during
corn formation at the proximal interphalangeal joint. transfers, and using a walker or cane
The toe begins to resemble the shape of the o Correct positioning, whereby all body parts are in
hammers inside a piano, thus its name. proper alignment, can help prevent and manage pain.
o Plantar Fasciitis - A common cause of heel pain, o Accidental bumping against the patient’s bed or
often mistaken for a spur, is plantar fasciitis. chair and rough handling of the patient during care
 The plantar fascia is a thick ligamentous band activities must be prevented.
in the bottom of the foot that runs from the ball o Nurses may also need to emphasize to other
of the foot to the heel, where it is attached. Poor caregivers the need for extra gentleness in turning
alignment of the foot that causes pronation or and lifting older patients.
supination of the foot during walking results in
stretching and stress of the plantar fascia.
 Plantar fasciitis is an inflammation of this band  Preventing Injury
at its heel attachment. Pain is the primary o Safety considerations are essential for all older
symptom and occurs in the center or the inner persons because of their high incidence of accidents
side of the heel. and musculoskeletal injuries and the prolonged time
 Pain is worse after a period of rest; most people required for healing.
experience the most pain in the morning. After o Prevention includes paying attention to the area
walking, the pain may subside but tends to where one is walking; climbing stairs and curbs
increase as pressure is put on the heel from slowly; using both feet for support as much as
walking or standing. Pain can radiate to the possible; using railings and canes for added balance;
ankle or arch of the foot if nerves become wearing properly fitting, safe shoes for good support;
irritated secondary to the swollen plantar fascia. and avoiding long trousers, nightgowns, or robes.
o Infections - Housing of the foot in shoes, particularly o The importance of the safe use of heat has already
the ones made from synthetic materials, creates a been mentioned; it is useful for patients to learn how
warm, moist environment that facilitates fungus and to measure water temperature and use hot-water
bacterial growth. bottles and heating pads safely.
 Onychomycosis is a fungal infection of the nail o Patients with peripheral vascular disease must be
or nail bed in which the toenail appears enlarged, warned that the local application of heat can cause
thick, brittle, and flaky. As the fungus forms circulatory demands that their body will be unable to
under the nail and displaces it up, the sides of meet; other means of pain relief may be more
the nail are pushed into the skin and cause pain. beneficial to them. Warm baths can reduce muscle
 Antifungal preparations assist in eliminating the spasm and provide pain relief, but they can also
infection, but these infections are stubborn to cause hypotensive episodes leading to dizziness,
treat. fainting, and serious injury.
 Tinea pedis, better known as athlete’s foot, is a o Carelessly turning patients so that legs hit the bed
fungal infection of the foot that can cause rail, dropping them into a chair during a transfer,
burning and itching; the skin surface will peel, restraining them in an unaligned position, roughly
crack, and be red, often with vesicle eruptions. handling a limb, or attempting to use force to
The breaks in the skin surface provide easy straighten a contracture can lead to muscle strain
entry for bacteria. and fractures.
o Ingrown Nails (Onychocryptosis)- Ingrown nails can o Gentle handling will prevent unnecessary
occur due to tight-fitting shoes or cutting the nail musculoskeletal discomfort and injury.
excessively short.
 As the nail grows, its edge cuts into the tissue,
leading to inflammation. Soaks and topical  Promoting Independence
antibiotics may be prescribed; usually, a o Any loss of independence associated with the
 limitations imposed by musculoskeletal problems  URINARY SYSTEM HEALTH PROMOTION:
has a serious impact on physical, emotional, and Basic health practices, which are easily incorporated into
social well-being. the daily schedule, can prevent a variety of urinary tract
o Nurses must explore all avenues to help patients problems. For instance, a good fluid intake can reduce
minimize limitations and strengthen capacities, the number of bacteria in the bladder.
thereby promoting the highest possible level of - Acidic urine, beneficial in preventing infection, can be
independence. enhanced by the intake of vitamin C and foods such as
o Canes, walkers, and other assistive devices can cranberries, prunes, plums, eggs, cheese, yogurt, fish, and
often provide significant aid in compensating for grains.
handicaps and should be used when feasible. -Catheterization significantly increases the risk of
Physical and occupational therapists can be valuable infection and should be avoided.
resources in determining appropriate assistive -The activity can eliminate urinary stasis, and frequent
devices for use with specific deficits. toileting can prevent urinary retention. The nurse can
teach older adults specific efforts to enhance voiding and
prevent retention, including the following:
5. URINARY SYSTEM  Voiding in an upright position
 Massaging bladder area
 Rocking back and forth
 Running water
EFFECTS OF AGING ON URINARY ELIMINATION  Soaking hands in warm water

- Age-related changes in the urinary tract may cause various - The reduced bladder capacity of older adults should be kept in
elimination problems. One of the greatest annoyances is urinary mind when individuals who are unable to ambulate independently
frequency, caused by hypertrophy of the bladder muscle and are placed in wheelchairs; they will not be able to sit all day
thickening of the bladder, which decreases the ability of the without needing to void, and unnecessary incontinence may result
bladder to expand and reduces storage capacity. In addition to if toileting assistance is not provided. Trips and activities should
frequency during the day, nighttime urinary frequency (nocturia) be planned to allow bathroom breaks at frequent intervals.
can be a problem. -For older adults experiencing nocturia, nurses can implement
- Often, kidney circulation improves when the person assumes a measures to promote patients’ safety. Because older adults’
recumbent position, so voiding may be required a few hours after increased threshold for light perception makes night vision
the individual lies down and at other times during the night. Age- difficult, nocturia could predispose them to accidents when
related changes in cortical control of micturition also contribute to attempting to walk to the bathroom in the dark. Nightlights should
nocturia; this problem, along with incontinence (which is not a be used to improve visibility during trips to the bathroom, and any
normal consequence of aging), can be noted in persons with clutter or environmental hazards that could cause a fall should be
dementia or other conditions affecting the cerebral cortex. Nurses removed. Reducing fluids immediately before bedtime may help,
should advise older adults and their caregivers that long-acting although they should not be significantly restricted.
diuretics, such as the thiazides, even when administered in the
morning, can also cause nocturia. If multiple episodes of nocturia
occur, a medical evaluation may be warranted to ensure that no
urinary tract problem is present. URINARY FUNCTION ASSESSMENT:

- Inefficient neurologic control of bladder emptying and weaker The interview should include a review of function, signs, and
bladder muscles can promote the retention of large volumes of symptoms. Ask questions pertaining to the following:
urine. In women, the most common cause of urinary retention is
fecal impaction; prostatic hypertrophy, present to some degree in  Frequency of voiding. “How often do you need to urinate
most older men, is the primary cause in men. during the day and during the night? Has there been any
recent change in that pattern?”
- Symptoms of retention include urinary frequency, straining,  Continence. “Do you ever lose control of your urine? Do
dribbling, palpable bladder, and the sensation that the bladder has you experience a steady stream of urine dribbling at all
not been emptied. Retention can predispose older individuals in times or at certain times? Is urine released when you
the development of urinary tract infections (UTIs). cough or sneeze? How soon do you need to toilet after
getting the urge to void before you lose control?”
 Retention. “Do you ever feel that you have not fully
- The filtration efficiency of the kidneys decreases with age,
emptied your bladder after you have voided? Do you have
affecting the body’s ability to eliminate drugs. The nurse should a sense of fullness in your bladder after voiding?”
observe the patient for signs of adverse drug reactions resulting
 Pain. “Does it burn when you void? Do you experience
from an accumulation of toxic levels of medications. Higher blood
pain in your lower abdomen or anywhere else? Is there
urea nitrogen levels may occur due to reduced renal function,
any tenderness, discomfort, itching, or pain anywhere
causing lethargy, confusion, headache, drowsiness, and other
along your genital area?”
symptoms.
 Urine. “Have you ever seen crystals or particles in your
urine? Is your urine ever pink, bloody, or discolored? Is it
- The decreased tubular function may cause problems in the as clear as tap water or as dark as rusty water? Does
concentration of urine; the maximum specific gravity at 80 years your urine ever have a strong odor? If so, what is that
of age is 1.024, whereas, at younger ages, it is 1.032. Reduced odor like?”
ability to concentrate and dilute urine in response to water or  Medications. “Do you take any prescription or
sodium excess or depletion occurs. nonprescription medications? If so, which ones? Do you
use any herbal preparations?”
- Decreased reabsorption from the filtrate makes proteinuria of 1.0
usually of no diagnostic significance in older adults. An increase in PHYSICAL EXAMINATION
the renal threshold for glucose is a serious concern because older
individuals can be hyperglycemic without evidence of glycosuria.
 Inspect, percuss, and palpate the abdomen for bladder
False-negative results in diabetic urine testing can occur for this
fullness, pain, or abnormalities.
reason.
 Test women for stress incontinence by doing the
following: Have the patient drink at least one full glass of
Changes in the renal threshold for glucose cause older adults to fluid and wait until she senses fullness of the bladder.
be hyperglycemic without having any evidence of glycosuria. -Instruct the patient to stand. If this is not possible, have
 her sit as upright as possible. cranberry juice in the diet of older adults. (It may be best to use
-Ask the patient to hold a 4 × 4 gauze at her perineum. forms such as capsules that have no sugar added to avoid the
-Instruct the patient to cough vigorously. high sugar content of some commercial brands; these capsules
-The test is negative if no leakage or leakage of only a and other freeze-dried forms of cranberry juice is available at most
few drops occurs. If residual urine is a the problem, a health food stores.)
postvoid residual may be ordered in which the patient is
catheterized within 15 minutes of voiding to determine - Nurses should question the rationale for orders for indwelling
the volume of urine remaining in the bladder. catheters and consider other options. The convenience of staff
 If incontinence is present, refer the patient for a (e.g., reducing the need to change soiled linens or to toilet a
comprehensive evaluation; it can prove useful to person) is not justification for inserting an indwelling catheter and
maintain a record or have the patient maintain a diary of exposing the individual to the risk of UTI. Early removal of the
each occurrence of incontinence and factors associated catheter should be encouraged as this has been found to reduce
with these incidents. the risk of UTI.

Urinary Tract Infection - Prostatitis is the most common UTI among older men. Although
nonbacterial prostatitis is responsible for some cases, most
- UTIs are the most common infection of older adults and increase infections are bacterial in origin. Acute bacterial prostatitis is
characterized by the systemic symptoms of fever, chills, and
in prevalence with age. Although UTIs occur more frequently in
malaise, whereas these symptoms are uncommon with chronic
women than in men at younger ages, the gap between the sexes
bacterial prostatitis. Both types will present urinary symptoms of
narrows in late life, which is attributable to reduced sexual
frequency, nocturia, dysuria, and varying degrees of bladder
intercourse in women and a higher incidence of bladder outlet
obstruction secondary to an edematous, enlarged prostate, as well
obstruction secondary to benign prostatic hyperplasia in men.
as lower back and perineal pain.
Organisms primarily responsible for UTIs are Escherichia coli in
women and Proteus species in men.
URINARY INCONTINENCE:
- The presence of any foreign body in the urinary tract or anything
that slows or obstructs the flow of urine (e.g., immobilization, GENERAL NURSING CONSIDERATIONS FOR URINARY
urethral strictures, neoplasms, or a clogged indwelling catheter) CONDITIONS
predisposes the individual to these infections.
- UTIs can result from poor hygienic practices, improper cleansing
after bowel elimination, a predisposition created by low fluid - Nurses need sensitivity in dealing with patients’ urinary problems.
intake and excessive fluid loss, and hormonal changes, which In addition to being areas that are uncomfortable for discussion
reduce the body’s resistance. Persons in a debilitated state or who for some persons, these disorders may raise fears and anxieties
have neurogenic bladders, arteriosclerosis, or diabetes also have a that tales of becoming incontinent in old age perhaps are valid.
high risk of developing UTIs. Of major consideration are catheter- Realistic explanations and a committed effort to correcting these
associated UTIs, which are the single most common type of disorders are vital. All levels of staff need to remember the
healthcare-associated infection. importance of discretion and dignity in managing these problems.
Staff members should not check to see if a patient’s pants are wet
in front of others, allow someone to sit on a bedside commode in
UTIs can result from poor hygienic practices, prostate problems, a hallway, bring in a group of students without the patient’s
catheterization, dehydration, diabetes, arteriosclerosis, neurogenic permission to observe a catheterization, or scold the patient for
bladders, and general debilitated states. having an accident in bed. Every effort should be made to
minimize embarrassment and promote a positive self-concept.
Diagnosis:
6. COGNITIVE & NEUROLOGIC FUNCTION
- The gerontological nurse should be alert to the signs and
symptoms of UTIs. Early indicators include burning, urgency, and EFFECTS OF AGING ON THE NERVOUS SYSTEM:
fever. Some older adults develop incontinence and delirium with
UTIs. Awareness of the patient’s normal body temperature helps
the nurse recognize the presence of fever—for instance, 99°F - The number of nerve cells declines, each cell has fewer dendrites,
(37°C) in a patient whose normal temperature is 96.8°F (35°C). and some demyelination of the cells occurs. These changes slow
Some urologists believe that many UTIs in older adults seem nerve conduction. Response and reaction times are slower;
asymptomatic due to lack of awareness of elevations in normal reflexes become weaker.
temperature from the baseline norm.
-The nurse can significantly facilitate diagnosis by informing the - Plaques, tangles, and atrophy occur in the brain to varying
physician of temperature increases from the patient’s normal level.
degrees; there is not always a relationship between these changes
Bacteriuria greater than 105 CFU/mL confirms the diagnosis of
and cognitive function.
UTI. As a UTI progresses, retention, incontinence, and hematuria
may occur.
- Free radicals accumulate with age and may have a toxic effect
on certain nerve cells. Cerebral blood flow decreases about 20%
Treatment: as fatty deposits gradually accumulate in the blood vessels, and
decreases are even greater in persons with small-vessel
- establish adequate urinary drainage and control the infection cerebrovascular disease due to diabetes and hypertension; this
through antibiotic therapy. The nurse should carefully note the contributes to an increased risk of strokes. -The brain has a
patient’s fluid intake and output. Forcing fluids is advisable, greater ability to compensate after injury than does the spinal cord,
provided that the patient’s cardiac status does not contraindicate but this ability to compensate declines with age.
this action.
- Intellectual performance tends to be maintained until at least age
- Observation for new symptoms, bladder distention, skin irritation, 80, although a slowing in central processing delays the time
and other unusual signs should continue as the patient recovers. required to perform tasks.
-Verbal skills are well maintained until age 70, after which there
-Cranberry juice has long been promoted as a means to reduce is a gradual reduction in vocabulary, a tendency to make semantic
UTIs; research now supports this belief. A study conducted at the errors, and abnormal prosody (rhythm and intonation).
Harvard Medical School demonstrated a reduction in the
frequency of bacteria and white blood cells in the urine of women - The number and sensitivity of sensory receptors, dermatomes,
who regularly consumed cranberry juice (Bass-Ware, Weed, and neurons decrease, resulting in dulling of tactile sensation.
Johnson, & Spurlock, 2014 ; Fiore & Fox, 2014 ). The There is also some decline in the function of cranial nerves
gerontological nurse may want to promote the daily inclusion of mediating taste and smell. Increased levels of taste, sound, scents,
touch, and lighting are required for perception by older persons as arms, hands, legs, and feet) lightly with your finger or a
compared with younger adults. cotton wisp and note if the patient is able to feel the
sensations. Compare analogous areas on both sides of
Subtle Indications of Neurologic Problems: the body and distal and proximal areas on the same
extremity.
 New headaches that occur in the early morning or  If these primary sensations are intact, test the patient’s
interrupt sleep ability to identify two simultaneous stimuli (e.g., touch
 Change in vision (e.g., sudden decreased acuity, double the right cheek and the left forearm).
vision, and blindness in portion of visual field)  To test cortical sensation (i.e., stereognosis), have the
 Sudden deafness, ringing in ears patient, again with closed eyes, identify various objects
placed in each hand (e.g., key, marble, and coin). The
 Mood, personality changes
inability to sense these objects is known as
 Altered cognition or level of consciousness
astereognosis.
 Clumsiness, unsteady gait
 Numbness, tingling of extremity
 Unusual sensation or pain over nerve Coordination and Cerebellar Function:

Assessment Guide: NEUROLOGIC FUNCTION  Hold up your finger and ask the patient to touch it and
then touch his or her nose; have the patient continue this
action as you move your fingers to different areas. Do
 Keen observation while interviewing the patient can aid in this point-to-point testing with both arms of the patient,
detecting a variety of neurologic problems: and note uneven, jerking movements and the inability to
 On initial inspection of the patient, observe for touch your finger or his or her nose.
asymmetry, deformity, weakness, paralysis, tremors, and  To test coordination in the lower extremity, have the
other abnormalities. patient lie down and run the heel of one foot against the
 Explore the presence of symptoms of neurologic shin of the other leg.
disorders, such as pain, tingling sensations, numbness,  Test the ability to make rapid alternating movements by
blackouts, headaches, twitching, seizures, sleep having the patient rapidly tap his or her index finger on
disturbances, dizziness, distortions of reality, weakness, the thigh or a table surface.
and changes in mental status.  Tandem walking, in which the patient walks heal to toe as
 If clinical abnormalities or symptoms are identified, though walking a tightrope, also tests coordination;
inquire into their origin, length of time present, and patients with arthritic deformities may not be able to
resulting limitations or problems. perform this test. Have weak or poorly coordinated
patients hold your hand during the tandem walking test.
SPEECH ASSESSMENT
Reflexes :
- During something as basic as simple introductions, speech Nurses can perform some tests of reflexes:
disorders can become evident. If speech problems exist, it is
important to differentiate problems with articulation (i.e.,  To test the corneal reflex, gently touch the cornea with a
dysarthria) and problems with the use of symbols (i.e., dysphagia): wisp of clean cotton. Tissue and gauze are too rough and
can cause corneal abrasions. Normally, the eye should
o With dysarthria, the symbols (in this case, words) are blink.
used correctly, but speech may be slurred or  Test the Babinski reflex (i.e., plantar response) by
distorted as a result of poor motor control. Subtle stroking the sole of the patient’s foot. Normally,the toes
dysarthrias can be disclosed by asking the patient to should flex; an abnormal response is extension and
pronounce the following syllables: me, me, me (to fanning of the toes.
test the lips)la, la, la (to test the tongue)ga, ga, ga (to  Additional Tests:Each of the cranial nerves can be tested
test the pharynx) to identify further problems. Lumbar puncture, cerebral
o Dysphasia can be receptive, expressive, or a angiography, pneumoencephalography, and computed
combination of both: To test for receptive aphasia, tomography scans are among other screening devices
ask the patient to follow a command (e.g., pick up used to evaluate neurologic problems. A review of mental
the pencil); the patient’s inability to understand what status is included in the assessment of the nervous
these symbols mean will prevent the command from system.
being followed.
o The patient with expressive aphasia will be able to SELECTED NEUROLOGIC CONDITIONS:
understand commands but will not be able to put
symbols together into an intelligent speech form.
Point to several objects and ask the patient to name Cerebrovascular Accidents
them; mild dysphasia (i.e., paraphasia) may be noted -Older persons with hypertension, severe arteriosclerosis, diabetes,
if the patient substitutes a close, although gout, anemia, hypothyroidism, silent myocardial infarction, TIAs,
inaccurate, word for the right one, such as calling a and dehydration and those who smoke are among the high-risk
shoe a boot or a watch a clock. candidates for a CVA.
o The ability to understand and express oneself -. The major types of CVA are ischemic, usually resulting from a
through the written word is important to evaluate thrombus or embolus, and hemorrhagic, which can occur from a
also. Ask the patient to write a short sentence that ruptured cerebral blood vessel.
you dictate and to read a sentence from a -Most CVAs in older individuals are ischemic, caused by partial or
newspaper. Ensure that the patient has the complete cerebral thrombosis. Light-headedness, dizziness,
educational and visual abilities to fulfill these headache, drop attack (feeling of being strongly and suddenly
demands. pulled to the ground), and memory and behavioral changes are
some of the warning signs of a CVA
-CVAs can occur without warning, however, and show highly
PHYSICAL EXAMINATION: variable signs and symptoms, depending on the area of the brain
-Sensation Ask the patient to close his or her eyes and to describe affected. Major signs tend to include hemiplegia, aphasia, and
the sensations felt. To help document areas where problems are hemianopsia.
identified, a figure drawing may prove useful. -Good nursing care can improve the patient’s chance of survival
and minimize the limitations that impair a full recovery.
 Touch various parts of the body (e.g., forehead, cheeks, -In the acute phase, nursing efforts have the following aims:
  Maintain a patent airway. -- To prevent unnecessary frustration for all parties, it is important
 Provide adequate nutrition and hydration. for the nurse to provide a realistic explanation of the speech
 Monitor neurologic and vital signs. disorder and to discuss with those who need to communicate with
the patient effective ways to do so.
Prevent complications associated with immobility

PARKINSON’S DISEASE
--The eyes of the unconscious patient may remain open
for a long time, risking drying, irritation, and ulceration of
-- affects the ability of the central nervous system to control body
the cornea.
movements as a result of impaired function of basal ganglia in the
-Corneal damage can be prevented by eye irrigations with
midbrain. It occurs when neurons that produce dopamine in the
a sterile saline solution followed by the use of sterile
substantia nigra die or become impaired.
mineral oil eye drops.
-Eye pads may be used to help keep the eyelids closed;
--Dopamine is necessary for smooth motor movement and has a
these are changed daily and frequently checked to make
role in emotions. With the damage of a significant number of
sure the lids are actually closed.
these dopamine-producing cells, the symptoms of Parkinson’s
-Regular mouth care and range-ofmotion exercises are
disease appear. By the time motor symptoms appear, nearly 80%
also standard measures.
of the dopamine neurons have been lost.

-- When the patient regains consciousness and stabilizes, -- Parkinson’s disease is more common in men and occurs most
more active nursing efforts can focus on rehabilitation frequently after the fifth decade of life. The incidence rises with
-Attention span is reduced, and long, complicated age, although most cases have been diagnosed by the time people
directions may be confusing. reach their seventh decade of life. Although its exact cause is
-Memory for old events may be intact, whereas recent unknown.
events or explanations are forgotten, a characteristic
demonstrated by many older persons without a history of -- The death of substantia nigra cells within the basal ganglia leads
CVA. to a significant reduction in dopamine, which is responsible for the
symptoms.
-- Patients may have difficulty transferring information
from one situation to another. -- The tremor is reduced when the patient attempts a purposeful
movement. Muscle rigidity and weakness develop, evidenced by
drooling, difficulty in swallowing, slow speech, and a monotone
--Confusion, restlessness, and irritability may arise from
voice. The patient’s face assumes a masklike appearance, and the
sensory deprivation.
skin is moist.

Emotional lability may also be a problem. -- Bradykinesia (slow movement) and poor balance occur.

-- To minimize the limitations imposed by these problems, -- Appetite frequently increases, and the person may demonstrate
the nurse may find the following actions helpful: emotional instability.

-- Postural instability is present. A characteristic sign is a shuffling

 Talk to the patient during routine activities. gait while leaning forward at the trunk. The rate of movement
 Briefly explain the basics of what has occurred, the increases as the patient walks, and the patient may not be able to
procedures being performed, and the activities to voluntarily stop walking.
expect.
 Speak distinctly but do not shout. -- As the disease progresses, the patient may become entirely
 Devise an easy means of communication, such as a unable to ambulate. Secondary symptoms include depression,
picture chart to which one can point. anxiety, sleep disturbances, dementia, forced eyelid closure,
 Minimize environmental noise, traffic, and clutter. decreased blinking, drooling, dysphagia, constipation, shortness of
 Aim for consistency of those providing care and of breath, urinary hesitancy, urgency, and reduced interest in sex.
care activities.
 Use objects familiar to patients (e.g., their own -- Carbidopa/levodopa in the form of Sinemet combines levodopa,
clothing and clock). which converts to dopamine, and carbidopa, which reduces
 Keep a calendar or sign in the room showing the day adverse effects and is the most widely used and effective drug for
and date. Parkinson’s disease.
 Supply sensory stimulation through conversation,
radio, television, wall decorations, and objects for -- Anticholinergics may be prescribed to decrease the amount of
patients to handle. acetylcholine in the brain to restore the normal neurotransmitters’
 Provide frequent positive feedback; even a minor balance; the effects of these drugs need to be closely monitored
task may be a major achievement for the patient. because they can exacerbate glaucoma and cause temporary
 Expect and accept errors and failures. anuria.

-- Amantadine, mono oxidase inhibitors, and catechol-

-- For patients who have suffered speech impairments as a result
Omethyltransferase inhibitors also can be prescribed to control
of their stroke, it is important to identify the type of impairment symptoms.
that is present. Patients with dysarthria usually are able to
understand speech but experience difficulty speaking due to poor -- Close monitoring of drug therapy is important. While they are
motor control, whereas patients with a dysphasia have problems taking levodopa, patients should avoid foods that are high in
understanding words and/or expressing themselves verbally. vitamin B6 , such as avocados, lentils, and lima beans, because
they will counteract the drug; dietary restrictions are not necessary
-- Caregivers and family members need to understand the type of if the patient is taking carbidopa–levodopa (Sinemet).
impairment that is present so they can communicate effectively.
Treating people with dysarthria as though they don’t understand -- Active and passive range-of-motion exercises maintain and
can be frustrating and insulting to those people, whereas improve joint mobility; warm baths and massage may facilitate
assuming that people with a dysphasia can understand because these exercises and relieve muscle spasms caused by rigidity.
they can pronounce words can be frustrating and unsafe to those
people. -- Contractures are a particular risk of older persons with
Parkinson’s disease.  Movement: Are tongue rolling, twitching, tremors, and
hand wringing present? Are movements hyperactive or
-- Tension and frustration will aggravate the patient’s symptoms; hypoactive?
therefore, it is important for the nurse to offer psychological  Facial expression: Is it masklike or overly dramatic? Are
support and minimize emotional upsets. there indications of pain, fear, or anger?
 Level of consciousness: Does the patient drift into sleep
-- The nurse should emphasize that the disease progresses slowly and need to be aroused (i.e., lethargic)? Does the patient
and that therapy can minimize the disability. offer only incomplete or slow responses and need
repeated arousal (i.e., stuporous)? Are painful stimuli the
-- Intellectual functioning may be impaired as the disease only thing the patient responds to (i.e., semiconscious)?
progresses, the person with Parkinson’s disease cannot be Is there no response, even to painful stimuli (i.e.,
assumed to be cognitively impaired; it is important that others do unconscious)? While observing the patient, general
not underestimate the mental abilities of the patient due to the conversation can aid in evaluating mental status.
speech problems and helpless appearance, as this can be
extremely frustrating and degrading to the patient, who may react
by becoming depressed or irritable.
Note the tone of voice, rate of speech, ability to articulate, use of
unusual words or combinations of words, and appropriateness of
-- Continuing support by the nurse can help the family maximize
speech. Also, evaluate mood during this time.
the patient’s mental capacity and understand personality changes
that may occur.
INTERVIEW:
-- Communication and mental stimulation should be encouraged - Effective questioning can reveal much about the patient’s mental
on a level that the patient always enjoyed. health. Ask direct questions to unveil specific problems, such as
the following:
DEMENTIA & DELIRIUM
 “How do you feel about yourself? Would you say others
DELIRIUM -A variety of conditions can impair cerebral circulation would say you are a good or bad person?”
and cause disturbances in cognitive function.  “Do you have many friends? How do you get along with
people?”
-- Sometimes the history, physical examination, or
 “Has anyone harmed you or do you feel that anyone is
laboratory tests will indicate the presence of an organic
trying to harm you? Who? Why?”
factor that has caused the disturbance; however, without
such evidence, the diagnosis of delirium can be  “Are you moody? Do you quickly go from laughing to
established by the symptoms and lack of any nonorganic crying or from being happy to sad?”
mental disorder that could cause them.  “Do you have trouble falling asleep or staying asleep?
How much sleep do you get?
-- The onset of symptoms with delirium tends to be rapid  Do you use any drug or alcohol to help you sleep?”
and can include disturbed intellectual function;  “How is your appetite? How do your appetite and eating
disorientation of time and place but usually not of identity; pattern change when you are sad or worried?”
altered attention span; worsened memory; labile mood;  “Do you ever have feelings of being nervous, such as
meaningless chatter; poor judgment; and altered level of palpitations, hyperventilating, and restlessness?”
consciousness, including hypervigilance, mild drowsiness,  “Are there any particular problems in your life or anything
and semicomatose. status. you are concerned about now?”
 “Do you see or hear things that other people do not?
-- Significant perceptual changes can occur, such as Have you ever heard voices? If so, how do you feel about
hallucinations (usually visual) and illusions (e.g., them?”
misinterpreting caregivers as police guards).  “Does life bring you pleasure? Do you look forward to
each day?”
-- Disturbances in sleep-wake cycles can occur; in fact,  “Have you ever thought about suicide? If so, what were
restlessness and sleep disturbances may be early clues. those ideas like? How would you do it?”
 “Do you feel you are losing any of your mental abilities? If
-- The patient may be suspicious, have personality so, describe how.”
changes, and experience illusions more often than  “Have you ever been hospitalized or had treatment for
delusions. mental problems? Has any member of your family?”

-- Physical signs, such as shortness of breath, fatigue,

Listen carefully to the answers and how they are given. It is
and slower psychomotor activities, may accompany
important to pick up nonverbal clues.
behavioral changes.

-- Any change in behavior or cognitive pattern warrants an COGNITIVE TESTING:

evaluation. There is the risk that delirium may not be -Even without the use of a tool, the nurse can assess basic
recognized if persons unfamiliar with the patient assume cognitive function in the following ways:
that poor cognition is normal for him or her.
 Orientation: Ask the patient his or her name, where he or
she is, the date, time, and season.
Assessment Guide: MENTAL HEALTH GENERAL  Memory and retention: At the beginning of the
OBSERVATIONS assessment, ask the patient to remember three objects
-Assessment of mental status actually begins the moment (e.g., watch, telephone, and boat). First, ask the patient to
the nurse meets the patient. Upon initial observation, pay recall the items immediately after being told; then, after
attention to the following indicators of mental health: asking several other questions, ask for a recall of the
three items again; near the end of the assessment, ask
what the three items were one last time.
 Grooming and dress: Is clothing appropriate for the
 Three-stage command: Ask the patient to perform three
season, clean and presentable, appropriately worn? Is the
simple tasks (e.g., “Pick up the pencil, touch it to your
patient clean? Is the hair clean and combed? Are makeup
head, and hand it to me.”).
and accessories excessive or bizarre?
 Judgment: Present a situation that requires basic
 Posture: Does the patient appear stooped and fearful? Is
problem solving and reasoning (e.g., “What is meant by
body alignment normal?
 the statement ‘A bird in the hand is worth two in the - Regardless of the level of intellectual function or
bush’?”). consciousness, it is important to speak to the patient and
 Calculation: Ask the patient to count backward from 100 offer explanations of activities or procedures being done.
by increments of 5; if this is difficult, ask the patient to Approach from the front, make eye contact and speak in
count backward from 20 by increments of 2. Simple a calm manner.
arithmetic problems may also be asked, if they are within
the realm of the patient’s educational experience. - While keeping explanations and questions simple, it
is important to avoid addressing the person as a child or ignoring
Whenever a cognitive function is tested, consider the unique the person while discussing him or her with others who are in the
experiences, educational level, and cultural background of the person’s presence.
patient, as well as the role of sensory deficits, health problems,
and the stress associated with being examined. - Avoid rushing and overwhelming the patient. If the
person becomes agitated or combative during the communication,
Persons with Alzheimer’s disease or other cognitive deficits may remain calm and relaxed. If the patient is in an area with other
become overwhelmed by the assessment and react with anger, people, attempt to guide him or her to a quieter area.
tears, or withdrawal. This is referred to as a catastrophic reaction.
The assessment may need to be discontinued temporarily and the
- Use gentle touch (e.g., stroking the arm) unless the
patient reassured and comforted.
person appears threatened or agitated by the contact. If the
patient becomes combative, keep a safe distance between you
PHYSICAL EXAMINATION and the patient.
- Physical health problems are often at the root of many cognitive
disturbances
- Avoid asking questions or arguing, and offer simple,
-A complete review of known diagnoses and medications being
used is crucial. In addition, a variety of laboratory tests may be reassuring comments. Try to divert the patient’s attention (e.g.,
conducted, including the following: complete blood count pointing out a new card that the patient received or a picture on
the wall).

 serum electrolytes
- Any information the nurse gleans concerning factors
 serologic test for syphilis
that trigger agitation for this patient and measures that can
 blood urea nitrogen
facilitate communication with him or her should be documented in
 blood glucose the patient’s record and shared with others who have contact with
 bilirubin the patient.
 blood vitamin level
 sedimentation rate
DEMENTIA
 urinalysis
-is an irreversible, progressive impairment in cognitive function
affecting memory, orientation, judgment, reasoning, attention,
- Delirium is reversible in most circumstances, and language, and problem-solving. It is caused by damage or injury to
prompt care, treating this condition as a medical the brain.
emergency, can prevent permanent damage.
Alzheimer’s Disease
- Treatment depends on the cause (e.g., stabilizing blood -Alzheimer’s disease is the most common form of dementia
glucose, correcting dehydration, and discontinuing a -Alzheimer’s disease is characterized by two changes in the brain:
medication).
 The first is the presence of neuritic plaques, which
- Treating the symptoms rather than the cause or contain deposits of β-amyloid protein (excess amounts
accepting the symptoms as normal and failing to obtain of this are found in persons with Alzheimer’s disease and
treatment can result not only in worsened mental status Down’s syndrome). β-Amyloid protein is a fragment of
but also in the continuation of a physical condition that amyloid precursor protein that helps the neurons grow
could be life-threatening. and repair. The β-amyloid fragments clump together into
plaques that impair the function of nerve cells in the brain.
- During the initial acute stage, establishing medical It is unclear at this point if the plaques are a cause or by-
stability and minimizing stimulation are primary goals. product of the disease.

 The second characteristic brain change is neurofibrillary

- Consistency in care is important; thus, the patient tangles in the cortex. Microtubules, structures within
benefits from interaction with only a limited number of healthy neurons, are normally stabilized by a special
people. protein called tau. In Alzheimer’s disease, tau is changed
and begins to pair with other threads of tau that become
- Providing frequent orientation and explanations fosters tangled. This causes the microtubules to disintegrate and
function and reduces anxiety and stress. collapse the neuron’s transport system.

- Controlling environmental temperature, noise, and

traffic flow are important. - There are also changes in neurotransmitter systems
associated with Alzheimer’s disease, including
reductions in serotonin receptors, serotonin uptake into
- Placing this patient in a quiet area away from the platelets, production of acetylcholine in the areas of the
mainstream activity is beneficial. brain in which plaque and tangles are found,
acetylcholinesterase (which breaks down acetylcholine),
- Bright lights should be avoided, but ample lighting is and choline acetyltransferase.
needed to enable the patient to adequately visualize the
environment. - The transitional stage between normal cognitive aging
and dementia in which the person has short-term
- The nurse should ensure that the patient does not harm memory impairment and challenges with complex
himself or herself or others and that physical care needs cognitive functions are referred to a mild cognitive
are met. impairment.
 - Possible Causes: can cause dementia:

o Although environmental factors play a role, genetic  Vascular dementia results from small cerebral
factors do increase the risk of Alzheimer’s disease infarctions. Damage to the brain tissue can be diffuse or
o Chromosomal abnormalities have been identified. A localized, the onset is more rapid, and the disease
strong argument for the genetic formulation of the progresses more predictably than Alzheimer’s disease. It
disease stems from its connection with Down’s is associated with risk factors such as smoking,
syndrome. hypertension, hyperlipidemia, inactivity, and a history of
o Chromosomes 14 and 1 have also been found to stroke or cardiovascular disease.
have mutations within families who have a high  Frontotemporal dementia is characterized by neuronal
prevalence of Alzheimer’s disease; these mutations atrophy affecting the frontal lobes of the brain rather
cause abnormal proteins to be produced. than by neurofibrillary tangles and plaques as in
o There is some investigation into the role of free Alzheimer’s disease. A unique characteristic of this
radicals in the development of Alzheimer’s disease. dementia is the appearance of behavioral rather than
Free radicals are molecules that can build up in cognitive abnormalities in the early stage. Also, rather
neurons, resulting in damage (called oxidative than poor memory, early cognitive changes can include
damage). The damage blocks substances from impairments in abstract thinking and speech and
flowing in and out of the cell, leading to brain language skills. Pick’s disease is the most common form
damage. Higher than normal levels of aluminum and of frontotemporal dementia.
mercury have been found in the brain cells of  Lewy body dementia is also known as cortical Lewy body
Alzheimer’s disease patients, causing some disease, is associated with subcortical pathology and the
speculation regarding the role of environmental presence of Lewy body substance in the cerebral cortex.
toxins in the disease. People with this dementia have fluctuations in mental
status, decompensate rapidly when they experience a
SIGNS & SYMPTOMS: medical condition, and often have idiosyncratic reactions
to cholinergic-type medications (e.g., sedatives and
antipsychotics). About one-fourth of the people
diagnosed with this dementia have a history of a family
member with dementia. Lewy body dementia is often
misdiagnosed as other forms of dementia.

 Creutzfeldt-Jakob disease is an extremely rare brain

disorder that causes dementia. It has a rapid onset and
progression and is characterized by severe neurological
impairment that accompanies dementia. It is believed
that this disease can be transmitted through a slow virus;
a familial tendency toward the disease is possible. The
pathological process displays destruction of neurons in
the cerebral cortex, overgrowth of glia, the abnormal
cellular structure of the cortex, hypertrophy, and
proliferation of astrocytes, and a sponge-like appearance
of the cerebral cortex. Symptoms are more varied than
with Alzheimer’s disease and include psychotic behavior,
heightened emotional lability, memory impairment, loss
of muscular function, muscle spasms, seizures, and
visual disturbances.
The greatest risk of suicide for a person with dementia is in the
early stage of the disease when an individual is aware of the  Wernicke’s encephalopathy and Parkinson’s disease are
changes experienced. responsible for a small percentage of dementias.
 AIDS may lead to the development of dementia in the
Treatment: final phase of the disease.
 Trauma and toxins are among the other causes of
dementia.
- There has been interest in estrogen’s role in enhancing
cognitive function, with speculation that estrogen has a role in
protecting postmenopausal women from developing Alzheimer’s
disease or another age-related cognitive decline; however, Caring for Persons with Dementia:
research has produced conflicting results as the women’s Health -The irreversible nature of dementia and its progressive
Initiative Memory Study demonstrated an increased risk of deteriorating course can have devastating effects on affected
dementia in postmenopausal women in women taking estrogen individuals and their families. A majority of the care required by
with progestin (Barron & Pike, 2012) persons with dementia falls within the scope of nursing practice.

- Antioxidants, anti-inflammatory agents, supplements (folic acid 1.Ensuring Patient Safety

and vitamins B6 and B12 ), a gene therapy that adds a nerve -Their poor judgment and misperceptions can lead to serious
growth factor to the aging brain and the development of a vaccine behavioral problems and mishaps. A safe, structured environment
are among the other areas being investigated in clinical trials is essential. The persons and components of the environment
(Université, 2013). should be consistent
-Items to trigger memory are useful to include, such as
photographs of the patient or a consistently used symbol (e.g.,
- Acetylcholine falls sharply in people with Alzheimer’s disease, flower or triangle) on the bedroom door or personal possessions.
medications that stop or slow the enzyme (acetylcholinesterase) Noise, activity, and lighting levels can overstimulate the patient
that breaks down acetylcholine have been developed to help and further decrease function; thus, they need to be controlled.
people with Alzheimer’s disease; these drugs include donepezil This is particularly useful in preventing and managing sundowner
(Aricept), rivastigmine (Exelon), and galantamine (Reminyl). syndrome.
Sundowner Syndrome:
Other Dementias: -Individuals with cognitive impairments may experience a
In addition to Alzheimer’s disease, a variety of other pathologies nocturnal confusion, named sundowner syndrome due to its
presentation “after the sun goes down.” Some of the factors that minimal.
increase the risk of this condition include unfamiliar environment d. Dignity. To become angry or laugh at the behaviors of a
(e.g., recent admission to a facility), disturbed sleep patterns (e.g., demented person is no less cruel than reacting in a similar fashion
from sleep apnea), use of restraints, excess sensory stimulation, to a stroke victim who falls during ambulation. These patients
sensory deprivation, or change in circadian rhythms. should be afforded the respect given to any adult, including
-Nurses can prevent and manage sundowner syndrome by, placing attractive clothing, good grooming, adult hairstyles, use of their
familiar objects in the person’s room, providing physical activity in names, privacy, and confidentiality.
the afternoon to help the person expend energy, adjusting the e. Connection. Persons with dementia continue to be valued
lighting in the environment to prevent the room from becoming human beings who are members of families, communities, and
dark in the evening, keeping a night-light on throughout the night, the universe. Interaction and connection with other people and
having frequent contact with the person to offer reassurance and nature show recognition and respect for the spiritual beings that
orientation, using touch to provide human contact and calm the live within the altered bodies and minds.
person, ensuring the environmental temperature is within a
comfortable range for the person, controlling noise and traffic 6.Supporting the Patient’s Family
flow in the evening, ensuring the person’s basic needs are met -Assistance and support to the families of patients are integral
(e.g., adequate fluids, toileting, and dry clothing). parts of nursing care for persons with dementia. The physical,
emotional, and socioeconomic burden of caring for a cognitively
2.Promoting Therapy and Activity impaired relative can be immense. It should not be assumed that
-Various therapies and activities can be offered to the patient with family members understand basic care techniques. The nurse
dementia, depending on the patient’s level of function. needs to review basic, specific care techniques, including lifting,
-Occupational therapy and expressive therapies can benefit those bathing, and managing inappropriate behaviors. The nurse can
with early dementia. Various degrees of reality orientation, ranging also help prepare families for the guilt, frustration, anger,
from daily groups to reminding the patient who he or she is during depression, and other feelings that normally accompany this
every interaction can be used. responsibility.
-Even the most regressed patient can maintain contact and derive -Helping families plan respite, network with support groups, and
stimulation through activities, such as listening to music, petting obtain counseling may be beneficial.
an animal, and touching various objects. Being touched is also a
pleasurable and stimulating experience INTEGUMENTARY FUNCTION
-Modified communication techniques can facilitate activity. Some
useful strategies include the following: Using simple sentences EFFECTS OF AGING ON THE SKIN
that contain only one idea or instruction, Speaking in a calm
manner using an adult tone (not baby talk), Avoiding words or Lines and wrinkles, thicker nails, and graying hair are constant
phrases that can be misinterpreted or sarcasm Offering reminders of the aging process. These result from common aging
opportunities for simple decisions, Avoiding arguments changes to the integumentary system that include flattening of the
(distractions can help), Recognizing efforts with positive feedback, dermal–epidermal junction, reduced thickness and vascularity of
Observing nonverbal expressions and behaviors. the dermis, decreased rate of epidermal turnover, degeneration of
elastic fibers, increased coarseness of collagen, and reduction in
3.Providing Physical Care melanocytes.
-The physical care needs of patients with dementia must not be
overlooked. These individuals may not complain that they are The increased fragility of the skin poses challenges to older adults
hungry, so no one may notice that they have consumed less than and their caregivers in that there are heightened risks for skin
one-quarter of the food served; they may not remember to drink tears, bruising, pressure injury, and skin infections. In addition, the
water, so they can become dehydrated; they may fight their bath effects of this system’s aging on appearance are highly visible
so strongly that they are left unbathed, and pressure ulcers on signs of the aging process, potentially affecting body image, self-
their buttocks may go unnoticed. concept, reactions from others, socialization, and other
-These patients need close observation and careful attention to psychosocial factors.
their physical needs. Consideration must be given to their
potential inability to communicate their needs and discomforts; a Assessment Guide for skin status:
subtle change in behavior or function, a facial grimace, or repeated
touching of a body part may give clues that a problem exists. GENERAL OBSERVATIONS
-Consistency in caregivers allow the caregivers to become familiar - Much of the status of the integumentary system is evident to the
with a patient’s unique behaviors and more quickly recognize a naked eye. A quick observation can assist in evaluating skin color,
deviation from that individual’s norm. moisture, and cleanliness, and the presence of lesions. Signs such
as pallor or flushing can provide clues to health problems.
4.Using Complementary and Alternative Therapies INTERVIEW
- A variety of alternative medical therapies are being used to treat -Ask the patient about itching, burning sensations on the skin
dementias. Nutritional supplements that have been used include surface, and other symptoms associated with skin problems. Also
vitamins B6 , B12 , C, and E; folic acid; zinc; and selenium. use this opportunity to review bathing and shampooing practices.

5.Respecting the Individual PHYSICAL EXAMINATION

-As patients regress, their dignity, personal worth, freedom, and
individuality may be jeopardized. Loved ones may view the Skin surface.
demented family member as a stranger living inside the body that -Examine the entire skin surface from head to toe, including
once housed the person they knew. behind the ears, within skin folds, under the breasts, and between
-Special attention must be paid to maintaining and promoting the the toes. Bathing and massages are good opportunities to inspect
following qualities: the skin in the course of patient care. Note moles, skin tears,
a. Individuality. The nurse should learn the personal history and bruises, discoloration, and any other unusual finding. Be aware
uniqueness of the patient and incorporate this into caregiving that areas of pressure may be difficult to detect in dark skinned
activities. persons.
b. Independence. Even if it takes three times longer to guide
patients through dressing than it would take to dress them, they Lesions.
should be afforded every opportunity for self-care. -Describe any lesions as specifically as possible in regard to their
c. Freedom. As major freedoms become limited, minor choices color (e.g., purple, black, and hypopigmented), configuration (e.g.,
and control become especially important. Nurses must be careful linear, separate, confluent, and annular), size (e.g., measurement
that, in the name of efficiency and safety, such severe restrictions of depth and diameter), drainage, and type. Terms used to
to freedom are not imposed that the quality of life becomes
describe the types of lesions include the following:
 Macule: a small nonpalpable spot or discoloration Keratosis
Papule: a discoloration less than ½ cm in diameter with -Keratoses, also referred to as actinic or solar keratoses, are small,
palpable elevation light-colored lesions, usually gray or brown, on exposed areas of
Plaque: a group of papules the skin. Keratin may be accumulated in these lesions, causing the
Nodule: a lesion ½ to 1 cm in diameter with palpable formation of a cutaneous horn with a slightly reddened and
elevation; the skin may or may not be discolored swollen base.
-Freezing agents and acids can be used to destroy the keratotic
Tumor: a lesion greater than 1 cm with palpable elevation;
lesions, but electrodesiccation or surgical excision ensures a
the skin may or may not be discolored
more thorough removal.
Wheal: a red or white palpable elevation that may occur -Close nursing observation for changes in keratotic lesions is vital
in variable sizes because these lesions are precancerous.
Vesicle: a lesion less than ½ cm in diameter that contains
fluid and has a palpable elevation Bulla: a lesion greater
than ½ cm in diameter that contains fluid and has a
palpable elevation Pustule: a lesion containing purulent
fluid; of variable size and palpable elevation
Fissure: a groove in the skin Ulcer: an open depression in
the skin that may occur in variable sizes

Mongolian spots. Consider that many persons of African, Asian, or

Native American backgrounds have Mongolian spots. These are
irregular, dark areas (resembling bruises) that may be found on
the buttocks, lower back, and to a lesser extent on the arms,
abdomen, and thighs. Skin Cancer
-There are three major skin cancers that are common in late life:
Skin turgor. Test skin turgor by gently pinching various areas of basal cell carcinoma, squamous cell carcinoma, and melanoma.
the skin. Skin turgor tends to be poor in most older adults; Basal cell carcinoma, the most common form of skin cancer,
however, the areas over the sternum and forehead do experience grows slowly and rarely metastasize.
less of an age-related reduction in turgor and are good areas for -Risk factors for its development include advanced age and
turgor assessment. exposure to the sun, ultraviolet radiation, and therapeutic radiation.
It commonly occurs on the face, although it can erupt anywhere
Pressure tolerance. Assess pressure tolerance by inspecting a on the body.
pressure point after the patient has been in the same position for -The growths tend to be small, dome-shaped elevations covered
half an hour; if redness is present, the patient must be on a turning by small blood vessels that often resemble benign, flesh-colored
schedule of every half an hour. If redness is not present, allow the moles with a “pearly” surface. The surface sometimes is dark,
patient to remain in the same position for 1 hour and inspect; if rather than shiny, if the growth contains melanin pigments.
redness is not apparent, increase increments by half an hour up to
2 hours.

Temperature. Obtain a gross assessment of skin temperature by

using the back of the hands and touching various areas. Note
coldness or temperature inequalities between the extremities.

SELECTED SKIN CONDITIONS

Pruritus
-The most common dermatologic problem among older adults is
pruritus. Although atrophic changes alone may be responsible for
this problem, pruritus can be precipitated by any circumstance
that dries the person’s skin, such as excessive bathing and dry
heat.
-Diabetes, arteriosclerosis, hyperthyroidism, uremia, liver disease,
cancer, pernicious anemia, and certain psychiatric problems can
also contribute to pruritus. If not corrected, the itching may cause
traumatizing scratching, leading to breakage and infection of the
skin. Prompt recognition of this problem and implementation of
corrective measures are, therefore, essential. If possible, the Vascular Lesions
underlying cause should be corrected. -Age-related changes can weaken the walls of the veins and
-Careful assessment is required to assure conditions, such as reduce the veins’ ability to respond to increased venous pressure. '
scabies, that demand special precautions are not present. Bath -Obesity and hereditary factors compound this problem.
oils, moisturizing lotions, and massage are beneficial in treating Weakened vessel walls cause varicose veins. The poor venous
and preventing pruritus. Vitamin supplements and a high-quality, return and congestion that result lead to edema of the lower
vitamin-rich diet may be recommended. extremities, which leads to poor tissue nutrition. As the poorly
-Topical application of zinc oxide is effective in controlling itching nourished legs accumulate debris, inadequately carried away with
in some individuals. Antihistamines and topical steroids may also the venous return, the legs gain a pigmented, cracked, and
be prescribed for relief. exudative appearance.
-Stasis dermatitis, an inflammatory condition associated with
chronic venous insufficiency, can result. Subsequent scratching,
irritation, or other trauma (which can result from tight elastic-band
stockings) that occurs with stasis dermatitis can then easily lead
to the formation of leg ulcers. These ulcers, known as stasis
ulcers, often appear on the medial aspect of the tibia above the
malleolus and, prior to skin breakdown, present as a dark
discoloration of the skin. Stasis ulcers need special attention to
facilitate healing.
-Infection must be controlled, and necrotic tissue removed before
healing will occur. Good nutrition is an important component of
the therapy, and a diet high in vitamins and protein is -Good skincare is another essential ingredient in prevention.
recommended. Once healing has occurred, the concern should be -The skin should be kept clean and dry; blotting the patient dry will
given to avoiding situations that promote stasis dermatitis. avoid irritation from rubbing the skin with a towel. Bath oils and
- The patient may need instruction regarding a diet for weight lotions, used prophylactically, help keep the skin soft and intact.
reduction or the planning of high-quality meals. Venous return can Massage of bony prominences and range-of-motion exercises
be enhanced by elevating the legs several times a day and by promote circulation and help keep the tissues well nourished.
preventing interferences to circulation, such as standing for long -The person who is incontinent should be thoroughly cleansed
periods, sitting with legs crossed, and wearing garters. with soap and water and dried after each episode to avoid skin
-Elastic support stockings may be prescribed and, although breakdown from irritating excreta
effective, can be a the challenge for some older adults to apply. -Treatment measures depend on the state of the pressure injury
-The nurse needs to assess the older adult’s ability to properly put as identified by the following signs:
on these stockings and provide instruction as needed. Some
patients may require ligation and stripping of the veins to prevent  Hyperemia. Redness of the skin appears quickly and can
further episodes of stasis dermatitis. disappear quickly if pressure is removed. There is no
break in the skin, and the underlying tissues remain soft.
Relieving the pressure by the use of a square of adhesive
foam is useful; it is advisable to protect the skin with a
product such as DuoDerm (Squibb) or Tegasorb (3M)
before applying the adhesive.
 Ischemia. Redness of the skin develops from up to 6
hours of unrelieved pressure and is often accompanied
by edema and induration. It can take several days for this
area to return to its normal color, 1033 during which the
epidermis may blister. Skin should be protected with
Vigilon, which contains water and is soothing to the area.
If the skin surface is broken, it should be cleansed daily
with normal saline or the product suggested by your
agency.
 Necrosis. Unremitting pressure extending over 6 hours
can cause ulceration with a necrotic base. This type of
Pressure Injury sore requires a transparent dressing that protects from
-Tissue anoxia and ischemia resulting from pressure can cause bacteria but is permeable to oxygen and water vapor.
necrosis, sloughing, and ulceration of tissue. This is commonly Thorough irrigation is essential during dressing changes.
known as a pressure injury, previously called pressure ulcer. Sometimes topical antibiotics are used. It may take
Stages: weeks to months for full healing to occur.
 Deep tissue damage. If pressure is not relieved, necrosis
will extend through the fascia and potentially to the bone.
-In addition to developing more easily in older persons, pressure Eschar, a thick, coagulated crust, is frequently present,
injuries require a longer period to heal than in younger people. and bone destruction and infection may occur. Unless
Therefore, the most important nursing measure is to prevent their eschar is removed, the underlying tissue will continue to
formation; to do this, it is essential to avoid unrelieved pressure. break down, so debridement is essential.
Encouraging activity or turning the patient who cannot move
independently is necessary.
-a turning schedule of every 2 hours may not be sufficient for GENERAL NURSING CONSIDERATIONS FOR SKIN CONDITIONS
every patient, and pressure injuries can develop under that turning Promoting Normalcy:
schedule. Shearing forces that cause two layers of tissue to move -Psychological support can be especially important to the patient
across each other should be prevented by not elevating the head with a dermatologic problem. Unlike respiratory, cardiac, and other
of the bed more than 30 degrees, not allowing patients to slide in disorders, dermatologic problems are often visibly unpleasant to
bed, and lifting instead of pulling patients when moving them. Use the patient and others.
of pillows, floatation pads, alternating pressure mattresses, and -Visitors and staff may unnecessarily avoid touching and being
water beds can disperse pressure from bony prominences. with the patient in reaction to his or her skin problems. -The nurse
-A high-protein, vitamin-rich diet to maintain and improve tissue can reassure visitors regarding the safety of contact with the
health is also essential to avoid formation of pressure injury. patient and provide instruction for any special precautions that
must be followed. hampered.
-The most important fact to emphasize is that the patient is still
normal, with normal needs and feelings, and will appreciate -Hearing changes are also common and may negatively
normal interactions and contact. Many older adults are distressed impact communication. Presbycusis (age-related
at the visible signs of aging reflected in wrinkles. sensorineural hearing loss) reduces the ability to hear s,
-Persons of all ages need to be advised that wrinkles can be sh, f, ph, and w sounds and may cause speech to be
prevented by avoiding excess sun exposure and using sunscreen. inaudible or distorted, as can impacted cerumen, which is
There are topical products (e.g., α- or β-hydroxy acids) that can a common problem in older adults.
reduce wrinkling.
-With cosmetic surgery advertisements being widespread, this -Older people may be self-conscious of this limitation and
option for gaining a more youthful-looking skin may be considered avoid situations in which they must interact. In turn,
by some older persons; advise individuals to seek reputable others may avoid them because of this difficulty.
providers who are experienced in these procedures. Telephone conversations can be affected by this problem,
limiting social contact even further for the individual who
Using Alternative Therapies may be socially isolated for other reasons.
-Today, the use continues, as evidenced by creams, lotions, and
-Approximately 10% of the older population has some
shampoos containing aloe, chamomile, and other plant products.
difficulty hearing telephone conversations. Assessing the
-Aloe vera has emollient properties when used externally, and
underlying cause of a hearing problem through
many people find it useful for treating minor cuts and burns. The
professional evaluation, including an audiometric
external application of chamomile extract is used for skin
examination, is the first step in the management or
inflammation.
correction of the problem.
-Witch hazel has long been used for its astringent effects and is
applied externally for the treatment of bruises and swelling.
-Essential oils are also increasingly used for the prevention and
treatment of skin problems, including thyme oil as an antiseptic, Promoting Vision
thyme linalool and rosewood oil for topical acne, rosemary oil for - Routine and thorough eye examinations, including tonometry, by
cell regeneration, and the oils of basil, cinnamon, garlic, lavender, an ophthalmologist are important in detecting and treating eye
lemon, sage, savory, and thyme for insect bites or stings. problems early in older individuals. The nurse should stress the
-Topical application of peppermint oil can have an anti- importance of an annual eye examination, to detect vision
inflammatory effect and speed the healing of wounds and mild changes and needs not only for alterations in corrective lenses but
burns. Some homeopathic and naturopathic remedies are being also for early discovery of problems, such as cataracts, glaucoma,
used to treat skin eruptions, as is acupuncture. and other disease processes.
- Biofeedback, guided imagery, and relaxation exercises can help
control the symptoms of some dermatologic disorders. -Annual eye examinations, prompt evaluation is required for any
-There is a belief that nutritional supplements can also be symptom that could indicate a visual problem, including burning or
beneficial for skin disorders; those most commonly recommended pain in the eye, blurred or double vision, redness of the conjunctiva,
are zinc, magnesium, essential fatty acids, and vitamins A, B spots, headaches, and any other change in vision.
complex, B6 , and E. Nurses should urge patients to discuss the
use of alternative therapies with their physicians. -Nutrients Beneficial to Vision:

o Essential Fatty Acids: Important to healthy retinal

function.
SENSORY FUNCTION o Flavonoid: Improves night vision and adaptation to dark;
promotes visual acuity; improves capillary integrity to
Effects of Aging on Vision and Hearing reduce hemorrhage risk in diabetic retinopathy.
o Vitamin A: Maintains healthy rods and cones in retina.
- The reduced elasticity and stiffening of the muscle o Vitamin B complex: May prevent elevated levels of
fibers of the lens of the eye that begins in the fourth homocysteine, which is associated with vascular
decade of life interferes with the ability to adequately problems affecting the retina.
focus and is the factor responsible for most older people o Vitamin C: Promotes normal vision; supplementation
requiring some form of corrective lenses; this condition may reduce the risk of cataracts.
is known as presbyopia. o Vitamin E: May aid in preventing cataracts;
supplementation in large doses can prevent macular
-Visual acuity progressively declines due to reduced pupil degeneration.
size, opacification of the lens and vitreous, and loss of o Selenium: May aid in preventing cataracts;
photoreceptor cells in the retina. The light perception
supplementation with vitamin E can reduce visual loss in
threshold decreases causing difficulty with vision at night
macular degeneration.
and in dimly lit areas. Dark and light adaptation takes
o Zinc: Promotes normal visual capacity and adaptation to
longer. Sensitivity to glare increases due to cataract
dark; supplementation can reduce visual loss in macular
formation.
degeneration; deficiency can facilitate cataract
development.
- Visual changes cause depth perception to become
Promoting Hearing
distorted, making the ability to judge the height of
walking surfaces more challenging. Visual fields become
-Some hearing deficits in old age can be avoided by good
smaller reducing peripheral vision. The eyes produce
care of the ears throughout the life. Such care should
fewer tears and are drier.
include prompt and complete treatment of ear infections,
prevention of trauma to the ear (e.g., from a severe blow
-Approximately half of all individuals who are identified
or a foreign object in the ear), and regular audiometric
as legally blind each year are 65 years of age or older.
examinations.
Visual limitations can make communication problematic
because facial expressions and gestures, which are as
-The nurse should examine an older adult’s ears
important as the words themselves, may be missed or
frequently for cerumen accumulation. Cerumen removal
misinterpreted. Lip reading to compensate for hearing
can be aided by gentle irrigation of the external auditory
deficits may be difficult, and written correspondence may
canal with warm water or a hydrogen peroxide and water
be limited because independent reading and writing
solution; commercial preparations are also available.
become almost impossible tasks. Remaining aware of
current events through newspapers and socialization -A forceful stream of solution should not be used during
through playing cards and other games may be
 this procedure because it can cause perforation of the ringing, or a sense of fullness in your ears?”
eardrum. It is wise for older persons to have assistance  “Do your ears accumulate a lot of wax? How do you
when irrigating ears because dizziness often occurs manage this?”
during the procedure. Even allowing water to run in the  “Is there ever drainage from your ears?”
ears during showers or shampoos can aid in loosening
cerumen.
-PHYSICAL EXAMINATION
-Avoid the use of cotton-tipped applicators for cerumen
removal, because they can push the cerumen back into Eyes
the ear canal and cause an impaction. Hairpins or similar
devices should never be used.  Inspect the eyes for unusual structure, drooping eyelids,
discoloration, and abnormal movement.
-Protection from exposure to loud noises, such as those  Loss of elasticity around the eyes, indicated by bags, is a
associated with factory and construction work, vehicles, common finding. Black-skinned persons may normally
loud music or drums, and explosions, is important have a slight yellow discoloration of the sclera. Note any
throughout the life; earplugs or other sound-reducing lesions on the eyelids.
devices should be used when exposure is unavoidable.  Palpation of the eyeballs with the eyelids closed can
reveal hard-feeling eyes with extremely elevated
intraocular pressure (IOP) and spongy-feeling eyes with
fluid volume deficits.
Assessment Guide VISION AND HEARING  Perform a gross evaluation of visual acuity by having the
patient read a Snellen chart or various sized lettering on a
-GENERAL OBSERVATIONS newspaper. If the patient is unable to see letters on the
chart or newspaper, estimate the extent of the visual
During interactions with the patient, note the
limitation by determining if the patient is able to see
signs of hearing deficits such as missed
fingers held up before him or can merely make out
communication, requests to have words
figures.
repeated, reliance on lip reading, and cocking of
 To perform a gross test of the visual field, have the
the head to one side in an effort to hear better.
patient focus straight ahead. While facing the patient,
Identify eye problems by noticing if the patient
bring your finger into the field of view. Note when the
uses eyeglasses, demonstrates difficulty seeing
patient indicates seeing your finger compared with when
(e.g., bumping into objects and unable to see
you are able to see it. If the patient has restrictions in
small print), or possesses eye abnormalities
seeing all portions of the visual field, review the exact
such as drooping eyelids, discolored sclera,
nature of this problem. A blind spot in the visual field (i.e.,
excess tearing, discharge, and unusual
scotoma) can occur with macular degeneration, a
movements of the eyes. Foul odors (e.g.,
narrowing of the peripheral field may be associated with
associated with incontinence or vaginitis) that
glaucoma, and blindness in the same half of both eyes
do not seem to bother the patient could reflect
(i.e., homonymous hemianopia) can be present in
diminished olfactory function; cigarette burns
persons who have experienced a cerebrovascular
on finger or unrecognized pressure ulcers may
accident.
indicate that the patient has reduced ability to
sense pressure and pain.  Test extraocular movements by having the patient follow
your finger as you move it to various points, horizontally
-INTERVIEW and vertically. Irregular, jerking eye movements can result
from disturbances in cranial nerves III, IV, or VI.
o Ask the patient about the date and type of the last
ophthalmic and audiometric examinations (e.g., Where
was the examination done? Was an ophthalmologist or Ears
optometrist seen? Did the eye examination include
tonometry? Was a full audiometric evaluation or basic  Inspection of the ears commonly shows cerumen
hearing screening done?). accumulation, increased hair growth, and atrophy of the
o If eyeglasses or hearing aids are used, ask questions tympanic membrane, which causes it to appear white or
about where, when, and how these appliances were gray.
obtained (e.g., reading glasses purchased from the local  Cerumen impactions should be noted and removed.
pharmacy versus prescription glasses; hearing aid  A small, crusted, ulcerated lesion on the pinna can be a
obtained via television advertisement). sign of basal or squamous cell carcinoma.
o Ask questions such as the following to disclose the  Perform a gross evaluation of hearing by determining the
presence of sensory problems: patient’s ability to hear a watch ticking. Check both ears.
 “Has there been any change in your vision? Please  Weber and Rinne tests can be performed to assess
describe.” sounds at different frequencies. These tests involve
 “Are your glasses as useful to you as they were placing a vibrating tuning fork next to the ear or against
when you first obtained them?” the skull; this will stimulate the inner ear to vibrate. The
 “Do you experience pain, burning, or itching in the Rinne tuning fork test helps evaluate a patient’s hearing
eyes?” ability by air conduction compared with that of bone
 “Do you ever see spots floating across your eyes? conduction. The Weber tuning fork test helps determine a
How often does this happen and how large and patient’s hearing ability by bone conduction only, and this
numerous are the spots?” test is useful when hearing loss is asymmetrical.
 “Do you ever see flashes of light or halos?”  In addition to presbycusis and conductive hearing losses,
 “Are your eyes ever unusually dry or watery?” ear or upper respiratory infections, ototoxic drugs, and
diabetes can be responsible for diminishing hearing.
 “Do you have difficulty with vision at night, in dimly lit
areas, or in bright areas?”
 “Does anyone in your family have glaucoma or other
Selected Vision and Hearing Conditions
eye problems?”
 “Have you noticed any change in your ability to hear? Cataracts
Please describe.”
 “Are certain sounds more difficult for you to hear - is a clouding of the lens or its capsule that causes the lens
than others?” “Do you ever experience pain, itching, to lose its transparency. Cataracts are common in older people
because everyone develops some degree of lens opacity with age. - the exact cause is unknown, glaucoma can be
associated with increased size of the lens, iritis, allergy,
- Everyone develops some degree of lens opacity with age, endocrine imbalance, emotional instability, and a family
although it is more severe in persons who have had significant history of this disorder
exposure to sunlight.
- An increase in IOP occurs rapidly in acute glaucoma and
- Exposure to ultraviolet B increases the risk of developing gradually in chronic glaucoma.
cataracts, emphasizing the importance of wearing proper
sunglasses to protect the eyes. o Acute Glaucoma
 also called closed-angle or narrow-angle
- Diabetes, cigarette smoking, high alcohol consumption, and glaucoma, the patient experiences severe eye
eye injury are also contributing factors. pain, headache, nausea, and vomiting, rapid
increased tension within the eyeball, edema of
- Symptoms: the ciliary body and dilation of the pupil occur.
 Vision becomes blurred, and blindness will
 No discomfort or pain is associated with cataracts result if this problem is not corrected within a
visual acuity is not affected, but as opacification continues, vision day, emphasizing that this is a medical
is distorted, night vision is decreased, and objects appear blurred. emergency demanding prompt attention.
 diagnostic test (i.e., gonioscopy) uses a contact
 Glare from sunlight and bright lights is extremely lens and a binocular microscope to allow direct
bothersome to the affected person; this is due to the examination of the anterior chamber and
cloudy lens causing light to scatter more than it would in differentiate closed-angle from open-angle
a clear lens. glaucoma.
 Nuclear sclerosis develops, causing the lens of the eye to  medications are now effective in treating the
become yellow or yellow-brown; eventually the color of acute attack (e.g., carbonic anhydrase inhibitors,
the pupil changes from black to a cloudy white. which reduce the formation of aqueous solution;
- Treatment and Cataract Surgery mannitol, urea, and glycerin, which reduce fluid
because of their ability to increase osmotic
 Patients with a single cataract may not necessarily tension in the circulating blood).
undergo surgery if vision in the other eye is good, and  An iridectomy may be performed after the acute
these individuals should concentrate on strengthening attack to prevent future episodes of acute
their existing visual capacity, reducing their limitations, glaucoma.
and using the safety measures applicable to any visually o Chronic Glaucoma
impaired person  or open-angle, glaucoma is more common than
 Sunglasses, sheer curtains over windows, furniture acute glaucoma.
placed away from bright light, and several soft lights  It often occurs so gradually that affected
instead of a single bright light source minimize individuals are unaware that they have a visual
annoyance from glare. It is beneficial to place items problem.
within the visual field of the unaffected eye, a  Peripheral vision becomes slowly but
consideration when preparing a food tray and arranging increasingly impaired so that people may not
furniture and frequently used objects. realize for a long time why they bump or knock
 Measures to Compensate for Visual Deficits in Older over items at their side.
Adults:  As the impairment progresses, central vision is
o Face the person when speaking. affected. People may complain of a tired feeling
o Use several soft indirect lights instead of a single in their eyes, headaches, misty vision, or seeing
glaring one. halos around lights—symptoms that tend to be
o Avoid glare from windows by using sheer curtains or more pronounced in the morning.
stained windows.  The cornea may have a cloudy appearance, and
o Use large print reading material. the iris may be fixed and dilated.
o Place frequently used items within the visual field.  Treatment, aimed toward reducing the IOP, may
o Avoid the use of low-tone colors and attempt to use consist of a combination of a miotic and a
bright ones. carbonic anhydrase inhibitor or of surgery to
o Use contrasting colors on doorways and stairs and establish a channel to filter the aqueous fluid
for changes in levels. (e.g., iridectomy, iridencleisis, cyclodialysis, and
o Identify personal belongings and differentiate the corneoscleral trephining).
room and wheelchair with a unique design rather - Care and Prevention of Complications:
than by letters or numbers
 Cataract surgery is an outpatient procedure and older o Vision lost due to glaucoma cannot be restored.
people usually withstand it well. Gerontological nurses o Physical straining and emotional stress should be
are in a position to reassure older patients and their prevented
families that age is no deterrent to cataract surgery. o Miotics may be instilled into the eye; acetazolamide
 Two types of surgical procedures are used: may be used. Mydriatics, stimulants, and agents that
elevate the blood pressure must not be administered.
o Intracapsular extraction is the surgical procedure of o It may benefit patients to carry a card or wear a
choice for the older patient with cataracts and bracelet indicating their problem to prevent
consists of removing the lens and the capsule. administration of these medications in situations in
o Extracapsular extraction is a simple surgical which they may be unconscious or otherwise unable
procedure in which the lens is removed and the to communicate.
posterior capsule is left in place. A common problem o Abuse and overuse of the eyes must also be
with extracapsular extraction is that a secondary prevented.
membrane may form, requiring an additional o Nurses need to teach patients about the disease and
procedure for discission of the membrane. its care and counsel them about the importance of
Glaucoma compliance
- a is a degenerative eye disease in which the optic nerve
is damaged from an above-normal intraocular pressure
(IOP).
Macular Degeneration Sunglasses will ease the discomfort associated with
photophobia. It is important that the underlying cause be
- the most common cause of blindness in people over treated—an infection, abrasion, or presence of a foreign
age 65, involves damage or breakdown of the macula, body. Corneal transplants are occasionally done for more
which results in a loss of central vision. advanced corneal ulcers

- most common form is involutional macular

degeneration, which is associated with the aging process,
although macular degeneration can also result from Hearing Deficits
injury, infection, or exudative macular degeneration.
Exposure to noise from loud music, jets, traffic, heavy
machinery, and guns cause cell injury and loss.

The higher incidence of hearing loss in men may be

associated with their more frequent employment in
occupations that subject them to loud noises (e.g., truck
driving, construction work, heavy factory work, and
military service).

Recurrent otitis media and trauma can damage hearing.

Certain drugs may be ototoxic, including aspirin,
bumetanide, ethacrynic acid, furosemide, indomethacin,
erythromycin, streptomycin, neomycin, karomycin, and
Rauwolfia derivatives; the delayed excretion of these
drugs in many older persons may promote this effect.

Diabetes, tumors of the nasopharynx, hypothyroidism,

syphilis, other disease processes, and psychogenic
factors can also contribute to hearing impairment.

In otosclerosis, an osseous growth causes fixation of the

footplate of the stapes in the oval window of the cochlea.
This may be a middle ear problem; it is more common
among women and can progress to complete deafness.
- Routine ophthalmic examinations can identify macular
degeneration and promote treatment that can prevent Tinnitus, a ringing or other sound in the ear, can be
additional vision loss. associated with age-related hearing loss, ear injury,
medications, or cardiovascular disease.
- Laser therapy has been used for the treatment of some
Infections of the middle ear are less common in older
forms of macular degeneration, but the involutional type
individuals; they usually accompany more serious
does not respond well to this procedure.
disorders, such as tumors and diabetes. The external ear
can be affected by dermatoses, furunculosis, cerumen
- Magnifying glasses, high-intensity reading lamps, and
impaction, cysts, and neoplasms.
other aids can prove helpful to patients with this
condition.
o Patient Care
 The first action in caring for someone with a
hearing deficit should be to encourage
Corneal Ulcer audiometric examination. Hearing impairment
should not be assumed to be a normal
Inflammation of the cornea, accompanied by a loss of consequence of aging and ignored.
substance, causes the development of a corneal ulcer, a  sometimes the underlying cause of the hearing
problem more common in older adults than in younger- problem can be corrected, frequently, older
aged individuals. persons must learn to live with varying degrees
of hearing deficits.
Febrile states, irritation, dietary deficiencies, lowered  It is not unusual for individuals with a hearing
resistance, and cerebrovascular accident tend to impairment to demonstrate emotional reactions
predispose the individual to this problem. to their hearing deficits.
 Unable to hear conversation, patients may
Corneal ulcers, which are extremely difficult to treat in become suspicious of those around them and
older persons, may scar or perforate, leading to accuse people of talking about them. Anger,
destruction of the cornea and blindness. impatience, and frustration can result from
repeatedly unsuccessful attempts to
The affected eye may appear bloodshot and show understand conversation.
increased lacrimation. Pain and photophobia are also  Patients may feel confused or react
present. inappropriately on receiving distorted verbal
communications.
Nurses should advise patients to seek prompt assistance  Limited ability to hear danger and protect
for any irritation, suspected infection, or other difficulty themselves may make them feel insecure.
with the cornea as soon as it is identified.  Being self-conscious of their limitation may
make them avoid social contact to escape
Early care is often effective in preventing the embarrassment and frustration.
development of a corneal ulcer and preserving visual
 Social isolation can be a serious threat; people
capacity.
sometimes avoid an older person with a hearing
deficit because of the difficulty in
Cycloplegics, sedatives, antibiotics, and heat may be
communication.
prescribed to treat a corneal ulcer.
 People with hearing loss should be advised to
request explanations and instructions in writing
 so that they receive the full content. Using large print games and playing cards and telephone dials
with enlarged numbers that glow in the dark can promote
interaction.
- Hearing Aids
Books and magazines with large print and recordings of current
o A variety of styles of hearing aids are available, events and popular literature can provide a source of recreation
including in the ear, behind the ear, over the ear, and and a means of keeping informed.
in the ear canal.
o hearing aid should never be purchased without being
specifically prescribed. Sometimes older persons
will attempt to improve hearing by purchasing an aid PRELIM
through a private party or a mail-order catalog, which
often results in disappointment and a waste of MULTIPLE CHOICE
money from an already limited budget.
o Patients must understand that, even with a hearing
aid, their problems will not be solved. Although
hearing will improve, it will not return to normal. 1.The practitioner who believes in the free radical theory of aging is
o Speech may sound distorted through the aid likely to recommend that the older adult
because when speech is amplified, so are all
environmental noises, which can be most a) avoid excessive intake of zinc or magnesium.
uncomfortable and disturbing to the individual. b) supplement his or her diet with vitamins C and E.
o Hearing Aid Care c) increase intake of complex carbohydrates.
 Turn the aid off or remove the battery when the d) avoid the use of alcohol or tobacco.
aid is not being worn. Store it in a safe, padded 2.To provide effective care to the older adult, the nurse must
container. understand that
 Clean the aid at least weekly. Wipe the aid off
and use a toothpick, pipe cleaner, or pick that a) older adults are not a homogeneous sociologic group.
may have come with the aid to clean the b) little variation exists in cohort groups of older adults.
channel. Do not use alcohol to clean the aid as c) health problems are much the same for similar age
this can cause drying and cracking. Avoid groups of older adults.
having hairspray, gels, or other chemicals come d) withdrawal by an older adult is a normal physiologic
in contact with the aid. response to aging.
 Protect the aid from exposure to extreme heat 3.The nurse is helping an older adult male client identify aspects
(e.g., hair dryers), cold weather, or moisture. of his work, recreation, and family life that describe his personal
 When changing the battery, turn off the aid first. identity. According to the Eight Stages of Life theory, this activity
facilitates
 Keep several new batteries available. Typically,
a battery will last about 80 hours.
a) body transcendence.
 When used appropriately, hearing aids may
b) ego transcendence.
correct hearing problems and allow older
c) ego differentiation.
individuals to maintain communication and
d) generativity.
social relationships.
4. A 76-year-old client is recovering from a mild cerebral vascular
accident (stroke). The home care nurse notes that he is talking
about updating his will and planning funeral arrangements with his
General Nursing Considerations for Visual and Hearing Deficits
partner. Which of the following responses is most appropriate for
the nurse to make?
To compensate for the multiple sensory deficits older persons
may experience, special attention must be paid to stimulation of
a) “You seem to be preoccupied with dying.”
all the senses during routine daily activities.
b) “You seem to be concerned about completing these
tasks.”
The diet can be planned to include a variety of flavors and colors.
c) “How have you been doing with your physical exercises
Perfumes, fresh flowers, and scented candles, safely used, can
lately?”
provide interesting fragrances.
d) “Let’s focus on how you are recovering rather than on
In an institutional setting, having a pot of fresh coffee brewing in your dying.”
the patients’ area can provide a pleasant and familiar aroma 5.Your 68-year-old client’s husband died recently. She is a retired
during the early morning hours; likewise, a tabletop oven can allow nurse who cared for her husband during an extended illness. She
for cookie baking and other cooking activities in the patients’ area, is now depressed and withdrawn and verbalizes feeling useless.
providing a variety of stimuli. Which action would be most beneficial to the client at this time?

Different textures can be used in upholstery and clothing fabrics. a) Encouraging her to take up a hobby such as gardening
Clocks that chime, music boxes, and wind chimes can vary b) Explaining that activity such as volunteering at a hospital
environmental sounds. The design of facilities for older people would make her feel better
should take into consideration the use of different shapes and c) Informing her that her feelings will pass with time
colors. Intellectual stimulation, through conversation, music, and d) Asking her to share some of her nursing experiences
books, for instance, is also vital. 6.A 62-year-old African American female client has recently been
diagnosed with end-stage renal disease. The client has cried often
To compensate for visual limitations, one should face the throughout your shift today. The client confided in you during a
individual and exaggerate gestures and facial expressions when conversation and stated, “I am going home to be with my Lord.”
speaking. Your best response as a nurse caring for this patient would be

To compensate for poor peripheral vision, which is common in a) I will let your doctor know right away
older people, one should approach these individuals from the front b) Would you like for me to call your family
rather than the side where their vision is limited and ensure that c) Would you like to see the chaplain or a spiritual advisor
seating allows for full sight of persons or objects with which they d) I think the Lord will welcome you home.
are interacting. 7.You are a new nurse caring for 20 older adults in a nursing
facility on Hall B. The patients range in age from 64 years to 104
Ample lighting is important and should be provided by several soft years. The individuals are from different cultures and include both
indirect lights rather than a single, bright, glaring source. men and women. You are aware that similarities exist among all
the patients and that a) serve to regulate nursing practice from within the
profession.
a) the patients will be cared for in exactly the same manner. b) serve as guidelines for legal action against nurses.
b) the patients are individuals. c) ensure legal conduct in the professional setting.
c) the youngest patient is just like the oldest patient. d) are of little value when dealing with ethical dilemmas.
d) being fearful is best until you gain all the needed 20. The Joint Commission on Accreditation Healthcare
information. Organizations (JCAHO) is a well-known organization established
8.An 87-year-old Asian man hospitalized for reoccurring shoulder to review health care facilities. As a nurse in a JCAHO-certified
pain tells you, the nurse, “ I worked in the field for years; I think I hospital, you are aware that the role of JCAHO is
have just worn my shoulder out.” You realize that the patient is
voicing a belief congruent with what theory? a) as a trend setter.
b) as a respected friend.
a) Error theory c) to set the industry standard.
b) Cross-linkage theory d) as a valued colleague.
c) Wear-and-tear theory 21. An 89-year-old client has been experiencing restlessness; you
d) Immunity theory are assigned to care for him tonight during the 11 PM to 7 AM shift.
9. Knowing the difference between normal age-related changes The patient has often been found by nursing staff wandering in
and pathologic findings is very important. Which finding should and out of other clients' rooms during the night. He also has an
the nurse identify as pathologic in a 72-year-old client? antipsychotic ordered for combative behavior. As the nurse caring
for the client, you are aware that you can
a) Increase in the number of infections
b) Increase in residual volume a) give him PRN.
c) Increase in response to touch, heat, and pain b) give the medication so that you free up staff.
d) Increase in sphincter bladder control c) tie the patient to his bed.
10. A 71-year-old widowed client is hospitalized for dehydration. d) only give the PRN medication as it is prescribed by the
During his admission interview he repeatedly talked about how he physician.
wished he was as energetic and strong as he was when he was 22. An alert and oriented 84-year-old client is receiving home care
younger. In planning the care for this client, the nurse should services after a cerebrovascular accident that has left her with left
include which of the following? -sided hemiparesis. She lives with her middle-aged son and
daughter-in-law. The nurse suspects she being physically abused
a) Changing the topic by her son. To elicit information effectively, the nurse should do
b) Interject a little humor which of the following?
c) Help the patient confront his peers
d) A “life review” a) Interview neighbors to gain information
11. A standard of care is a guideline for nursing practice which b) Confront the son regarding the suspicion
establishes an expectation for the nurse to provide the older adult c) Confront the daughter-in-law with the suspicion
client with care that is d) Directly ask the client if she has been physically struck or
hurt by anyone
a) within the client’s financial resources. 23. Your older adult client has signed the consent form for a
b) in accordance with established facility policies and research study but has changed her mind. The nurse tells the
procedures. client that she has changed her mind based on which of the
c) based on orders by the attending physician. following principles?
d) reasonably expected to be safe and appropriate.
12. The most important reason for nurses to be legally informed a) Autonomy and informed consent
about the rights of older adults is so that the nurse can b) Advanced medical directives and designation of health
care
a) preserve the rights of the older adult. c) Justice and right to know
b) serve as an expert witness in trials. d) Living wills and durable power of attorney
c) assist older adults in filing lawsuits.
d) assist with creating new laws for older adults.
17. Your client is a 97-year-old man who has severe coronary 24. The nurse is caring for an 86-year-old man who has terminal
artery disease. His daughter informs you that he has a living will end-stage renal failure. The patient requested that the nurse give
and durable power of attorney. A living will differs from a durable him an extra dose of pain medication so that he can "go ahead
power of attorney in that a living will and die." The nurse is aware of the code of ethical conduct for
nurses and that
a) is an example of an advance medical directive.
b) allows designated person to make decisions if the client a) she is free to assist the patient in the suicide.
becomes incompetent. b) she must get an order from the doctor.
c) provides a written expression of a client’s wishes in the c) she is prohibited from participating in assisted suicide.
event of terminal illness. d) she must review the will before continuing care.
d) is rarely honored because it is not a legal document. 25. An older adult client you are caring for is offered the
18. The nurse is caring for a 67-year-old client who has terminal opportunity to participate in research on a new therapy for arthritis.
cancer. The client is having difficulty making a decision about The researcher asks the nurse to obtain the client’s consent. What
signing an advance medical directive. The primary responsibility of is the most appropriate action for the nurse to take?
the nurse in relation to the patient’s advance medical directive is
to make certain that the client a) Be sure the client can read the consent
b) Read the consent form to the client and allow him or her
a) signs the advance directive before her condition to ask questions
deteriorates. c) Leave the consent at the bedside so that the client’s
b) discusses her prognosis with her physician so that she daughter can read it
can make an informed decision. d) Refuse to be the one to obtain the client’s consent
c) understands it is not necessary if she has a durable 26. An 80-year-old client is confused after undergoing surgical
power of attorney. repair of a fractured hip. Her health history reveals that she takes
d) understands the information contained in the advance digitalis (Digoxin) for congestive heart failure. This client’s
directive. confusion is most likely
19. The Ethical Code for Nurses and Standards and Scope of
Gerontological Nursing Practice are similar in that they both a) a sign of early dementia that often occurs after a stress
event.
 b) the result of toxicity from the Digoxin and unrelated to 34. An 80-year-old client is being treated in an acute care setting.
her surgery. His nurse needs to assess his functional level this morning to
c) the consequences of interacting physical and determine the effects of the last week’s treatments intended to
psychosocial factors. restore his function. In this case, which of the following is the
d) an acute medical problem that requires immediate most useful tool for the nurse to use?
attention.
27. A 71-year-old man is admitted to the acute care facility with a) Instrumental Activities of Daily Living Scale
suspected lung cancer. On the third day after his admission, the b) The Katz Index of Activities of Daily Living
nurse notes that his blood pressure is 164/92 mm Hg. c) Short Portable Functional Status Questionnaire
Considering the client’s age, the nurse should d) The Braden Scale of Functional Status
35. You note on your older adult’s medical record that she has
a) report the abnormal blood pressure to the client’s undergone the Beck Depression Inventory. You recognize that this
physician. test
b) ask another nurse to take the client’s blood pressure.
c) compare the blood pressure reading with his past a) describes a variety of symptoms and attitudes
readings. associated with depression.
d) ignore it because it is within the normal range for older b) examines the cognitive aspects of mental function, such
adults. as orientation and depression.
28. Today is the sixth postoperative day for an 88-year-old client c) attempts to detect the presence and degree of
who underwent bowel surgery. He was alert and oriented until the intellectual depression.
evening, when he became confused and incontinent of urine and d) is a 30-question instrument designed to screen for
stool. The nurse should suspect which factor as the most likely depression.
cause of the client’s acute confused state? 36. An 81-year-old white man is scheduled for a physical exam in
the outpatient clinic in which you work. You should be
a) The client’s age aware and anticipate
b) The client’s family history of dementia
c) The client’s preadmission medication profile a) a short, easy procedure.
d) The presence of a urinary tract infection b) little interaction between client and nurse because he is
29. Any nurse who cares for older adult clients should understand hard of hearing.
the clinical features associated with dementia, such as c) the client will have a lot of energy.
d) ensuring that the client is comfortable.
a) loss of intellectual functions. 37. A 97-year-old African American woman was recently
b) increased disorientation during the night. diagnosed with ovarian cancer. As the nurse caring for
c) sudden, abrupt onset of disorientation. the patient, you are aware that you can assess the older
d) impairment of recent memory. person’s social function by using what assessment tool?
30. While assessing an older adult client, the nurse notes that the
client’s head and shoulders are drooping and she is slow to a) Interrelationship Score
respond to questions. Based on this observation, the nurse should b) Functional Status
c) Tailoring Test
a) allow the client to lie down and then continue with the d) APGAR
interview. 38. As a nurse providing care to older people, you realize that
b) document observations of the behavior and continue nursing-focused assessments occur in traditional settings of the
with the interview. hospital, home, and long-term care facility as well as in
c) stop the interview and continue the assessment at nontraditional living units, hospice facilities, and independent
another time. living units. The setting dictates
d) increase the pace of the interview so that it can be
completed quickly. a) documentation.
31. The nurse notices that her older adult client is restless and b) only an understanding of potential problems.
agitated. He does not speak or understand English, and an c) the way data collection and analysis should be managed
interpreter is not available. What approach would be most to serve clients best.
effective to assess the client for his current problem? d) application of understanding of needs.
39. An 81-year old patient presented to the emergency department
a) Speak in a loud voice and ask, You aren’t in pain, are you with a self-report of multiple vague signs and symptoms, including
b) Look directly at him and whisper, Are you uncomfortable lethargy, incontinence, and weight loss. You understand that
c) Deliberately and slowly repeat the word pain. physical frailty and impairments affect the ability of an older
d) Point to his incision, grimace, and ask, Are you in pain patient to live independently. This is a major contributor to the
32. Which question, when conducting a health history on an older need for
adult, best addresses the client’s present health status?
a) acute care.
a) “When did you receive your last tetanus/diphtheria b) independent living.
immunization?” c) hospice care.
b) “Who is your current health care provider?” d) long-term care.
c) “Do you get around in your house easily, or are you 40. You are working in an outpatient clinic caring for geriatric
concerned about falling?” clients. Your 68-year-old female client arrived 1 hour late for her
d) “Have you had any hospitalizations, surgeries, or appointment and is noticeably shaking and perspiring. She reports
traumatic injuries?” missing her bus, causing her to be late for her appointment. You
33. The nurse is admitting a 70-year-old client to the hospital for realize that several factors influence the client’s ability to
treatment of severe dehydration. The client is weak and participate meaningfully in the interview. What factor may affect
confused. The nurse should understand that this interview?

a head-to-toe assessment should be immediately performed. a) Anxiety

b) Pain
assessing the client at this time would deplete her energy reserves. c) Sensory perceptual deficits
d) Reduced energy level
the physical assessment should be postponed until after the client
is hydrated.
SEMI FINALS
the client should first be assessed for fluid volume deficit.
MULTIPLE CHOICE sick sinus syndrome. She has an intermittent saline lock
and is receiving oral isoproterenol (Isuprel). On entering
her room, the nurse finds the client on the bathroom floor
and notes her pulse is 42 beats/min. The nurse’s first
1. The effects of normal physiologic aging on the cardiovascular action should be to
system are most readily noted in older adults when they
are a) call the client’s family.
b) prepare for cardioversion.
a) sleeping. c) administer intravenous atropine as ordered.
b) exercising. d) administer the prescribed isoproterenol (Isuprel) early.
c) eating. 11 Which nursing activity is important to add to the plan of
d) lying in a supine position. care for the older adult client suspected of having
2. Cigarette smokers are four times as likely to die of sudden orthostatic hypotension?
cardiac death than nonsmokers because smoking
a) Assessing skin turgor and oral mucous membranes
a) promotes the development of anemia. b) Monitoring all blood pressure readings when the client is
b) produces coronary artery stricture. lying down
c) results in carbon monoxide poisoning. c) Taking blood pressure readings from both arms
d) increases platelet aggregation. d) Teaching the client about the use of sublingual
3 When assessing the older adult’s blood pressure, the nitroglycerin
nurse recognizes that secondary hypertension may exist 12 A 77-year-old client is being discharged after the
if the client insertion of a permanent pacemaker for a
bradyarrhythmia. It is set to fire at 80 beats/min. The
a) consumes a diet high in saturated fats. client should be taught to notify her practitioner if
b) leads a sedentary lifestyle.
c) has diabetes mellitus. a) her urine output increases significantly.
d) is of African American decent. b) she experiences fatigue or dizziness.
4 When administering a β-blocker such as Lopressor to an c) her radial pulse goes below 80 beats/min.
older adult client with hypertension, the nurse should d) she feels a sudden increase in energy.
monitor for 13 A 72-year-old client underwent an aortic valve
replacement 4 days ago. He is currently alert and
a) episodes of dizziness or syncope. oriented, and his incision is dry and intact. His cardiac
b) signs and symptoms of thromboembolism. monitor shows atrial fibrillation. Which nursing diagnosis
c) muscle weakness and dry mouth. takes priority at this time?
d) increases in serum potassium.
5 When teaching older adult clients about hypertension, of a) High risk for injury related to altered tissue perfusion
importance is information about b) Knowledge deficit: disease process and follow-up care
c) Pain related to surgical incision
a) signs and symptoms associated with heart attacks. d) Activity intolerance related to fatigue
b) the need for restricting sodium and potassium intake. 14 A 68-year-old client is being treated for congestive heart
c) the need for yearly blood pressure monitoring. failure secondary to long-standing renal disease. The
d) the benefit of relaxation techniques. nurse recognizes that because of his age and renal
6 An older client reports dizziness and becomes disease, he is most likely exhibiting signs and symptoms
disoriented during a treadmill test for cardiac endurance. of
The nurse recognizes this response as a(n)
a) right-sided heart failure.
a) normal age-related response. b) right- and left-sided heart failure.
b) early indication of ischemia. c) acute chronic heart failure.
c) atypical response for this age group. d) systolic heart failure.
d) indication of cerebral compromise. 15 An older adult male has been recently diagnosed with
7 Which point about exercise should receive special hypertension. He is being treated with a thiazide diuretic
emphasis when teaching a 68-year-old male client who and dietary management along with lifestyle
has unstable angina after an acute myocardial infarction? modifications. The nurse knows that he understands the
Exercise should treatment if he makes which of the following statements?

a) be gradually increased during recovery. a) “I will use a large amount of salt substitute.”
b) include walking and swimming. b) “I have stopped smoking, so the damage is reversed.”
c) build endurance. c) “I will exercise to reduce my blood pressure.”
d) be avoided. d) “I need to cut back to two 4-ounce glasses of wine a
8 The nurse may accurately conclude that the older client day.”
with coronary artery disease has achieved an important outcome 16 A 76-year-old client is being assessed in the emergency
of care when the client is able to department for cardiovascular problems. The nurse
understands that some of the common symptoms
a) discuss the need for resuming former activities. associated with cardiovascular disease are
b) return to her usual activities of daily living.
c) identify at least two of her modifiable risk factors. a) chest discomfort and increased sputum production.
d) lower her blood pressure by 10%. b) weight changes and mood swings.
9 The nurse must initiate which independent nursing c) headaches and fainting.
activity for the older client who is in the acute phase of d) shortness of breath and chest discomfort.
recover after a myocardial infarction? 17 Teaching older adult clients measures to prevent
respiratory infection is based on the understanding that
a) Assisting with ambulation older adults
b) Applying oxygen during activity
c) Administering prescribed morphine sulfate to prevent a) retain greater amounts of carbon dioxide, so they exhibit
angina respiratory acidosis.
d) Encouraging active and passive range-of-motion b) tend to be hypoxic because of ineffective breathing
exercises patterns.
10 A hospitalized older adult client has been diagnosed with c) have difficult clearing secretions because of reduced
 ciliary function. 27 An 88-year-old client is being treated for dehydration and
d) have fewer alveoli available for effective gas exchange. confusion. Her chest radiograph study shows
18 An older adult’s pulmonary function studies indicate that consolidation in the left lower lobe. Her vital signs are
his vital capacity is reduced and his residual volume is respirations, 28 breaths/min; temperature, 99˚ F; blood
increased. The nurse recognizes that these test results pressure, 118/62 mm Hg; and pulse, 88 beats/min. She is
reflect very weak and has no cough. Which nursing diagnosis is
most appropriate for this client on the basis of these
a) deeper breathing patterns related to an older age. data?
b) altered inspiratory and expiratory capabilities.
c) significant airway obstruction. a) Self-care deficit related to weakness and confusion
d) bronchopulmonary infection. b) Ineffective airway clearance related to perceptual
19 Before administering the drug theophylline to the older impairment and absent cough
adult who has a respiratory problem, the nurse should c) Activity intolerance related to fatigue and confusion
determine whether the client d) Altered oral mucous membranes related to dehydration
and mouth breathing
a) smokes cigarettes. 28 During morning rounds, the nurse notes that a 76-year-
b) has an elevated serum potassium level. old client with pneumonia is restless. Assessment
c) has shortness of breath. reveals crackles in the left lower lung lobe. On the basis
d) has chest pain. of the client’s data, the nurse should first
20 Which of the following nursing diagnoses is most
appropriate for the older adult after having general a) position the client on the right side.
surgery? b) obtain a sputum specimen for culture.
c) administer the prescribed sedative.
a) Airway clearance, ineffective related to narcotic d) call for stat arterial blood gases.
administration 29 An older client has just had arterial blood gases drawn.
b) Incontinence, functional related to anesthesia The nurse knows
c) Sleep pattern disturbance related to frequent position
changes a) arterial PH is the same unless influenced by an acute
d) High risk for aspiration related to diminished cough reflex illness.
21 The nurse suspects that an older adult client has asthma. b) to gently shake the collection syringe.
Which clinical finding, if noted, best supports the nurse’s c) to vigorously shake the collection syringe.
suspicion? d) to aspirate 0.1 mL of saline into the syringe.
30 A 66-year-old woman is admitted to the hospital. She has
a) Use of accessory muscles with respiration smoked three packs per day for 40 years. While providing
b) Bilateral lower lung crackles her history, she becomes breathless, pauses frequently
c) Decreased respiratory depth and rate between words, and appears extremely anxious. She has
d) Client report of chest pain a cough with thick white sputum production. Her chest is
22. Emphysema differs from asthma and chronic bronchitis barrel-shaped and she is cyanotic. On the basis of these
in that emphysema results in data, the nurse will need to develop a plan of care for a
client with
a) an FEVa1 or peak expiratory flow rate ≥80% predicted.
b) hypertrophy of the bronchial mucous glands. a) tuberculosis.
c) enlarged alveoli distal to the terminal bronchioles. b) chronic obstructive pulmonary disease.
d) airway inflammation and hypersensitivity. c) asthma.
23 Which finding in the darkly pigmented older adult should d) pneumonia.
alert the nurse to the presence of cyanosis? 31 The nurse is checking tuberculin skin test results at a
long-term care facility. One client has an area of
a) Decreased respiratory rate indication measuring 12 mm in diameter. The nurse is
b) Dark color around the mouth aware that this finding indicates
c) Nasal flaring
d) Bradycardia a) inactive tuberculosis.
24 When teaching older adults about lung cancer, they b) a normal reading.
should be taught that a primary risk factor is c) a positive reaction that can indicate exposure to
tuberculosis.
a) excessive intake of vitamin A. d) the client needs to be rechecked in 3 days.
b) folic acid deficiency. 32 The nurse should understand that the primary difference
c) use of tobacco. between type 1 and type 2 diabetes in the older adult is
d) exposure to hairspray. that type 1 diabetic clients
25 An older client is admitted to the hospital with reports of
recent weight loss and a chronic cough. His practitioner a) retain their ability to produce small to moderate
orders a tuberculin skin test, the results of which are quantities of insulin.
negative. The most appropriate conclusion is that the b) can generally control their diabetes through diet and
exercise.
a) technique used was probably inaccurate. c) demonstrate more insulin resistance than loss of
b) test results were false-negative and the client has secretion.
tuberculosis. d) always require insulin administration to control their
c) client does not have tuberculosis. blood glucose.
d) test should be repeated. 33 You note that your older adult client with diabetes
26 An older adult client who has tuberculosis is being mellitus is running a higher than usual blood glucose
treated with the drugs isoniazid 300 mg daily, rifampin level. On further investigation, you determine that he is
600 mg daily, and pyrazinamide 1500 mg daily. Which also receiving Cardizem (a calcium-channel blocker),
signs or symptoms warrant reporting because they consumes a 1200 calorie/day diet, drinks approximately
indicate an adverse drug reaction? 4 cups of caffeinated coffee each day, and eats fruit at
bedtime. The most appropriate advice to give the client is
a) Decreased uric acid and liver function studies that he should
b) Chronic cough, fever, and weakness
c) Anemia, hypersensitivity, and seizures a) increase his morning dose of insulin by 5 units.
d) Red-orange urine and burning on urination b) switch to decaffeinated coffee or tea.
 c) decrease his daily intake from 1200 to 1000 calories.
d) refrain from eating a nighttime snack.
34 You have just completed teaching your older adult 1. Which age-related change is the nurse most likely to encounter
diabetic client about the disease, its treatment, and when assessing the older adult client’s musculoskeletal system?
complications. Which statement, if made by the client,
indicates that she needs further teaching? A.Increased muscle mass in the legs and torso

a) “If I start feeling unusually tired, I should notify my health B.Shorter height compared with that of younger years
care provider.”
b) “I need to perform foot care daily to prevent ulcer C.Hyperextension of the spine
formation.”
c) “I should regulate my insulin intake according to how I D.Increased bone density of the spine and long bones
feel.”
d) “I may develop infections more easily than I used to.” 2.When caring for the older adult client who has had a hip fracture,
35 You are responsible for teaching a newly diagnosed the nurse must take measures to prevent the occurrence of which
diabetic about his diet, oral hypoglycemic agent, and common complication?
home care. Therefore it is very important to teach the
client that A.Chronic renal failure

a) alcohol intake is contraindicated for persons taking oral B.Immobility

hypoglycemic agents.
b) dietary intake is not a consideration when taking oral C.Hypoglycemia
hypoglycemic agents.
c) oral hypoglycemic agents are similar to insulin in that D.Pressure ulcers
hyperglycemia is a complication of both.
d) few, if any, side effects are associated with oral 3.An effective nursing activity to reduce or control pain in the older
hypoglycemic agents. adult client who has a hip fracture is for the nurse to
36 You are caring for several older adult clients. Which client
is more likely to have a normal decrease in thyroid A.administer higher dosages of the ordered pain
function? medication initially.

a) A 65-year-old woman who has diabetes mellitus B.administer ordered pain medication with aspirin or
b) A 79-year-old woman who is generally healthy acetaminophen.
c) A 67-year-old woman who has mild rheumatoid arthritis
37 You are caring for an older adult client who recently C.elevate the client’s knee on the affected side with a
underwent abdominal surgery for which the prognosis is pillow.
very good. However, you are concerned that your client
D.keep the affected limb in alignment during turning.
may have hypothyroidism on the basis of other signs and
symptoms. Which problems should be reported because
4.An older adult client is 8 days post-op after surgical pinning of a
they often indicate hypothyroidism in the older adult?
hip fracture. Plans are being made for his discharge to home.
Which of the following findings, if noted, is evidence that expected
a) Heat intolerance, low-grade fever, and patchy hair loss
outcomes are being met?
b) Polycythemia, tachycardia, and oral candidiasis
c) Bradycardia, decreased appetite, and cold intolerance
A.The client is eating well and has no elimination
d) Increased blood pressure, postural hypotension, and
problems.
blurred vision
38 Your 76-year-old female client is being treated for
B.The client can transfer independently from his bed to
hypothyroidism. Which nursing diagnosis is most
the chair.
appropriate considering her age and medical diagnosis?
C.The client requests pain mediation every 4 to 6 hours.
a) Constipation related to decreased metabolic function
b) Self-care deficit related to restlessness and agitation
D.The client states that he will have someone at home to
c) Depression related to organic brain deterioration
help care for him.
secondary to thyroid dysfunction
d) Heat intolerance related to metabolic dysfunction 5.Your older adult client has been diagnosed with osteoarthritis, a
39 When evaluating the older adult client, data may indicate condition in which articular cartilage thins. Based on your
that the client has hypothyroidism. The clinical signs may understanding of the client’s disease process, you recognize that
include the client most likely has
a) blurred vision. A.severe flexion and fixation of the spine.
b) dizziness when rising from a lying position.
c) not feeling hungry. B.joint stiffness when rising in the morning.
d) anorexia, weight loss, and falls.
40 Teaching for the older adult client with newly diagnosed C.joint swelling without redness or pain.
hyperthyroidism should include information about the
need for D.aching pain that is not relieved by rest or application of
heat.
a) decreasing his or her intake of foods high in calories or
fat. 6.Which of the following objective findings, if noted, supports the
b) maintaining a vigorous daily exercise program. nursing diagnosis of self-care deficit for the older adult client with
c) monitoring daily blood thyroid levels for at least 1 year. osteoarthritis?
d) monitoring for clinical manifestations of hypothyroidism.
A.Client has a weight loss of 10 lb over a 2-month period.
FINALS B.Client reports inability to wash or brush hair.
MULTIPLE CHOICE C.Client takes frequent rest periods during bath time.
 D.Client spills food when attempting to feed self. C.gentamicin (Garamycin).

7.You are assisting a 65-year-old female client with planning an D.linezolid (Zyvox).
appropriate exercise program to prevent osteoporosis. Of the
exercises she enjoys, which will benefit her the most? 13When caring for older adults, which problem should the nurse
expect to encounter because it represents a normal age-related
A.Swimming change in the urinary system?

B.Bicycling A.Urinary incontinence

C.Walking B.Low-grade bladder infection

D.Rowing C.Nocturia

8.Your older adult female client has been given a prescription for D.High incidence of urinary residual volume
alendronate sodium (Fosamax) to retard the progression of her
osteoarthritis. Important teaching regarding this drug is that it 14.An 87-year-old client who does not have a history of urinary
should be incontinence has suddenly become incontinent. In dealing with
this problem, the nurse’s first action should be to
A.taken daily, 30 minutes before the intake of food or
fluids. A.review his medication record for medications that may
be causing urinary incontinence.
B.taken with as little water as necessary to swallow the
pill. B.seek an order from the physician for an indwelling
urinary catheter to prevent skin breakdown.
C.followed by 1 hour of rest in a reclining position.
C.limit his fluid intake to reduce his feeling of having to
D.followed with 8 oz of milk or a milk substitute such as void so often.
soy protein.
D.remind him every 2 hours that he needs to void and
9.An older adult client has been admitted to the hospital with assist him to a bedside commode or toilet.
suspected Paget’s disease. What clinical manifestation will the
nurse want to monitor for in an attempt to differentiate Paget’s 15.An older adult client reports “losing urine” when she bends over
disease from other types of musculoskeletal diseases? or gets out of a chair. In light of her symptoms, which nursing
diagnosis most accurately addresses her problem?
A.Red, swollen upper and lower extremity joints
A.Altered urinary function, overflow incontinence
B.Pain on awakening that subsides with activity
B.Altered urinary function, urge incontinence
C.Headache and/or mild hearing loss
C.Altered urinary function, functional incontinence
D.Back deformity in the absence of pain
D.Altered urinary function, stress incontinence
10.A patient is recovering from osteomyelitis. Which outcome is
specific for this condition as opposed to other forms of arthritis? 16.When assessing the client for urinary incontinence, which client
symptom best supports the nursing diagnosis of overflow
A.The client will correctly identify the need for antibiotic incontinence?
therapy.
A.“I have trouble starting my urinary stream.”
B.The client will verbalize the necessity of follow-up care
and monitoring. B.“It burns so badly after I urinate that I hold it as long as
I can.”
C.The client will describe her pain as 1 on scale of 1 to 5.
C.“I can’t make it to the toilet when I feel the need to
D.report the presence of increased mobility. urinate.”

11.A 94-year-old woman was found lying on the floor in the long- D.“I constantly dribble urine.”
term care facility. She was unable to move without severe pain in
her left hip. She is admitted to the orthopedic unit with a diagnosis 17.An older adult client’s urinary incontinence is being addressed
of left hip fracture. Buck’s extension traction is used before by prompted voiding. An important aspect of this procedure is to
surgery. The nurse inspects the foot and notes the traction tapes
are lengthwise on opposite sides of the limb. The nurse’s A.reprimand the client for urinating at times other than
response to the client is those scheduled.

A.“I can turn you for comfort.” B.keep the client on the toilet until voiding occurs.

B.“I can lift your leg.” C.allow the client to void at times other than those
scheduled.
C.“I’ll call your doctor.”
D.withhold fluids for 8 hours after incontinence occurs.
D.“How long has your foot been numb?”
18.What factor, which often exacerbates the problem, can often
12.An effective medicine for the treatment of pain and be overlooked when planning care for the incontinent older adult?
inflammation of acute gout is
A.The presence of constipation or fecal impaction
A.colchicine (Novocholchine).
B.The amount of diaphoresis the client has
B.allopurinol (Zyloprim).
C.The client’s ability to get to the commode
 D.The amount of food the client is eating each day 25.The plan of care for an older adult client with seborrheic
dermatitis of the scalp and eyebrows should include
19.Indwelling urinary catheters are often a source of infection for
the older adult client. Urinary catheterization is contraindicated in A.cleaning lesions with a weak hydrogen peroxide
an older adult client who solution daily.

A.has a deep, nonhealing coccygeal pressure sore. B.cleaning the eyebrows with soap and water.

B.has end-stage cancer. C.applying hydrocortisone 10% to scalp lesions only.

C.is unable to void sufficiently and has urinary retention. D.applying selenium shampoo to scalp and eyebrows.

D.is cognitively impaired but voids when reminded to do 26.An older adult male client who has benign prostatic
so. hypertrophy also has xerosis with severe pruritus. Which nursing
intervention is most appropriate for this client?
20.An older adult male client was in generally good health until
yesterday, when he received injuries from an automobile accident. A.Teaching him to clean his perineal area frequently with
The nurse should add the diagnosis of high risk for renal mild soap
dysfunction to his plan of care because
B.Encouraging him to take a warm shower daily
A.persons, regardless of age, commonly develop renal
failure after sustaining physical trauma. C.Calling his practitioner for an antihistamine order

B.older adults have less ability to maintain homeostasis D.Teaching him to avoid bath oils or emollient lotions
when physiologically stressed. after bathing

C.he will be receiving renally toxic drugs to protect him 27.Which older adult client is at increased risk for developing
from secondary infections. impaired skin integrity related to candidiasis?

D.he will require the use of an indwelling urinary catheter A.A 60-year-old with a history of bacterial pneumonia
for several days.
B.A 72-year-old with hyperglycemia and incontinence
21.An older adult woman has a resistant strain of pneumoniA.
Which factor, if it occurs, places her at increased risk for the C.A 58-year-old newly diagnosed with lung cancer
development of acute renal failure?
D.A 90-year-old emaciated client receiving
A.Administration of intravenous narcotics antihypertensives

B.Administration of total parenteral nutrition 28.An 87-year-old client developed herpes zoster after surgical
repair of a hip fracture. Which nursing diagnosis should be given
C.Inadequate fluid maintenance priority during the acute phase of herpes zoster?

D.Urinary incontinence A.Social isolation related to isolation precautions

22.Of the many factors associated with the development of B.Self-care deficit related to severe pain and fatigue
chronic renal failure, which condition is least likely to promote its
development in the older adult? C.Self-esteem disturbance related to presence of lesions

A.Long-term prostate enlargement D.High risk for infection related to ruptured vesicles

B.Diabetes mellitus 29.The presence of which skin assessment finding, if noted on an

older adult client, should cause the nurse to suspect a
C.Polycystic kidney disease premalignancy?

D.Coronary artery disease caused by atherosclerosis A.Numerous small red papules on the chest and back

23.You are a nurse working on a medical-surgical unit. A client is B.An oozing, rough, reddish macule on the ear
admitted with acute renal failure. You must continually assess for
C.An irregularly shaped mole on the face or shoulders
A.acid reflux.
D.Brown, greasy lesions on the neck
B.decreased blood urea nitrogen and creatinine levels.
30.An older adult client has been taught measures to prevent the
C.hypercalcemia. development of skin cancer. Which statement, if made by the
client, indicates that he needs more teaching?
D.hyponatremia and hyperkalemia.
A.“I will miss my gardening activities.”
24.The nurse is completing an admission assessment on a 69-
year-old client who has benign prostate hyperplasia. The nurse B.“I should buy a sunscreen with an SPF of 15 or higher.”
should obtain an in-depth assessment about
C.“Now I have a good excuse to wear the straw hat my
A.family history. wife hates!”

B.internal bleeding. D.“My cool long-sleeved shirts will work just fine while I’m
golfing.”
C.vital sign history.
31.When assessing the older adult client’s skin for indications of
D.urinary patterns. melanoma, the nurse should inspect for a(n)
 A.thick, adherent scale with a soft center. monthly Friday appointment.” Which of the following responses by
the nurse is most appropriate?
B.small, inflamed lesion that bleeds easily.
A. “Please come away from the door. I'llshow you your
C.irregularly shaped nevus (mole). room.”

D.small, purple, hard nodule beneath the skin surface. B. “It's Tuesday and you are in the hospital. I'm Anne, a
nurse.”
32.An older adult client with a history of peripheral vascular
disease has been admitted to the hospital for treatment of a leg C. “The door is locked to keep you from getting lost.”
ulcer. The nurse recognizes that the client will most likely have
D. “I want you to come eat your lunch before you go the
A.a deep, necrotic, painless wound on her affected leg. doctor.”

B.shiny, dry, cyanotic skin on the affected leg. 38. An 83-year-old woman is admitted to the unit after being
examined in the emergency department (ED) and diagnosed with
C.multiple shallow, crusty lesions on the affected leg. delirium. After the admission interviews with the client and her
grandson, the nurse explains that there will be more laboratory
D.a pale, painful extremity with paresthesia. tests and x-rays done that day. The grandson says, “She has
already been stuck several times and had a brain scan or
33.You note that your older adult client has an open, draining something. Just give her some medicine and let her rest.” The
wound on the medial aspect of his right leg. The skin surrounding nurse should tell the grandson which of the following? Select all
the wound is reddish-brown with surrounding erythema and that apply.
edemA. Based on this information, which nursing diagnosis
should you add to your client’s plan of care? A. “I agree she needs to rest, but there is no one specific
medicine for your grandmother's condition.”
A.Impaired skin integrity related to altered venous
circulation B. “The doctor will look at the results of those tests in the
ED and decide what other tests are needed.”
B.Impaired skin integrity, peripheral related to arterial
insufficiency C. “Delirium commonly results from underlying medical
causes that we need to identify and correct.”
C.Impaired skin integrity related to diabetic neuropathy
D. “Tell me about your grandmother's behaviors and
D.Impaired skin integrity, open wound related to pressure maybe I could figure out what medicine she needs.”
ulcer
E. “I'll ask the doctor to postpone more tests until
34.A home nurse is visiting a client who has a draining venous tomorrow.”
ulcer. Which observation, if made by the nurse during the visit,
indicates that the client needs more teaching about the ulcers? 39. The nurse is attempting to draw blood from a woman with a
diagnosis of delirium who was admitted last evening. The client
A.The client’s legs are elevated. yells out, “Stop; leave me alone. What are you trying to do to me?
What's happening to me?” Which response by the nurse is most
B.The client’s dressing is dry and intact. appropriate?

C.The client’s compression stockings are off. A. “The tests of your blood will help us figure out what is
happening to you.”
D.The client’s bed is elevated with 15-cm blocks.
B. “Please hold still so I don't have to stick you a second
35.A 65-year-old man is seen in the outpatient clinic for treatment time.”
of psoriasis. The nurse should anticipate which of the following
findings? C. “After I get your blood, I'll get some medicine to help
you calm down.”
A.Increased bowel movements
D. “I'll tell you everything after I get your blood tests to the
B.Scant amount of urination laboratory.”

C.Discolored nails 40. A 90-year-old client diagnosed with major depression is

suddenly experiencing sleep disturbances, inability to focus, poor
D.Joint alignment recent memory, altered perceptions, and disorientation to time
and place. Lab results indicate the client has a urinary tract
36.The nurse of a bedridden 74-year-old woman is evaluating infection (UTI) and dehydration. After explaining the situation and
whether the family members understand how to position the client giving the background and assessment data, the nurse should
correctly. Which of the following should the nurse observe? make which of the following recommendations to the client's
primary health care provider?
A.Upper arms and legs should be supported by two
pillows. A. A prescription to place the client in restraints.
B.The family should change the position at least every 2 B. A reevaluation of the client's mental status.
hours.
C. The transfer of the client to a medical unit.
C.Moisture should be placed under the back of the neck.
D. A transfer of the client to a nursing home
D.The extremities should be extended to cause
contractures.

37. A 69-year-old client is admitted and diagnosed with delirium.

Later in the day, he tries to get out of the locked unit. He yells,
“Unlock this door. I've got to go see my doctor. I just can't miss my