N F Chp 23 - Aging

Questions and Answers

At what age does old age typically begin according to common classifications?

65 (correct)

Which classification refers to individuals aged 75 to 85?

Young old

Old old

Elderly

Middle old (correct)

What is a crucial difference that nurses should recognize when assessing older adults?

There is no overlap between dementia and delirium.

Dementia and delirium are the same conditions.

Delirium is always permanent.

Depression can mimic symptoms of dementia. (correct)

Which age group is considered 'Young old' in the classification system?

65-75 Signup and view all the answers

What term describes the phenomenon of older adults taking multiple medications simultaneously?

Polypharmacy Signup and view all the answers

Which cognitive function involves linking recognized cues to a client's clinical presentation?

Analyze cues Signup and view all the answers

What is the primary purpose of prioritizing hypotheses in patient care?

To establish urgent care priorities Signup and view all the answers

Which of the following is an appropriate nursing finding related to the normal aging process?

Skin wrinkles due to increased elasticity Signup and view all the answers

What is the first step in the cognitive function model according to the clinical judgement model?

Recognize cues Signup and view all the answers

Which intervention is essential when taking action to promote a client's health?

Implementing planned nursing interventions Signup and view all the answers

How should a nurse evaluate the effectiveness of a client's response to nursing interventions?

By determining if expected outcomes were met Signup and view all the answers

What is a key assessment sign indicating potential aging-related issues in older adults?

Thinning hair and brittle nails Signup and view all the answers

Which aspect is important for nurses to consider when assessing older adults?

Environmental and lifestyle factors Signup and view all the answers

Which nursing intervention may help alleviate the patient's experience of explosive foul-smelling diarrhea related to Clostridium difficile?

Offer bland, low-residue foods Signup and view all the answers

What is an appropriate nursing intervention for managing fluid and electrolyte imbalance in the patient experiencing diarrhea?

Request an intravenous (IV) infusion Signup and view all the answers

How should the nurse respond to a patient's statement of feeling weak after an episode of diarrhea?

Implement a hydration schedule Signup and view all the answers

Which infection control measure is most appropriate for a patient with Clostridium difficile?

Place the patient on contact isolation precautions Signup and view all the answers

Which dietary recommendation is least appropriate for a patient recovering from Clostridium difficile?

Encourage orange juice intake Signup and view all the answers

What nursing assessment is critical for monitoring a patient's response to diarrhea?

Assess skin turgor and mucous membranes Signup and view all the answers

Which nursing intervention should be prioritized when dealing with decreased patient voiding due to increased bladder capacity?

Implement a schedule for regular voiding Signup and view all the answers

During a physical assessment, which finding would indicate the need for a nurse to focus on potential dehydration in the patient?

Decreased urine output and dry mucous membranes Signup and view all the answers

Which action is recommended to ensure patient safety while bathing?

Assist the patient in and out of the tub to prevent falling. Signup and view all the answers

What is the appropriate nursing action for removing a gown without snaps while maintaining IV access?

Thread the bag and tubing through the gown sleeve, keeping the line intact. Signup and view all the answers

To promote maximal breathing in a patient with pneumonia, which position should the nurse assist the patient into?

Fowler's Signup and view all the answers

What should the nurse do when a post-operative patient feels faint after standing?

Lower the patient back to the side of the bed and pivot her back into bed. Signup and view all the answers

What position should be maintained for a patient on bedrest after a spinal cord injury to prevent footdrop?

Dorsiflexion Signup and view all the answers

What is the best method to ensure patient privacy during a procedure?

Give the patient options for privacy and allow them to lock the door. Signup and view all the answers

Which nursing intervention best facilitates breathing for a patient with respiratory distress?

Using a pillow to elevate the patient's head. Signup and view all the answers

What is the recommended approach when assisting a patient with mobility after surgery?

Assist the patient while ensuring they are fully supported. Signup and view all the answers

Which nursing intervention is most appropriate for managing the patient's nutritional needs given his condition?

Offer bland, low-residue foods to minimize gastrointestinal irritation Signup and view all the answers

What is a key communication technique that a nurse should use to assess the patient's feelings about his condition?

Encourage sharing by asking open-ended questions about his feelings Signup and view all the answers

Which potential nursing intervention is least appropriate for managing a patient with Clostridium difficile infection?

Offer foods that are spicy to stimulate appetite Signup and view all the answers

In assessing the patient's report of increased diarrhea after consuming orange juice, what is the best initial nursing action?

Educate the patient on the potential effects of acidic foods on diarrhea Signup and view all the answers

Which symptom indicates that a patient with Clostridium difficile may need further nursing intervention?

Presence of blood in stool Signup and view all the answers

What approach should a nurse take when providing care to an older adult recovering from Clostridium difficile infection?

Prioritize the patient's comfort and dignity during personal care Signup and view all the answers

What nursing intervention could help maintain the dignity of a patient with Clostridium difficile who needs assistance with bowel movements?

Ensure the patient has access to a private bathroom at all times Signup and view all the answers

Which of the following is a misconception related to dietary management for patients experiencing diarrhea from Clostridium difficile infection?

All foods should be avoided until diarrhea subsides Signup and view all the answers

Which nursing intervention is essential when a patient reports abdominal cramping with diarrhea and is at risk for dehydration?

Request an IV infusion Signup and view all the answers

What communication technique should the nurse utilize when the patient expresses feelings of weakness?

Empathize and ask for more details about their feelings Signup and view all the answers

Which nursing diagnosis is most appropriate for a patient managing stress related to a chronic illness and caregiver responsibilities?

Caregiver role strain Signup and view all the answers

When managing a patient with a history of Clostridium difficile infection, which practice should be emphasized to prevent infection spread?

Washing hands with soap and water after contact Signup and view all the answers

What is a crucial assessment for an older adult with an unsteady gait during bath assistance?

Evaluate the environment for hazards Signup and view all the answers

In caring for a patient with diarrhea, which symptom should the nurse specifically monitor for indicating dehydration?

Dry skin and mucous membranes Signup and view all the answers

When considering interventions for a client with ineffective coping strategies, which would be least appropriate?

Encourage the client to avoid their feelings Signup and view all the answers

Which nursing intervention should be prioritized for a patient who is exhibiting signs of caregiver role strain?

Encourage taking frequent breaks Signup and view all the answers

Study Notes

Classification of Older Adults

Middle age spans approximately 40 to 65 years.
Old age begins at 65, with classifications as follows:
- Young old: 65 to 75 years
- Middle old: 75 to 85 years
- Old old: 85 years and older

Physical and Mental Changes

Aging involves notable physical and mental changes that can raise concerns.
It's essential to differentiate between normal aging processes and pathological changes.

Recognizing Cognitive Impairments

Distinguish between dementia, delirium, and depression as various cognitive impairments often present with overlapping symptoms.
Each condition requires specific interventions and management strategies.

Polypharmacy Concerns

Polypharmacy refers to the simultaneous use of multiple medications, posing risks for older adults.
Nurses can help by conducting thorough medication reviews, educating patients about their medications, and identifying potential interactions.

Nursing Role in Elder Abuse

Nurses have a crucial role in identifying and reporting suspected elder abuse.
Awareness of signs of abuse or neglect is vital for the safety and well-being of older adults.

Clinical Judgement Model in Nextgen NCLEX

Consists of 6 cognitive functions crucial for effective nursing care.
Function 1: Recognize Cues (Assessment) - Filtering information from signs, symptoms, health history, and environment.
Function 2: Analyze Cues (Analysis) - Connecting recognized cues to client presentations, identifying needs and problems.
Function 3: Prioritize Hypotheses (Analysis) - Setting care priorities based on health issues, including environmental factors and test results.
Function 4: Generate Solutions (Planning) - Establishing expected outcomes and nursing interventions to meet client needs.
Function 5: Take Actions (Implementation) - Executing appropriate interventions to promote and restore health based on nursing knowledge.
Function 6: Evaluate Outcomes (Evaluation) - Assessing client responses to interventions and determining if outcomes were achieved.

Assessment Priorities

ABCs: Airway, Breathing, Circulation - Essential order of patient care.
Vital Signs - Regular monitoring of temperature, pulse, blood pressure, and respiratory rate.
Level of Consciousness - Range from awake and alert to comatose, indicating patient's neurological status.

Normal Aging Process Nursing Findings

Wrinkles on Face and Arms - Common due to decreased skin elasticity.
Skin Pigmentation - Change due to prolonged sun exposure.
Thinner Toenails, Bluish Tint - May indicate broader health concerns.

Caregiving in Aging Adults

Bruising on forearms and decreased urination may highlight fragile skin and increased bladder capacity, indicating age-related changes.

Patient Needs and Nursing Interventions

For Clostridium Difficile (C.diff) Infection:
- Nutritional care: Offer bland, low-residue foods; avoid gas-producing foods; consider bedside commode for ease of access.
- Fluid & Electrolyte management: Monitor for dehydration; IV infusion as needed; testing stool can be necessary.
- Infections: Hand hygiene is critical and may require contact isolation.

Effective Communication Techniques

Supportive responses to patient concerns regarding well-being can foster trust and encourage sharing feelings.

Patient Positioning for Breathing Difficulties

Fowler's Position recommended for maximizing thoracic cavity expansion and improving breathing.

Safety in Patient Mobility

Use caution with patients post-surgery; if a patient feels faint, return them to a safe position or seek assistance.

Prevention of Footdrop in Bedrest Patients

Dorsiflexion positioning is key in preventing footdrop for patients with spinal cord injuries.

Recommendations for Bathing Procedure Care

Assist patients safely, particularly those with IV access, ensuring to maintain IV line integrity while dressing and bathing.

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Description

This quiz covers Chapter 23 from the Nursing Fundamentals textbook, focusing on the classification of older adults, their physical and mental changes, and the recognition of dementia, delirium, and depression. It also addresses the role of nurses in polypharmacy management and elder abuse suspicion.