Chapter 3

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. A nursing faculty member working with students explains that the fastest growing subset of the older
population is which group?
a. Elite old
b. Middle old
c. Old old
d. Young old

____ 2. A nurse working with older adults in the community plans programming to improve morale and
emotional health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim

____ 3. A nurse caring for an older patient on a medical-surgical unit notices the patient reports frequent
constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment
should the nurse perform first?
a. Auscultate bowel sounds.
b. Check skin turgor.
c. Perform an oral assessment.
d. Weigh the patient.

____ 4. A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection
by the patient demonstrates a need for further review?
a. Barley soup
b. Black beans
c. White rice
d. Whole-wheat bread

____ 5. A nurse is working with an older patient admitted with mild dehydration. What teaching does the
nurse provide to best address this issue?
a. “Cut some sodium out of your diet.”
b. “Dehydration can cause incontinence.”
c. “Have something to drink every 1 to 2 hours.”
d. “Take your diuretic in the morning.”

____ 6. A home healthcare nurse is planning an exercise program with an older patient who lives at home
independently but whose mobility issues prevent much activity outside the home. Which exercise
regimen would be most beneficial to this adult?
a. Building strength and flexibility
b. Improving exercise endurance
c. Increasing aerobic capacity
d. Providing personal training
____ 7. An older adult recently retired and reports “being depressed and lonely.” What information should
the nurse assess as a priority?
a. History of previous depression
b. Previous stressful events
c. Role of work in the adult’s life
d. Usual leisure time activities

____ 8. A nurse is assessing coping in older women in a support group for recent widows. Which statement
by a participant best indicates potential for successful coping?
a. “I have had the same best friend for decades.”
b. “I think I am coping very well on my own.”
c. “My kids come to see me every weekend.”
d. “Oh, I have lots of friends at the senior center.”

____ 9. A home healthcare nurse has conducted a home safety assessment for an older adult. There are five
concrete steps leading out from the front door. Which intervention would be most helpful in keeping
the older adult safe on the steps?
a. Have the patient use a walker or cane on the steps.
b. Install contrasting color strips at the edge of each step.
c. Instruct the patient to use the garage door instead.
d. Tell the patient to use a two-footed gait on the steps.

____ 10. An older adult is brought to the emergency department because of sudden onset of confusion. After
the patient is stabilized and comfortable, what assessment by the nurse is most important?
a. Assess for orthostatic hypotension.
b. Determine if there are new medications.
c. Evaluate the patient for gait abnormalities.
d. Perform a delirium screening test.

____ 11. An older adult patient takes medication three times a day and becomes confused about which
medication should be taken at which time. The patient refuses to use a pill sorter with slots for
different times, saying “Those are for old people.” What action by the nurse would be most helpful?
a. Arrange medications by time in a drawer.
b. Encourage the patient to use easy-open tops.
c. Put color-coded stickers on the bottle caps.
d. Write a list of when to take each medication.

____ 12. An older adult patient is in the hospital. The patient is ambulatory and independent. What
intervention by the nurse would be most helpful in preventing falls in this patient?
a. Keep the light on in the bathroom at night.
b. Order a bedside commode for the patient.
c. Put the patient on a toileting schedule.
d. Use side rails to keep the patient in bed.

____ 13. An older patient had hip replacement surgery and the surgeon prescribed morphine sulfate for pain.
The patient is allergic to morphine and reports pain and muscle spasms. When the nurse calls the
surgeon, which medication should he or she suggest in place of the morphine?
a. Cyclobenzaprine (Flexeril)
 b. Hydromorphone hydrochloride (Dilaudid)
c. Ketorolac (Toradol)
d. Meperidine (Demerol)

____ 14. A nurse admits an older patient from a home environment where she lives with her adult son and
daughter-in-law. The patient has urine burns on her skin, no dentures, and several pressure ulcers.
What action by the nurse is most appropriate?
a. Ask the family how these problems occurred.
b. Call the police department and file a report.
c. Notify Adult Protective Services.
d. Report the findings as per agency policy.

____ 15. A nurse caring for an older patient in the hospital is concerned the patient is not competent to give
consent for upcoming surgery. What action by the nurse is best?
a. Call Adult Protective Services.
b. Discuss concerns with the healthcare team.
c. Do not allow the patient to sign the consent.
d. Have the patient’s family sign the consent.

Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 16. A nursing student working in an Acute Care of the Elderly unit learns that frailty in the older
population includes which components? (Select all that apply.)
a. Dementia
b. Exhaustion
c. Slowed physical activity
d. Weakness
e. Weight gain

____ 17. A home healthcare nurse assesses an older patient for the intake of nutrients needed in larger
amounts than in younger adults. Which foods found in an older adult’s kitchen might indicate an
adequate intake of these nutrients? (Select all that apply.)
a. 1% milk
b. Carrots
c. Lean ground beef
d. Oranges
e. Vitamin D supplements

____ 18. A nurse working with older adults assesses them for common potential adverse medication effects.
For what does the nurse assess? (Select all that apply.)
a. Constipation
b. Dehydration
c. Mania
d. Urinary incontinence
e. Weakness
____ 19. A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older
adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.)
a. Confusion
b. Evidence of abuse
c. Incontinence
d. Problems with behavior
e. Sleep disorders

____ 20. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last month’s
visit. What actions should the nurse perform first? (Select all that apply.)
a. Assess the patient’s ability to drive or transportation alternatives.
b. Determine if the patient has dentures that fit appropriately.
c. Encourage the patient to continue the current exercise plan.
d. Have the patient complete a 3-day diet recall diary.
e. Teach the patient about proper nutrition in the older population.

____ 21. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the
registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assess skin redness when turning.
b. Document Braden Scale results.
c. Keep the patient’s skin dry.
d. Obtain a pressure-relieving mattress.
e. Turn the patient every 2 hours.

____ 22. A nurse admits an older patient to the hospital who lives at home with family. The nurse assesses that
the patient is malnourished. What actions by the nurse are best? (Select all that apply.)
a. Contact Adult Protective Services or hospital social work.
b. Notify the provider that the patient needs a tube feeding.
c. Perform and document results of a Braden Scale assessment.
d. Request a dietary consultation from the healthcare provider.
e. Suggest a high-protein oral supplement between meals.
Chapter 3
Answer Section

MULTIPLE CHOICE

1. ANS: C
The old old is the fastest growing subset of the older population. This is the group comprising those
85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between
75 and 84 years of age; and the elite old are over 100 years of age.

PTS: 1 DIF: Cognitive Level: Remembering KEY: Adulthood | aging | old old
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance
2. ANS: A
All activities would be beneficial for the older population in the community. However, failure in
performing one’s own activities of daily living and participating in society has direct effects on
morale and life satisfaction. Those who lose the ability to function independently often feel
worthless and empty. An exercise program designed to maintain and/or improve physical functioning
would best address this need.

PTS: 1 DIF: Cognitive Level: Applying

KEY: Independence | autonomy | older adult
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Psychosocial Integrity
3. ANS: C
Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods
and constipation from the lack of fiber. The nurse should perform an oral assessment to determine if
these problems exist. The other assessments are important, but will not yield information specific to
the patient’s food preferences as they relate to constipation.

PTS: 1 DIF: Cognitive Level: Applying KEY: Nutrition | dentures | older adult
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
4. ANS: C
Older adults need 35 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber
include barley, beans, and whole-wheat products.

PTS: 1 DIF: Cognitive Level: Applying KEY: Nutrition | fiber | older adult
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
5. ANS: C
 Older adults often lose their sense of thirst. Plus older adults have less body water than younger
people. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult
drink something each hour or two, whether or not he or she is thirsty. Cutting “some” sodium from
the diet will not address this issue. Although dehydration can cause incontinence from the irritation
of concentrated urine, this information will not help prevent the problem of dehydration. Instructing
the patient to take a diuretic in the morning rather than in the evening also will not directly address
this issue.

PTS: 1 DIF: Cognitive Level: Applying KEY: Dehydration | older adult | hydration
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
6. ANS: A
This older adult is mostly homebound. Exercise regimens for homebound patients include things to
increase functional fitness and ability for activities of daily living. Strength and flexibility will help
the patient to be able to maintain independence longer. The other plans are good but will not
specifically maintain the patient’s functional abilities.

PTS: 1 DIF: Cognitive Level: Applying

KEY: Exercise | functional ability | older adult
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
7. ANS: C
Often older adults lose support systems when their roles change. For instance, when people retire,
they may lose their entire social network, leading them to feeling depressed and lonely. This loss
from a sudden change in lifestyle can easily lead to depression. The nurse should first assess the role
that work played in the patient’s life. The other factors can be assessed as well, but this circumstance
is commonly seen in the older population.

PTS: 1 DIF: Cognitive Level: Applying KEY: Depression | older adult

MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Psychosocial Integrity
8. ANS: A
Friendship and support enhance coping. The quality of the relationship is what is most important,
however. People who have close, intimate, stable relationships with others in whom they confide are
more likely to cope with crisis. The person who is “coping well on my own” may actually need
resources to help with this transition. Having children visit is important but not as important as
intimate, long-term friendships. “Friends at the senior center” may refer to good acquaintances and
not real friends.

PTS: 1 DIF: Cognitive Level: Remembering KEY: Coping | relationships | older adult
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Psychosocial Integrity
9. ANS: B
 As a person ages, he or she may experience a decreased sense of touch. The older adult may not be
aware of where his or her foot is on the step. Combined with diminished visual acuity, this can create
a fall hazard. Installing contrasting color strips at the end of each step will help increase awareness.
If the patient does not need an assistive device, he or she should not use one just on stairs. Using an
alternative door may be necessary but does not address making the front steps safer. A two-footed
gait may not help if the patient is unaware of where the foot is on the step.

PTS: 1 DIF: Cognitive Level: Analyzing KEY: Safety | falls | older adult
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. ANS: B
Medication side effects and adverse effects are common in the older population. Something as
simple as a new antibiotic can cause confusion and memory loss. The nurse should determine if the
patient is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities,
and delirium may be important once more is known about the patient’s condition.

PTS: 1 DIF: Cognitive Level: Applying

KEY: Medications | medication safety | older adult
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. ANS: C
Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for
evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer
might be helpful if the person doesn’t accidentally put them back in the wrong spot. Easy-open tops
are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the
medication bottles themselves, the reminder is always with the medication.

PTS: 1 DIF: Cognitive Level: Applying

KEY: Medications | medication safety | older adult
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. ANS: A
Although this older adult is independent and ambulatory, being hospitalized can create confusion.
Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the
bathroom will help reduce the likelihood of falling. The patient does not need a commode or a
toileting schedule. Side rails used to keep the patient in bed are considered restraints and should not
be used in that fashion.

PTS: 1 DIF: Cognitive Level: Applying KEY: Falls | safety | older adult
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
13. ANS: B
Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on
the Beers list of potentially inappropriate medications for use in older adults and should not be
suggested. The nurse should suggest hydromorphone hydrochloride.

PTS: 1 DIF: Cognitive Level: Remembering KEY: Medications | Beers list | older adult
MSC: Integrated Process: Communication and Documentation
 NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
14. ANS: D
These findings are suspicious for abuse. Healthcare providers are mandatory reporters for suspected
abuse. The nurse should notify social work, case management, or whomever is designated in
policies. That person can then assess the situation further. If the police need to be notified, that is the
person who will notify them. Adult Protective Services is notified in the community setting.

PTS: 1 DIF: Cognitive Level: Applying KEY: Abuse | older adult

MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
15. ANS: B
In this situation, each facility will have a policy designed for assessing competence. The nurse
should bring these concerns to an interdisciplinary care team meeting. There may be physiologic
reasons for the patient to be temporarily too confused or incompetent to give consent. If an acute
condition is ruled out, the staff should follow the legal procedure and policies in their facility and
state for determining competence. The key is to bring the concerns forward. Calling Adult Protective
Services is not appropriate at this time. Signing the consent should wait until competence is
determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts
as to the patient’s ability to provide consent. Simply not allowing the patient to sign does not address
the problem.

PTS: 1 DIF: Cognitive Level: Applying

KEY: Competence | autonomy | older adult
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

16. ANS: B, C, D
Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and
exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations.

PTS: 1 DIF: Cognitive Level: Remembering KEY: Frailty | frail elderly | older adult
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Health Promotion and Maintenance
17. ANS: A, B, D, E
Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium;
carrots have vitamin A; vitamin D supplement has vitamin D; and oranges have vitamin C. Lean
ground beef is healthier than more fatty cuts, but does not contain these needed nutrients.

PTS: 1 DIF: Cognitive Level: Applying

KEY: Nutrition | nutritional requirements | older adults
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
18. ANS: A, B, E
Common adverse medication effects include constipation/impaction, dehydration, and weakness.
Mania and incontinence are not among the common adverse effects, although urinary retention is.
 PTS: 1 DIF: Cognitive Level: Remembering KEY: Medications | adverse effects
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
19. ANS: A, C, E
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and
evidence of falls.

PTS: 1 DIF: Cognitive Level: Remembering KEY: SPICES | older adult

MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
20. ANS: A, B, D
Assessment is the first step of the nursing process and should be completed prior to intervening.
Asking about transportation, dentures, and normal food patterns would be part of an appropriate
assessment for the patient. There is no information in the question about the older adult needing to
lose weight, so encouraging him or her to continue the current exercise regimen is premature and
may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be
tailored to the patient’s needs, which the nurse does not yet know.

PTS: 1 DIF: Cognitive Level: Applying KEY: Nutrition | older adult

MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
21. ANS: C, D, E
The nurses’ aide or UAP can assist in keeping the patient’s skin dry, order a special mattress on
direction of the RN, and turn the patient on a schedule. Assessing the skin is a nursing responsibility,
although the aide should be directed to report any redness noticed. Documenting the Braden Scale
results is the RN’s responsibility as the RN is the one who performs that assessment.

PTS: 1 DIF: Cognitive Level: Applying

KEY: Skin breakdown | older adult | delegation | unlicensed assistive personnel
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
22. ANS: C, D, E
Malnutrition in the older population is multifactorial and has several potential adverse outcomes.
Appropriate actions by the nurse include assessing the patient’s risk for skin breakdown with the
Braden Scale, requesting a consultation with a dietitian, and suggesting a high-protein meal
supplement. There is no evidence that the patient is being abused or needs a feeding tube at this time.

PTS: 1 DIF: Cognitive Level: Applying

KEY: Nutrition | malnutrition | older adult | Braden Scale
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care