The nurse evaluates the UA of a female patient with an indwelling catheter. The UA reports show gross contamination of the urine. Rank the nursing interventions in order, beginning with the first intervention the nurse should implement. 

1. Provide perineal hygiene

2. Provide urinary catheter care

3. Check the duration of catheterization

4. Obtain a urine specimen from a sterile port

An older female client was recently diagnosed with dementia and the daughter is present to receive education on how to care for her mom. THe nurse knows that older adults are a risk for inadequate nutrition. Which of the following suggestions for interventions should the nurse provide? (Select all that apply)

a. Use patterned dishes and table coverings.

b. serve finger foods

c. Use a gentle tone of encouragement and avoid scolding.

d. Set hot food aside to allow it to cool slightly.

e. Sit nect to the client at her level.

During an evening shift assessment of an older man in his bed, the nurse suspects that he may be at risk for falls. Rank the nurse's actions according to priority.

1. Call for someone to bring the sign.

2. Show the older man how to use the call bell.

3. Perform a fall risk assessment.

4. Instruct the patient to call for help.

A nurse is caring for an older adult with a recently healed diabetic foot ulcer. Which of the following would be an appropriate intervention to prevent further diabetic wounds?

a. minimize walking to 10 - 15 feet at a time.

b. Obtain annual comprehensive foot exams.

c. Walk barefoot so that shoes do not rub.

d. Eat only protein to prevent tissue wasting.

A registered nurse in a nursing home is responsible for promoting healthy skin and feet of the residents. She understands which of the following related to fungal growth?

a. Candida albicans is naturally present on skin

b. Onychomycosis is quickly eradicated with antifungal creams or powders

c. A ram's-horn nail should be cut to give a smooth, rounded edge.

d. A licensed practical nurse is qualified to care for the feet of a patient with diabetes.

When an older adult complains of itching on one side of the thoracic region, the nurse recognizes this complaint as an early symptom of which of the following disease processes?

a. Xerosis

b. Pruritis

c. Herpes zoster

d. Herpes simplex

The nurse helps the physician perform a vision exam on an older bed-bound client. After the test is completed, the physician writes an order for and asks the nurse to obtain a prefilled Lucentis (anti-vascular endothelial growth factor) syringe from the pharmacy to

a. slow vision loss from age-related macular degeneration (AMD)

b. disperse yellow deposits under the retina from cataracts

c. decrease central vision from glaucoma

d. moisten the eye from wet AMD

In determining the risk of a pressure ulcer and planning care for an older adult who is 6 feet tall and weighs 155 pounds, the nurse should use which of the following assessment findings to reduce the individual's risk for a pressure ulcer? (select all that apply)

a. height of 6 feet

b. dry mucous membranes

c. urinary incontinence

d. fasting glucose 35 mg/dL

c. Osteoarthritis of lumbar spine

a. height of 6 feet

c. urinary incontinence

c. Osteoarthritis of lumbar spine

A client with normal age-related sensorineural changes may have the most difficulty distinguishing which of the following? (select all that apply)

a. High-pitched sounds

b. An orange towel hanging on the wall

c. dark colors

d. Rapid speech

a. High-pitched sounds

d. Rapid speech

The nurse is teaching older adults about maintaining health and wellness. Which of the following recommendations should the nurse include in the teaching to maintain optimal vision? (select all that apply)

a. Use yellow or amber lenses to decrease glare

b. Wear sunglasses that block sun rays

c. use warm incandescent lighting

d. Visit the ophthalmologist every five years

a. Use yellow or amber lenses to decrease glare

b. Wear sunglasses that block sun rays

c. use warm incandescent lighting

While assisting an older client in toileting, the nurse notices that the client's urine is strong smelling. Which of the following is the nurse's next nursing action?

a. increase oral fluid intake

b. review laboratory results

c. assess mucous membranes in the mouth and nose

d. assess skin turgor at the sternum

The following nursing interventions represent each of the four steps of a nutritional... Rank in order of importance.

1. Measure the midopoint of the upper arm

2. Obtain blood for serum transferrin level

3. Examine lips, gums, and oral cavity

4. Obtain up-to-date list of medications

Which of the following are the signs and symptoms of a urinary tract infection in adults that differ from classical UTI symptoms (select all that apply)

a. Acute mental status changes

b. Abdominal pain

c. dysuria

d. Decreased appetite

e. Flank pain

a. Acute mental status changes

b. Abdominal pain

d. Decreased appetite

During assessments of an older client, the nurse must conduct a comprehensive drug assessment. Which of the following approaches should the nurse use before asking the client how he or she uses each medication?

a. "pill box"

b. "Brown bag"

c. "plastic bag"

d. "paper bag"

Which of the following evidence-based resources should a nurse use to guide the assessment, treatment, and evaluation of bladder incontinence for an older adult in a long-term care facility?

a. Nursing Standard Practice Protocol

b. The Borun Center training modules

c. The American Geriatrics Society guidelines

d. The Centers for Medicare and Medicaid Services guidelines

Monitor weight and BP

Inspect feet

Review self-monitoring glucose record

Review/adjust medications as needed

Review self-management skills/goals

Assess mood

Nutrition- if they live alone, what do you need to know to best help this client in their home? 

Fluid intake of 64 ounces daily is essential.

At least 1500 mL of fluid/day

Healthy older people are less hungry and are fuller before meals, consume smaller meals, eat more slowly, have fewer snacks between meals, and become satiated after meals more rapidly than younger people.

The older person who eats alone is considered a candidate for malnutrition.

A nurse is caring for an older adult who has type 2 diabetes mellitus with unstable blood sugar levels, glaucoma, and an open wound on the foot. Which of the following goals will the nurse develop the plan of care? (select all that apply)

a. There will be no signs and symptoms of infection

b. Blood sugar will remain below 120

c. Patient will have zero falls

d. Patient will see better in two weeks

a. There will be no signs and symptoms of infection

b. Blood sugar will remain below 120

c. Patient will have zero falls

Examine medications, Meds are leading cause of constipation

Fluid, Fiber, and Exercise!

Positioning (Squatting), establishing a routine, Laxatives, and Enemas.

Sodium Phosphate enemas (Fleets) should not be used- lead to metabolic disorders. Use oil retention enemas.

If rehydration of the stratum corneum is not sufficient to control itching, cool compress, or oatmeal or Epsom salt baths may be helpful.

Be alert for infections

Which of the following factors should be routinely assessed by the nurse in the patient care environment to decrease the risk of falls? (select all that apply)

a. Location of the nurses' station

b. Appropriate footwear

c. Outdoor grounds

d. Grab bars in place

b. Appropriate footwear

c. Outdoor grounds

d. Grab bars in place

The nurse evaluates the urinalysis (UA) of a female patient with an indwelling urinary catheter. The UA report shows gross contamination of the urine. Rank the nursing interventions in order, beginning with the first intervention the nurse should implement.

1. Provide perineal hygiene

2. Provide urinary catheter care

3. Check the duration of catheterization

4. Obtain a urine specimen from a sterile port

Individuals may not seek treatment for UI because they are embarrassed to talk about the problem or think that it is a normal part of aging.

Older people want more information about bladder control, and nurses must take the lead in implementing approaches to continence promotion and public health education about UI.