loss, grief, sensory, caring of older adult

A home health nurse notices that an older adult client the nurse has known for several years is wearing strong cologne. The nurse implements which intervention based on this observation?

• Asks if someone has given the client new cologne.

• Checks that the house has working carbon dioxide detectors.

• Ensures that smoke detectors are present in the house.

• Tells the client to use electric space heaters rather than the gas furnace.

Answer explanation

Older adults experience a decline in the sensitivity to airborne chemical stimuli. They may apply more cologne because they cannot smell it as they once did. The nurse should ensure that smoke detectors are in the home and working, because the client may not be able to smell smoke from a fire. Carbon dioxide is odorless and not related to the client’s smell ability. Space heaters are a hazard for older adults and should not be recommended.

Which client is at greatest risk of developing sensory deprivation?

• an 84-year-old with progressive hearing loss living in an assisted living facility

• a 50-year-old newly diagnosed with breast cancer and having first chemotherapy treatment today

• a 32-year-old with a fractured pelvis, on bed rest in a private room

• an 18-year-old with a traumatic head injury who is in an intensive care unit

Answer explanation

Private rooms, mobility restraints (such as traction or bed rest), isolation, and few visitors are all risk factors for sensory deprivation. Intensive care units, lengthy verbal explanations prior to procedures, and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload.

A nurse is providing care to a client who is confused. The nurse is reviewing the client's laboratory test results. Which finding would the nurse identify as a possible contributing factor to the client's confusion?

• Total serum calcium level 14.2 mg/dL

• Serum sodium level 140 mEq/L

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• Serum glucose level 82 mg/dL

• Serum potassium level 4.1 mEq/L

Answer explanation

An elevated level of serum calcium can cause severe defects in neuromuscular activity with cognitive manifestations of lethargy or decreased level of consciousness. When the total serum calcium exceeds 14 mg per deciliter (normal level is 8.5 to 10.5 mg per deciliter), confusion is common. A serum sodium level below 135 mEq/L or above 145 mEq/L may result in cognitive impairment. Serum glucose levels below 70 mg per deciliter typically cause shakiness or nervousness but can progress to cause altered cognition. A serum potassium level of 4.1 mEq/L is normal.

The nurse is preparing the body of a client who was killed in a car accident for the family to view. Which step would be contraindicated?

• Remove all the IVs and other medical tubing.

• Clean, position, and cover the client with a sheet, exposing only the head and a hand.

• Inform the family that they can have as much time alone with the client as they wish.

• Respect all religious and cultural practices of the family.

Answer explanation

In an effort to limit exposure to the disturbing sight of equipment and medical supplies, the nurse should, if possible, remove unneeded items and clean, position, and cover the client. However, under some circumstances (such as an unexpected death), intravenous and other lines and tubes should not be removed, as the body may need to be examined by a medical examiner. Having time alone with the client is an important step for some families, whereas others appreciate the presence of a nurse, a spiritual leader, or friends. Religious and cultural beliefs and customs should be observed as much as possible.

An older adult client comes to the clinic for his yearly influenza vaccination. During the visit he asks the nurse, "I've heard about this other vaccine for pneumococcal pneumonia. How often do I need to get this vaccine?" The nurse would encourage the client to receive this vaccination at which frequency?

• Every year

• Every other year

• Every 3 years

• Every 5 years

After a blow to the head, the nurse assesses the client who is aware of self, sleepy and slow to respond. Which action will the nurse take first?

• Contact the health care provider immediately.”

• “Continue to observe the client.”

• “Document vital signs.”

• “No action is needed at this time.”

Answer explanation

A normal state of awareness is one in which there is awareness of self and the external environment, including being well-oriented and responsive. The nurse will be concerned about the negative consequences of the client’s head injury and should contact the health care provider about the abnormal activity. The nurse will continue to monitor the client and take vital signs secondarily.

A home care nurse is making a home visit to a 78-year-old client being cared for by an adult child and in-law. The client has missed several follow up visits to the health care provider over the past several months. The client states, "My child is so busy. I do not want to bother him or her.” When the nurse asks the adult child about the missed visits, the child replies, "My parent just saw the doctor a couple months ago. My parent does not need to see the doctor again. Besides, it costs too much money.” What is the nurse’s next course of action?

• Make an appointment to discuss concerns with the in-law.

• Encourage the client to stand up for oneself and insist on going to the appointments as scheduled.

• Report the neglect to the authorities.

• Give the adult child a 30-day warning to remedy the concern, or a report would be filed.

Answer explanation

The situation described suggests neglect: the refusal or failure by those responsible to provide health care for a vulnerable older adult. Nurses and other health care professionals are obligated to report suspected abuse, including neglect, in adults 60 years of age or older for those who are dependent on others for their care. Giving the caregivers a warning and making an appointment to talk to the in-law before reporting prolongs the neglect and could endanger the client’s health. Abuse in older adults is often silent; older adults may not be willing or able to stand up to their caregivers.

The nurse is assisting a visually impaired client to ambulate. What would be most appropriate for the nurse to do?

• Stand behind the client supporting him at the waist.

• Stand just slightly in front of the client on his nondominant side.

• Grasp his dominant arm, leading him forward.

• Stand facing the client, walking backwards as he walks forward.

Answer explanation

When assisting a visually impaired client with ambulation, stand on the client's nondominant side, about 1 foot in front of him. Have the client grasp your arm with the nondominant hand and use the dominant hand to feel around for barriers or landmarks. Always maintain an uncluttered environment.

A home care nurse visits an older adult client with dementia due to Alzheimer's disease. As a result of the client's confused thinking, the client is experiencing significant difficulty in communicating with family members. Which intervention would be most appropriate for this client?

• Orient the client to reality.

• Validate the client's current needs.

• Provide appropriate sensory appliances.

• Maintain levels of sensory stimulation.

Answer explanation

The nurse should use validation therapy by validating the client's current needs in order to facilitate communication and to minimize the adverse consequences of confused thinking. Validation therapy is a type of interpersonal interaction in which the health professional attempts to understand and validate the client's current needs. Reality orientation is recommended for orienting people with reversible states of confusion. Providing appropriate sensory appliances like glasses and hearing aids, and maintaining levels of sensory stimulation, are not helpful in dementia or irreversible confusion.

The nurse is caring for a client who has terminal lung cancer and is unconscious. What assessment would indicate to the nurse that the client's death is imminent?

• Mottling of the lower limbs

• Slow, steady pulse

• Pursed lip breathing

• Increased swallowing

Answer explanation

The time of death is generally preceded by a period of gradual diminishing of bodily functions. During this time, the nurse may observe increased intervals between respirations, weakened and irregular pulse, and skin color may change or become mottled. The client will not be able to swallow secretions, so suctioning, frequent and gentle mouth care, and possibly the administration of a transdermal anticholinergic drug may be required.