Older Adults
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A home health care 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 client use a walker or cane on the steps.
b. Teach the client to hold the handrail when using the steps
c. Instruct the client to use the garage door instead.
d. Tell the client to use a two-footed gait on the steps.
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. Holding the handrail would
help keep the person safer. If the client does not need an assistive device, he or she
would not use a cane or walker 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 client is unaware of where the foot is on the step.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Older adult, Safety MSC: Client Needs
Category: Safe and Effective Care Environment: Safety and Infection Control
, 2. An older adult is brought to the emergency department because of sudden onset of
confusion. After the client 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 client for gait abnormalities.
d. Perform a delirium screening test.
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 would determine if the client is taking any new medications. Assessments for
orthostatic hypotension, gait abnormalities, and delirium may be important once more
is known about the client’s condition.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Medication safety MSC: Client Needs
Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. An older adult client takes medication three times a day and becomes confused about
which medication should be taken at which time. The client 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 client to use easy-open tops.
c. Put color-coded stickers on the bottle caps.
d. Write a list of when to take each medication.
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