Which of the following over-the-counter drugs pose serious risks for older adults?

a. Pseudoephedrine
b. Antihistamines
c. NSAIDs
d. A and C
e. All of the above
Rationale: Even when taken at indicated dosages, there are serious risks when older
adults take medications containing pseudoephedrine which include hypertension,
vasospasm, arrhythmia, and stroke. Most drugs with anticholinergic properties are
inappropriate for use by older adults. Anticholinergic side effects include cognitive
dysfunction, disrupted sleep, confusion, hallucinations, and delirium. They may result in
decreased vision and motor reflexes, placing the individual at risk for injury from a fall or
motor vehicle accident. Gastrointestinal bleeding is the major risk factor associated with
NSAID use, and studies have shown that older adults are at increased risk compared with
younger individuals.
In elderly patient, a myocardial infarction may present in an atypical fashion with:
a. Right-sided chest pain
b. Shortness of breath
c. Weight loss
d. Fever
e. Both A and B
Rationale: Most myocardial infarctions in older adults do not present with chest pain.
Physicians and nurses need to be aware of patients at risk who present with vague
symptoms of fatigue, nausea, and a decline in functional status. When patients do
present with a more classic picture of an acute event, a more common complaint than
chest pain is shortness of breath.
The seven stages of Alzheimers provide a general idea of how abilities change during
the course of the disease. When a patient with Alzheimers develops noticeable problems
finding the right word or name, remembering names when introduced to new people, has
more difficulty performing tasks in social or work settings, loses or misplaces a valuable
object and has increasing problems with planning or organizing, his or her difficulties
most closely resemble:
a. Stage 1: Small cognitive decline
b. Stage 2: Very mild cognitive decline
c. Stage 3: Mild cognitive decline
d. Stage 4: Moderate cognitive decline
e. Stage 5: Moderately severe cognitive decline
Stage 7 or severe or late-stage Alzheimers is characterized by which of the following?
a. Loss of ability to respond to the environment
b. Wandering
c. Forgetfulness of recent events
d. Confusion as to date and place
e. None of these answers
In Stage 7 or late Alzheimers disease, patients lose the ability to respond to their
environment, to carry on a conversation and eventually, cannot control body movement.
Which of the following statements about Advance Directives is true?
a. In patients who lack the capacity to make decisions, a health care proxy should be
appointed by the nearest living relative.
b. Appointment of a durable power is preferable over a living will.
c. A health care proxy is allowed to make bank transactions, sign checks, apply for
disability, or simply writes checks to pay the utility bill while an individual is
medically incapacitated.

d. Advance Directs is a term which refers to treatment preferences and the

designation of a surrogate decision-maker in the event that a person should
become unable to make medical decisions on her or his own behalf.
Advance Directives generally fall into three categories: living will, power of attorney, and
health care proxy. A Living Will is a written document that specifies what types of
medical treatment are desired should the individual become incapacitated. A Health Care
Proxy is a legal document in which an individual designates another person to make
health care decisions if he or she is rendered incapable of making their wishes known. A
Durable Power of Attorney is a legal document where an individual provides the power of
attorney to someone in the case of an incapacitating medical condition. The durable
power of attorney allows that designated individual to make medical decisions, bank
transactions, sign Social Security checks, apply for disability, or simply write checks to
pay the utility bill while an individual is medically incapacitated.
Which of the following is not a common presenting symptom of delirium?
a. Impaired attention
b. A clear level of consciousness
c. Withdrawal
d. Agitation
Management of delirium includes all of the following except:
a. Maintaining proper fluid intake and nutrition
b. Use of memory cues such as calendars and clocks
c. Correcting sensory deficits
d. Use of physical restraints
Physical restraints should be avoided. Severely delirious patients may benefit from
constant observation (sitters) since they may pull out intravenous lines, climb out of bed
and not be compliant. Correcting sensory deficits includes the use of eyeglasses and
hearing aids.
Which of the following should be suspected in elderly or demented patients who exhibit
an acute or subacute deterioration in behavior, cognition, or function?
a. Delirium
b. Depression
c. Infection
d. All of these answers
An underlying cause should first be sought. It is important to exclude infection
(especially urinary tract infection), metabolic abnormality or structural brain lesion.
In older adults, infectious disease may present with which of the following?
a. Decreased appetite or fluid intake
b. Absence of fever
c. Confusion
d. A and C
e. All of these answers
Nurses should be able to recognize atypical presentations of illness in older adults. For
example, subtle changes like a decrease in function or a diminished appetite can often
be the first sign of a medical illness.
In contrast to the usual signs of an acute abdomen (pain, diminished or absent bowel
sounds, and fever), elderly patients may present with:
a. Agitation
b. Abdominal discomfort, constipation, and some tachypnea
c. Withdrawal
d. Wandering

In older adults, an acute abdomen may present silently with mild discomfort and
constipation with some tachypnea, and possibly some vague respiratory symptoms.
Therefore, it is extremely important for nurses to recognize those patients with
significant bowel disturbances and a change in food or fluid intake.
A hospice patient on pain medication and a benzodiazepine insists on driving and has
done so in the past. What is the attending nurses duty in this situation?
a. The nurse has a duty to alert the patients caretaker or relative
b. The nurse has no duty to intervene
c. The nurse should alert the police
d. At minimum, the nurse should inform the patient of the danger of driving while
mentally impaired and document having given the patient this advice
At minimum, the nurse would need to inform the patient of the risk of driving while
impaired, if the patient is impaired. Some patients on long-term medication for chronic
pain are impaired, but that is not necessarily a given. If, in the nurse's opinion, the
patient is an imminent threat to self and others, and the patient insists on driving, then
the nurse has a responsibility to communicate the specifics to someone in a position to
do something. This could be a relative, caretaker, the Department of Motor Vehicles, or
the police. There is a HIPAA exception for such a communication. Buppert, C. Am I Liable
for the Actions of an Impaired Patient? Medscape.October 16, 2013.
Which of the following statements is true regarding an end-of-life discussion with a
terminally patient?
a. All patients should be given complete details about their illness and prognosis.
b. The discussion should take place during clinical rounds with only the patient
present.
c. The patient should be invited to express what his or her understanding is in regard
to his or her condition.
d. If the patient expresses no emotion, family members should be allowed to make
the decision.
Some element of privacy should be arranged for the discussion, and the patient should
decide which family members or friends should be present. The patient should be asked
how he or she perceives his or her medical condition. The patient should be invited to
determine the amount of information he or she would like to receive. Knowledge about
the patients condition should be provided in small increments while checking for the
patients level of understanding. The patients emotions should be confirmed with
empathy. The clinician should then summarize the discussion and plan the next meeting.
End-of-Life Conversation Guidelines. Canadian Medical Association Journal. Published
online July 15, 2013
According to a recent study, four medication classes causes most of the problems related
to drug interactions in older patients. All of the following are among this high risk group
of medications except:
a. Warfarin
b. Insulin
c. Low-dose aspirin
d. Oral anti-platelet agents
The fourth medication class likely to cause adverse drug interactions in the elderly is the
class of oral hypoglycemics. The Beers List suggests that the following medications
should also be used very cautiously in older adults: first generation antihistamines,
muscle relaxants, benzodiazepines, digoxin > 0.125 mg, and tertiary tricyclic
antidepressants.A new medication added to an older adult's regimen may cause an
adverse event that is then misinterpreted as a new medical problem. This starts a vicious
circle of testing, more medication, more drug/drug reactions, and more adverse events.
Budnitz DS, et al. Emergency hospitalizations for adverse drug events in older
Americans. N Engl J Med. 2011;365:20022012. The American Geriatrics Society 2012
Beers Criteria.J Am Geriatric Soc. 2012. DOI: 10.1111/j.1532-5415.2012.03923.x.

Hypoactive delirium in elderly patients is frequently mistaken for:

a. Head injury
b. Stroke
c. Psychosis
d. Depression
Hypoactive delirium (quiet, withdrawn behavior) is commonly mistaken for either
depression or dementia in older adults.
All of following statements about depression are true except:
a. Psychological and pharmacological treatment of depression is less effective in
older adults than in younger adults
b. Older adults with depression are at increased risk of suicide and are more likely
than younger adults to complete suicide.
c. Patients with a history of depression have increased rates of cognitive decline and
dementia in late life
d. Depression has been linked to cardiovascular disease and cognitive impairment
Psychological and pharmacological treatment of depression are as effective in older
adults as they are in younger adults. The other statements are true. Rodda, J. Depression
in older adults.BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5219 (Published 28
September 2011) . Kohler, S., et al. Depressive Symptoms and Cognitive Decline in
Community-Dwelling Older Adults.J Am GeriatrSoc58:873879, 2010.
How can older adults prevent falls?
a. Have their vision checked at least once a year
b. Ask their doctor to review their medicines
c. Exercise regularly
d. All of these answers
Each year, one in every three adults age 65 and older falls. Falls can cause moderate to
severe injuries, such as hip fractures and head traumas, and can increase the risk of
early death.In addition to these measures, older adults can make their homes safer by
reducing tripping hazards, adding grab bars inside and outside the tub or shower and
next to the toilet, adding railings on both sides of stairways, and improving the lighting in
their homes.
Which of the following is most true regarding sexuality in older adults?
a. Nurses should only discuss sexual issues if they are initiated by the older adult.
b. The many disabling medical conditions of older adults inevitably prevent the
expression of sexuality.
c. Sexual desires, thoughts, and actions continue throughout all decades of life.
d. Normal aging changes make sexual health extremely difficult to achieve.
Nurses play an important role in assessing and managing normal and pathological aging
changes in order to improve the sexual health of older adults. Nurses should attempt to
discuss normal age-related physiological changes, address the effects of medications
and medical conditions on sexual function, and facilitate communication with older
adults and their families regarding sexual health.
Which of the following can aid in differentiating delirium from dementia?
a. Level attention
b. Speed of onset
c. Duration
d. All of these answers
Onset is typically acute in delirium and gradual in dementia. Duration is typically short in
delirium (days to weeks) and prolonged in dementia (months to years). Level of attention
is generally impaired in delirium and normal in dementia (except in severe cases).
Age-associated changes in the respiratory system include:

a.
b.
c.
d.

Increased tidal volume

Reduced pulmonary functional reserve with exertion
Increased chest wall compliance
Increased secretions

Age-associated changes in the pulmonary system include decreased respiratory muscle

strength,a stiffer chest wall with reduced compliance, drier mucous membranes,
decreased cough reflex, decreased respiratory excursion and chest/lung expansion with
less effective exhalation and reduced pulmonary functional reserve with exertion causing
dyspnea and reduced exercise tolerance.
The most common type of healthcare-associated infection is:
a. Catheter-associated urinary tract infection
b. Ventilator-associated pneumonia
c. Surgical site infection
d. Central catheter-associated bloodstream infection
Catheter-associated urinary tract infections represent up to 40% of all healthcare
infections.
Evidence-based nursing care strategies to be employed in addressing age-related
musculoskeletal changes include:
a. Encouragement of physical activity
b. Use of calcium and Vitamin D supplements
c. Regular use of NSAIDs of control pain symptoms
d. All of these answers
Regular use of NSAIDs in the elderly poses a significantly increased risk of
gastrointestinal bleeding. Judicious use of NSAIDs is preferred. The use of calcium and
vitamin D supplements is controversial.
Which of the following statements is true in regard to a patients pain level and its
treatment?
a. A nurse can tell how much pain a patient is experiencing by closely observing him.
b. Intramuscular injection is a good way to deliver pain medication.
c. Increases in vital signs are an indication that the patient is experiencing pain.
d. A patient may sleep despite being in pain.
Vital signs may increase for brief periods with acute pain, but this may not occur in
patients with chronic pain. Besides pain, an increase in vital signs can signal other
problems such as anxiety or deterioration in the patients clinical status. Intramuscular
injections of pain medication are characterized by irregular absorption. Patients can
sleep despite pain, especially those who have been living with pain for a long time and
are exhausted. Observing a patients behavior is not a substitute for patient self-report.
Depressed elderly patients are more likely than younger patients to present with:
a. Sadness
b. Weight loss
c. Agitation
d. Apathy
Older adults are more likely to present with an agitated depression. Depression in older
adults is also characterized by a preoccupation with somatic symptoms related to
appetite changes, vague gastrointestinal symptoms, constipation, and sleep
disturbances. Sadness may or may not be reported.
Treatment of incontinence-associated dermatitis (IAD) includes:
a. Vigorous cleansing preferably with betadine solution
b. Gentle cleansing
c. Application of talcum power
d. Application of a moist dressing

e. All of these answers

Treatment of IAD consists of gentle cleansing, moisturization, and application of a skin
protectant or moisture barrier.
An 89-year-old woman, hospitalized for a urinary tract infection, exhibits redness of the
perineum, perianal, and inner thighs with irregular borders. This skin lesion most likely
represents:
a. Intertriginous dermatitis
b. Atopic dermatitis
c. Incontinence-associated dermatitis
d. Diffuse pressure ulcer
The distribution of the redness and its irregular borders are highly suggestive of IAD.
A hospitalized thin elderly male exhibits erythema of intact skin over the sacrum. His
nurse reports that he has been incontinent of stool at least two occasions. What clinical
feature can help distinguish ulcer from incontinence-associated dermatitis in this
patient?
a. Blanchability of the affected area
b. Size of the affected area
c. The patients overall level of mobility
d. Tenderness of the affected area
Wounds that are associated with a pressure/shear etiology are characterized by
nonblanchable erythema. The nurse or physician can gently press on the erythematous
area to determine whether or not it blanches. Lesions that do not blanch and are located
over a bony prominence should be classified as stage I pressure ulcers. Skin
pigmentation influences assessment accuracy; it may be difficult to detect in darkly
pigmented skin. In this case, palpation of the tissue to determine changes infirmness or
temperature is helpful (a pressure ulcer will exhibit induration and increased warmth).
A mildly obese elderly woman exhibits erythema along the intergluteal cleft and groin
creases. A linear break is noted in the skin in one of the groin creases. The surrounding
skin appears macerated. The most likely etiology for this skin lesion is:
a. Incontinence-associated dermatitis
b. Intertriginous dermatitis
c. Stage I pressure ulcer
d. Atopic dermatitis
Intertriginous dermatitis is skin damage caused by trapped perspiration and frictional
forces between opposing skin surfaces and usually appears as inflammation and linear
lesions at the base of skin folds (e.g., under pendulous breasts or in the groin crease).
Risk factors for atypical presentation of medical illness include which of the following?
a. Multiple medications
b. Cognitive impairment
c. Age >85
d. All of these answers
Risk factors for atypical presentation of medical illness include all of the above. The
presence of multiple comorbidities is an additional risk factor.
Examples of nonspecific symptoms that may represent specific illness in older adults
include which of the following?
a. Confusion
b. Falling
c. Self-neglect
d. All of these answers

Additional nonspecific symptoms that may represent specific medical illness are:
incontinence, apathy, anorexia, dyspnea, and fatigue.
Which of the following statements is/are true in regard to family caregiving?
a. Caregiving often results in chronic stress which compromises caregivers physical
and psychological health.
b. Caring for a person with dementia is particularly challenging, causing more severe
negative health effects than other types of caregiving
c. Depression is one of the most negative effects of caregiving
d. All of these answers
Caregiving can also be beneficial, enabling caregivers to feel good about themselves,
learn new skills, and strengthen family relationships.
A number of empirically derived factors have been consistently documented as
associated with improved quality of life (QOL) from the perspective of patients with
dementia. These factors include:
a. Ability to engage in pleasant activities
b. Mood
c. Ability to perform activities of daily living
d. All of these answers
For family caregivers reporting about QOL of their care recipient, factors include mood,
engagement in pleasant activities, physical functioning, and cognitive functioning.
In older adults, both hypothyroidism and hyperthyroidism can present as:
a. Delirium
b. Hyperactivity
c. Depression
d. Psychosis
Both hypo- and hyper-thyroid disease may present as diminished energy and apathy and
be misdiagnosed as depression in older adults.
Which of the following most significantly reduces the incidence of catheter-associated
urinary tract infection (CAUTI)?
a. Antibacterial ointment application to urethra meatus
b. Changing indwelling catheters at routine fixed intervals
c. Routine catheter irrigation with 0.9% sodium chloride solution
d. Catheterization only when indicated and prompt catheter removal
Only one intervention listed above decreases the incidence of CAUTI based on the
evidence: reducing urinary catheter days. Catheter irrigation, instillation of antimicrobial
solutions into the catheter or drainage bag, and antibiotic ointments applied to the
urinary meatus have not been shown to decrease catheter-associated urinary tract
infection.
The responsibility of communicating the plan of care that the medical team has devised
for the medically complex older adult prior to discharge rests with the:
a. Nurse
b. Social worker
c. Family caregiver
d. Physician
Each member of the interdisciplinary team provides crucial elements in the in-depth
assessment of patient and caregiver needs and communicates related findings and
instructions. However, it is the nurse who is most directly and consistently involved in
the patient-centered relationship and coordinates communication among the different
practitioners to organize the discharge plan.
Which of the following is true in regard to medication errors?

a. When administering high-alert drugs, nurses should routinely conduct

independent double checks before administration.
b. Most medication errors occur when a nurse neglects to follow the five rights of
medication administration.
c. Error reporting is a valuable tool for measuring a nurses medication competency.
d. Following a write-down/read-back procedure is optional for orders given orally or by
telephone.
Error reporting is a tool for evaluating weaknesses in the entire medication
administration process, not for assessing a nurses competence. The five rights refers
to: the right patient, the right drug, the right dose, the right route, and the right time.
The vast majority of errors are more complex and the result of system failures. Following
a write-down/read-back procedure is essential in preventing errors related to orders
given orally or by telephone. High-alert drugs are drugs that, when misused, can cause
serious injury or death. Because the consequences of misuse can be devastating, nurses
should routinely conduct independent double checks before administering these
medications: opioids, heparin and insulin.
Nursing strategies intended to address age-related respiratory changes include:
a. Use of incentive spirometry
b. Maintaining patent airways through upright positioning and repositioning
c. Maintain hydration and mobility
d. All of these answers
Supplemental oxygen and suctioning also assist with respiratory function.
Which of the following is/are age-related changes in the musculoskeletal system?
a. Increase in bone density
b. Increase in lean body mass
c. Sarcopenia
d. Thickening of ligaments and tendons
Sarcopenia refers to a decline in muscle mass and strength. Additional age-related
changes include decreased ligament and tendon strength, reduced bone density,
intervertebral disc degeneration, articular cartilage erosion, changes in stature with
kyphosis and height reduction.