Advanced Assessment Interpreting Findings 3rd Edition Goolsby Grubbs- Test Bank

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Advanced Assessment Interpreting Findings 3rd Edition Goolsby Grubbs- Test Bank

Chapter 2. An Overview of Genetic Assessment

 

Multiple Choice

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

 

____       1.   The first step in the genomic assessment of a patient is obtaining information regarding:

A. Family history
B. Environmental exposures
C. Lifestyle and behaviors
D. Current medications

 

 

____       2.   An affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained is called a(n):

A. Consultand
B. Consulband
C. Index patient
D. Proband

 

 

____       3.   An autosomal dominant disorder involves the:

A. X chromosome
B. Y chromosome
C. Mitochondrial DNA
D. Non-sex chromosomes

 

 

____       4.   To illustrate a union between two second cousin family members in a pedigree, draw:

A. Arrows pointing to the male and female
B. Brackets around the male and female
C. Double horizontal lines between the male and female
D. Circles around the male and female

 

 

____       5.   To illustrate two family members in an adoptive relationship in a pedigree:

A. Arrows are drawn pointing to the male and female
B. Brackets are drawn around the male and female
C. Double horizontal lines are drawn between the male and female
D. Circles are drawn around the male and female

 

 

____       6.   When analyzing the pedigree for autosomal dominant disorders, it is common to see:

A. Several generations of affected members
B. Many consanguineous relationships
C. More members of the maternal lineage affected than paternal
D. More members of the paternal lineage affected than maternal

 

 

____       7.   In autosomal recessive (AR) disorders, individuals need:

A. Only one mutated gene on the sex chromosomes to acquire the disease
B. Only one mutated gene to acquire the disease
C. Two mutated genes to acquire the disease
D. Two mutated genes to become carriers

 

 

____       8.   In autosomal recessive disorders, carriers have:

A. Two mutated genes; one from each parent that cause disease
B. A mutation on a sex chromosome that causes a disease
C. A single gene mutation that causes the disease
D. One copy of a gene mutation but not the disease

 

 

____       9.   With an autosomal recessive disorder, it is important that parents understand that if they both carry a mutation, the following are the risks to each of their offspring (each pregnancy):

A. 50% chance that offspring will carry the disease
B. 10% chance of offspring affected by disease
C. 25% chance children will carry the disease
D. 10% chance children will be disease free

 

 

____     10.   A woman with an X-linked dominant disorder will:

A. Not be affected by the disorder herself
B. Transmit the disorder to 50 % of her offspring (male or female)
C. Not transmit the disorder to her daughters
D. Transmit the disorder to only her daughters

 

 

____     11.   In creating your female patient’s pedigree, you note that she and both of her sisters were affected by the same genetic disorder. Although neither of her parents had indications of the disorder, her paternal grandmother and her paternal grandmother’s two sisters were affected by the same condition. This pattern suggests:

A. Autosomal dominant disorder
B. Chromosomal disorder
C. Mitochondrial DNA disorder
D. X-linked dominant disorder

 

 

____     12.   A woman affected with an X-linked recessive disorder:

A. Has one X chromosome affected by the mutation
B. Will transmit the disorder to all of her children
C. Will transmit the disorder to all of her sons
D. Will not transmit the mutation to any of her daughters

 

 

____     13.   Which of the following are found in an individual with aneuploidy?

A. An abnormal number of chromosomes
B. An X-linked disorder
C. Select cells containing abnormal-appearing chromosomes
D. An autosomal recessive disorder

 

 

____     14.   The pedigree of a family with a mitochondrial DNA disorder is unique in that:

A. None of the female offspring will have the disease
B. All offspring from an affected female will have disease
C. None of the offspring of an affected female will have the disease
D. All the offspring from an affected male will have disease

 

 

____     15.   Which population is at highest risk for the occurrence of aneuploidy in offspring?

A. Mothers younger than 18
B. Fathers younger than 18
C. Mothers over age 35
D. Fathers over age 35

 

 

____     16.   Approximately what percentage of cancers is due to a single-gene mutation?

A. 50% to 70%
B. 30% to 40%
C. 20% to 25%
D. 5% to 10%

 

 

____     17.   According to the Genetic Information Nondiscrimination Act (GINA):

A. NPs should keep all genetic information of patients confidential
B. NPs must obtain informed consent prior to genetic testing of all patients
C. Employers cannot inquire about an employee’s genetic information
D. All of the above

 

 

____     18.   The leading causes of death in the United States are due to:

A. Multifactorial inheritance
B. Single gene mutations
C. X-linked disorders
D. Aneuploidy

 

 

____     19.   Which of the following would be considered a “red flag” that requires more investigation in a patient assessment?

A. Colon cancer in family member at age 70
B. Breast cancer in family member at age 75
C. Myocardial infarction in family member at age 35
D. All of the above

 

 

____     20.   When patients express variable forms of the same hereditary disorder, this is due to:

A. Penetrance
B. Aneuploidy
C. De novo mutation
D. Sporadic inheritance

 

 

____     21.   Your 2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as:

A. Variable expressivity related to inherited disease
B. Dysmorphic features related to genetic disease
C. De novo mutations of genetic disease
D. Different penetrant signs of genetic disease

 

 

____     22.   In order to provide a comprehensive genetic history of a patient, the NP should:

A. Ask patients to complete a family history worksheet
B. Seek out pathology reports related to the patient’s disorder
C. Interview family members regarding genetic disorders
D. All of the above

 

Chapter 2. An Overview of Genetic Assessment

Answer Section

 

MULTIPLE CHOICE

 

  1. ANS:   A

A critical first step in genomic assessment, including assessment of risk, is the use of family history. Family history is considered the first genetic screen (Berry & Shooner 2004) and is a critical component of care because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury 2003).

 

PTS:    1

 

  1. ANS:   D

A proband is defined as the affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained (Pagon et al. 1993–2013). The proband is the affected individual that brings the family to medical attention.

 

PTS:    1

 

  1. ANS:   D

Autosomal dominant (AD) inheritance is a result of a gene mutation in one of the 22 autosomes.

 

PTS:    1

 

  1. ANS:   C

A consanguineous family is related by descent from a common ancestry and is defined as a “union between two individuals who are related as second cousins or closer” (Hamamy 2012). Consanguinity, if present in the family history, is portrayed using two horizontal lines to establish the relationship between the male and female partners.

 

PTS:    1

 

  1. ANS:   B

For adopted members of the family, use brackets as the appropriate standardized pedigree symbol ([e.g., brackets]).

 

PTS:    1

 

  1. ANS:   A

Pedigrees associated with autosomal dominant (AD) disorders typically reveal multiple affected family members with the disease or syndrome. When analyzing the pedigree for AD disorders or syndromes, it is common to see a “vertical” pattern denoting several generations of affected members.

 

PTS:    1

 

  1. ANS:   C

In autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents. Autosomal recessive disorders must be inherited through both parents (Nussbaum et al. 2007). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease.

 

PTS:    1

 

  1. ANS:   D

Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutation is on an autosome.

 

PTS:    1

 

  1. ANS:   A

It is important that parents understand that if they both carry a mutation, the risk to each of their offspring (each pregnancy) is an independent event: 25% disease free, 25% affected, and 50% carrier.

 

PTS:    1

 

  1. ANS:   B

Everyone born with an X-linked dominant disorder will be affected with the disease. Transmission of the disorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female).

 

PTS:    1

 

  1. ANS:   D

A man with an X-linked dominant disorder will transmit the mutation to 100% of his daughters (they receive his X chromosome) and none of his sons (they receive his Y chromosome). The pedigree of a family with an X-linked dominant disorder would reveal all the daughters and none of the sons affected with the disorder if the father has an X-linked disorder.

 

PTS:    1

 

  1. ANS:   C

An X-linked recessive disorder means that in a woman, both X chromosomes must have the mutation if she is to be affected. Because males have only one copy of the X chromosome, they will be affected if their X chromosome carries the mutation.

 

PTS:    1

 

  1. ANS:   A

An individual with an abnormal number of chromosomes has a condition called aneuploidy, which is frequently associated with mental problems or physical problems or both (Jorde, Carey, & Bamshad 2010; Nussbaum et al. 2007).

 

PTS:    1

 

  1. ANS:   B

Mitochondrial DNA is inherited from the ovum and, therefore, from the mother. The pedigree of a family with a mitochondrial DNA disorder is unique in that all offspring (regardless of gender) of an affected female will have the disease, and none of the offspring from an affected male will have the disease.

 

PTS:    1

 

  1. ANS:   C

Some individuals or couples have unique identifiable risks that should be discussed prior to conception whenever possible. For example, women who will be 35 years of age or older at delivery (advanced maternal age) are at increased risk for aneuploidy.

 

PTS:    1

 

  1. ANS:   D

The majority of cancers are sporadic or multifactorial due to a combination of genetic and environmental factors; however, approximately 5% to 10% of all cancers are due to a single-gene mutation (Garber & Offit 2005).

 

PTS:    1

 

  1. ANS:   D

On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based upon their genetic information when it comes to health insurance and employment, paving the way for patient personalized genetic medicine without fear of discrimination (National Human Genome Research Institute 2012).

 

PTS:    1

 

  1. ANS:   A

Most disease-causing conditions are not due to a single-gene disorder but are due to multifactorial inheritance, a result of genomics and environmental or behavioral influences. In fact, the leading causes of mortality in the United States—heart disease, cerebrovascular disease, diabetes, and cancer—are all multifactorial. Most congenital malformation, hypertension, arthritis, asthma, obesity, epilepsy, Alzheimer’s, and mental health disorders are also multifactorial.

 

PTS:    1

 

  1. ANS:   C

Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders.

 

PTS:    1

 

  1. ANS:   A

Some disorders have a range of expression from mild to severe. This variability is referred to as the penetrance of genetic disease. For example, patients with neurofibromatosis (NF1), an AD disorder of the nervous system, may manifest with many forms of the disease. For instance, some patients with NF1 may have mild symptoms, like café-au-lait spots or freckling on the axillary or skin, while others may have life-threatening spinal cord tumors or malignancy (Jorde, Carey, & Bamshad 2010; Nussbaum et al. 2007).

 

PTS:    1

 

  1. ANS:   B

Assessing for dysmorphic features may enable identification of certain syndromes or genetic or chromosomal disorders (Jorde, Carey, & Bamshad 2010; Prichard & Korf 2008). Dysmorphology is defined as “the study of abnormal physical development” (Jorde, Carey, & Bamshad 2010, 302).

 

PTS:    1

 

  1. ANS:   D

Asking the patient to complete a family history worksheet prior to the appointment saves time in the visit while offering the patient an opportunity to contribute to the collection of an accurate family history. Reviewing the family information can also help establish family rapport while verifying medical conditions in individual family members. If a hereditary condition is being considered but family medical information is unclear or unknown, requesting medical records and pathology or autopsy reports may be warranted.

 

PTS:    1

Chapter 20. Older Patients

 

Multiple Choice

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

 

____       1.   Based on the 2010 Census of the United States, the fastest growing segment of the population is:

A. Adults aged 65 to 75
B. Adults aged 75 to 85
C. Adults aged 85 to 95
D. Adults aged 100+

 

 

____       2.   The order of the physical examination in the older patient should:

A. Begin with gait observation or transfer ability from wheelchair to exam table
B. Begin with activities that cause the least expenditure of energy
C. Be performed in a head-to-toe sequence
D. Be a focused physical examination limited to the patient symptoms

 

 

____       3.   A functional assessment is the most appropriate type of evaluation of well older patients. A basic component of the functional assessment is:

A. Activities of Daily Living (ADL) score
B. Instrumental Activities of Daily Living (IADL) score
C. 10-minute Screener for Geriatric Conditions
D. All of the above

 

 

____       4.   A preliminary, concise test to screen patients for dementia in primary care is the:

A. Mini-mental status exam (MMSE)
B. Mini-Cog Clock Drawing test
C. Geriatric Depression Scale
D. Physical Self-Maintenance Scale

 

 

____       5.   After a preliminary screen for dementia, a highly sensitive test that should be used to assess for cognitive impairment of the older patient is:

A. The Montreal Cognitive Assessment (MoCA)
B. Mini-mental status exam (MMSE)
C. Mini-Cog Clock Drawing test
D. Activities of Daily Living (ADL)

 

 

____       6.   The MMSE has been criticized because:

A. Patients who are being tested require education
B. It is not applicable for patients from varied cultures
C. It cannot differentiate between delirium, dementia, and depression in the older patient
D. All of the above

 

 

____       7.   The most common reason for functional decline in nursing home patients is:

A. Heart failure
B. Stroke
C. Urinary tract infection
D. Myocardial infarction

 

 

____       8.   One of the most common causes for cognitive impairment in older patients suffering from infection is:

A. Delirium
B. Depression
C. Dementia
D. Pseudodementia

 

 

____       9.   Which of the following is a preventable condition in sedentary hospitalized older adults?

A. Falls
B. Decubitus ulcer
C. Delirium
D. All of the above

 

 

____     10.   What are some tests of mobility to include in a physical examination of older adults?

A. Get up and go
B. Tinetti Evaluation
C. Fall toolkit
D. All of the above

 

 

____     11.   Prior to giving clearance for an older adult to take part in an exercise regimen, the ____ assessment tool should be used by the clinician.

A. Get up and go
B. Tinetti scale
C. PARmed-X
D. PAR-Q

 

 

____     12.   The rapid pace walk is a good screening test for driving ability of the elderly. The patient is timed to walk as swiftly as possible along a 10 foot path. A completion time of greater than____ indicates possible need for intervention.

A. 9 seconds
B. 8 seconds
C. 7 seconds
D. 6 seconds

 

 

____     13.   During examination of the eyes, dilation of the pupil is needed to check for:

A. Distance vision
B. Macular degeneration
C. Cataracts
D. Peripheral vision

 

 

____     14.   A get up and go test involves having the patient rise from a chair, walk 20 feet, turn and walk back to the examiner. This should be completed within____ seconds.

A. 10
B. 15
C. 20
D. 25

 

 

____     15.   The functional reach test is a good predictor of:

A. Susceptibility to fall
B. Complete range of motion
C. Dependence in ADLs
D. A & C

 

 

____     16.   Adults tend to lose 1 inch every ____ years after age 40.

A. 30
B. 25
C. 20
D. 15

 

 

____     17.   For measuring weight in patients in long-term care facilities:

A. Always use same scale
B. Record the patient’s clothing
C. Calculate the body mass index (BMI)
D. All the above

 

 

____     18.   A BMI of less than ____ is an indicator of high risk for malnutrition.

A. 21
B. 22
C. 23
D. 24

 

 

____     19.   A total weight of less than ____ pounds is an indicator for high risk for malnutrition.

A. 120
B. 115
C. 110
D. 100

 

 

____     20.   Useful laboratory measures that indicate protein–energy malnutrition in hospitalized elders include a serum albumin level below____.

A. 3.4 g/dl
B. 4.2 g/dl
C. 5.2 g/dl
D. 6.4 g/dl

 

 

____     21.   A useful laboratory measure that indicates protein-energy malnutrition in hospitalized elders include a total cholesterol below____.

A. 190 mg/dl
B. 180 mg/dl
C. 170 mg/dl
D. 160 mg/dl

 

 

____     22.   Obesity defined as a BMI greater than ____ is an independent risk factor for functional decline in the elderly patient.

A. 20
B. 24
C. 30
D. 35

 

 

____     23.   The best indicator of fluid status in the elderly is____.

A. Patient thirst
B. Patient weight
C. BUN/creatinine ratio
D. Serum creatinine

 

 

____     24.   Which of the following is regarded as a “quality of care” indicator?

A. Frequent episodes of dehydration
B. Pattern of weight loss
C. Chronic constipation
D. Repeat urinary tract infections

 

 

____     25.   Which of the following statements is true?

A. Women have a higher prevalence of functional decline than men at the upper end of BMI
B. Men have a higher prevalence of functional decline than women at the upper end of BMI
C. To be sure the elderly patient’s fluid needs are met, the clinician should rely on the patient’s thirst
D. The “get up and go” test is a more accurate assessment of gait and balance than the Tinetti Mobility Scale.

 

Chapter 20. Older Patients

Answer Section

 

MULTIPLE CHOICE

 

  1. ANS:   D

According to 2010 United States census data, the number of older adults, aged 65 and over, increased by 15.3% from 2000 to a total of 40.4 million (13.1% of the total United States population); it is estimated that number will increase to about 55 million by 2020 (Administration on Aging, 2011). The fastest growing group among older adults since the 1990 census are those over 100 years of age, increasing by 53% to a total of 53,364 in 2010 (National Center for Health Statistics, 2013). Most of these centenarians are considered to be among the most vulnerable to frailty and disability, which, coupled with the likelihood that they will live alone and, therefore, require support services, such as nursing home care, has caused dire predictions about the failure of the Medicare and Medicaid systems.

 

PTS:    1

 

  1. ANS:   B

The approach to the physical examination of older adults will not differ greatly from standard examination techniques presented in this text. Some tests of functional ability are not routinely considered in the usual examination of the adult; those are presented in the various sections that follow. With older adults who are debilitated, it is important to focus the examination and reduce extraneous activities and distractions. Whenever possible, begin the examination with maneuvers that can be accomplished with the patient in his or her current position. For example, when the patient arrives to the examination seated in a wheelchair, check vital signs, heart rate, extremities, or anything else that can be done in the seated position first. If a patient’s ability to transfer from the wheelchair is in question, observe the transfer before the patient becomes fatigued. The exertion of getting on the examination table could fatigue an individual enough to preclude optimal performance. Likewise, perform all supine or standing examinations together to preserve the patient’s stamina. A reordering of the sequence of the examination should be done in a logical and thoughtful manner.

 

PTS:    1

 

  1. ANS:   D

For the well elderly, the 10-Minute Screener for Geriatric Conditions is a useful tool for general practice (Bluestein & Rutledge 2006). This brief screening tool (Table 20.2) addresses vision, hearing, leg mobility, urinary incontinence, nutrition and weight loss, memory, depression, and physical disability. Using a combination of subjective and objective measures, the 10-Minute Screener covers all the basic ADL and IADL functions in a manner that fits well within the outpatient examination. A positive screen requires further evaluation, in some cases by a specialist or a geriatric specialist.

 

PTS:    1

 

  1. ANS:   B

See Box 20.2, Box 20.3, Box 20.4 and Table 20.2, Table 20.3.

 

PTS:    1

 

  1. ANS:   A

One instrument that holds promise for rapid screening in primary care is the Mini-Cog (Box 20.4); it takes 2 to 4 minutes to administer, has good sensitivity (76% to 99%) and specificity (89% to 96%), and has been validated in primary care (Harvan & Cotter 2006). A positive screen on the Mini-Cog requires a more thorough evaluation. The Montreal Cognitive Assessment (MoCA) is the most sensitive instrument for detecting mild cognitive impairment; the MoCA website contains detailed instructions and normative data for the test in 35 languages (www.mocatest.org).

 

PTS:    1

 

  1. ANS:   D

The most commonly used and widely tested instrument (USPSTF 2003) for the next step in the evaluation of cognitive function, which measures more than just short- and long-term memory, is the Mini-Mental State Examination (MMSE). Domains measured by the MMSE include orientation to time and place, registration, attention and calculation, recall, naming, repetition, comprehension, reading, writing, and drawing. Testing with the MMSE takes approximately 10 minutes, and it must be administered in a standard manner to obtain valid results. The total possible score is 30 points; however, scores are highly correlated with age and educational level of the individual (Ashla 2000; Harvan & Cotter 2006). Scores on the MMSE will not differentiate between delirium and dementia, although both conditions will cause scores below the cutoff of 24 (Francis, 2000). Comprehensive information on the development, reliability and validity testing, and scoring of the MMSE can be found online (www4.parinc.com). The MMSE is available for purchase only to qualified health-care professionals through Psychological Assessment Resources. A description of the qualifications for purchase can be found at www4.parinc.com.

 

PTS:    1

 

  1. ANS:   C

Clinical practice guidelines suggest that in 77% of episodes of functional decline in long-term care residents, infection is the cause, and the most frequent site of such infection is the urinary tract (55%).

 

PTS:    1

 

  1. ANS:   A

Delirium is a reversible condition frequently caused by infection (Table 20.4). After treatment of infection, delirium is usually resolved.

 

PTS:    1

 

  1. ANS:   A

Many of the geriatric syndromes are adverse events that occur as a result of immobility and hospitalization or inappropriate prescribing of medications; such syndromes require systems interventions to improve or change outcomes. Among these syndromes are four—falls, delirium, pressure ulcers, and underfeeding—that have been labeled as “medical errors” because they are largely preventable in hospitalized elders (Tsilimingras, Rosen, & Berlowitz 2003). It is important that nurse practitioners have a basic understanding of the risk factors, causes, and clinical presentations of geriatric syndromes and routinely assess for factors that may be amenable to intervention beyond the medical issues. Prevention is particularly important in managing geriatric syndromes both in the hospitalized and in the community-residing elder.

 

PTS:    1

 

  1. ANS:   D

The get-up-and-go test is a simple screening measure that takes only minutes and can be conducted by trained staff. Instruct the patient to stand up from a seated position without using his or her arms or the chair arms for support, walk a few feet away, turn around and return to the chair, and sit down again without using any support. If the examiner observes any instability or difficulty with this test, further evaluation of gait and balance is required. Using the example of falls again, a home safety evaluation that includes questions about lighting, clutter on floors, footwear, bathroom configuration, stairways, sidewalks, and the availability of help in the case of a fall can focus attention on areas where safety can be improved to prevent falls. A useful tool that can be completed by patients or their families is available online in the Falls Toolkit (www.gericareonline.net/tools/eng/falls) from the Practicing Physicians Education in Geriatrics (2006). In the case of patients who have fallen frequently, a home visit by a nurse or physical therapist is very helpful to determine what risk factors are modifiable.

 

PTS:    1

 

  1. ANS:   C

Older adults are increasingly turning to exercise for socialization and fitness, and this trend should be supported. The question always arises: How much screening and assessment should be conducted prior to initiating an exercise program? The Canadian Society for Exercise Physiology has developed a useful evidence-based, seven-question screening tool, the Physical Activity Readiness Questionnaire (PAR-Q) for screening adults up to age 69 (2002). The recommendation for those over age 69 who are not accustomed to being active is to consult with a health-care provider prior to initiating a formal exercise program. The questions on the PAR-Q require a yes or no response; any response of yes requires further screening by a health-care provider. There is a companion form, the PARmed-X, for the clinician to complete prior to the individual beginning a formal exercise program. The PARmed-X includes a clearance as well as suggestions for special prescriptions for conditions such as chronic obstructive pulmonary disease. There are relatively few absolute contraindications to exercise listed on the PARmed-X; they include acute infectious processes, dissecting aortic aneurysm, severe aortic stenosis, active or recent myocarditis, acute myocardial infarction or heart failure, and acute thrombotic or embolic processes. Once any acute illness is resolved, the adult should be rescreened and allowed to exercise to tolerance.

 

PTS:    1

 

  1. ANS:   A

The rapid pace walk is specifically suggested (AMA, 2010) as a good predictor of driving safety. The client is timed walking as swiftly as possible along a 10-foot path marked on the floor both away from and toward the examiner. A cane can be used, but this should be noted on the chart. A completion time of greater than 9 seconds indicates a possible need for intervention.

 

PTS:    1

 

  1. ANS:   B

An examination of the eyes should always include measuring ocular pressure to rule out glaucoma, which is a serious cause of blindness and is more common with aging; screening for close and distance vision, particularly when there are questions related to driving or medication-taking ability; dilating the pupil to examine the retina for macular degeneration, a common cause of blindness in the elderly; and screening for cataracts, also increasingly common with age. Referral to an optometrist or an ophthalmologist is ideal and may be covered by Medicare and other insurance, depending on the diagnosis.

 

PTS:    1

 

  1. ANS:   B

The timed get-up-and-go test should be administered to all clients who have experienced a fall or who report difficulty with strenuous activities, such as fast walking, heavy housework, shopping, or climbing stairs. It is easy to perform and takes very little additional time during the examination. Place a chair in an unobstructed location and instruct client to rise from the seated position, walk 20 feet, turn, walk back to the chair, and sit down. Time this activity with a stopwatch. In populations that cannot complete the task in 15 seconds or less, research has shown a strong correlation (0.6–0.8) with other measures of gait and balance (Gerety 2000).

 

PTS:    1

 

  1. ANS:   D

The functional reach test is another useful test for upper extremity function that correlates well with an increased risk for falls and dependence (Behrman et al. 2002). Give the client the following instructions: Stand with your feet hip-width apart and your right (dominant) side next to, but not touching, a wall. Extend your right arm (or whichever is closest to the wall) parallel to the floor at shoulder height with your fingers extended. Now reach forward as far as you can, bending at the waist, but do not lift your heels off the floor. The examiner measures the distance in centimeters from the back of the shoulder to the tip of the middle finger in the “normal reach” position and again in the “forward reach” position. Differences greater than 25 cm are a significant predictor of falls and increased dependence in ADLs and IADLs.

 

PTS:    1

 

  1. ANS:   C

One of the key factors in tracking malnutrition is measuring and recording clients’ heights and weights. Most adults overestimate their height and underestimate their weight on self-report; height is a particular problem because adults tend to lose 1 inch of height every 20 years after age 35 to 40. Measurement of standing height is difficult if there is any degree of kyphosis (underestimates the actual height).

 

PTS:    1

 

  1. ANS:   D

Obtain an accurate weight, and make sure the scale is calibrated. For residents of long-term care facilities, always use the same scale for the same patient and, if there is a change in scale, make sure to note that beside the weight. Document what the patient is wearing, and always weigh in that same state. Significant weight loss is a quality indicator measure, and a pattern of weight loss in any facility will trigger an investigation by state and federal regulatory agencies. Ask the patient’s usual body weight if possible. Calculate ideal body weight using the same formula as for any other population. Once you have obtained an accurate height and weight, calculate the body mass index (BMI).

 

PTS:    1

 

  1. ANS:   A

A BMI of less than 21 or a total body weight of less than 100 pounds is an indicator of a high risk for protein-energy malnutrition.

 

PTS:    1

 

  1. ANS:   D

Once you have obtained an accurate height and weight, calculate the body mass index (BMI). For amputees, add the following percentages of the weight obtained on the scale prior to calculating the BMI: below knee 6%, at knee 9%, above knee 15%, arm 6.5%,  and arm below elbow 3.6%. The formula for calculating BMI is the same for the elderly as for any other population. A BMI of less than 21 or a total body weight of less than 100 pounds is an indicator of a high risk for protein-energy malnutrition.

 

PTS:    1

 

  1. ANS:   A

Useful laboratory measures that indicate protein-energy malnutrition or potentially poor outcomes in hospitalized elders include a serum albumin level below 3.4 g/dL and total cholesterol below 160 mg/dL.

 

PTS:    1

 

  1. ANS:   D

Useful laboratory measures that indicate protein-energy malnutrition or potentially poor outcomes in hospitalized elders include a serum albumin level below 3.4 g/dL and total cholesterol below 160 mg/dL.

 

PTS:    1

 

  1. ANS:   C

Although a lot of attention is devoted to undernutrition, obesity, defined as a BMI of greater than 30, or 20% greater than ideal body weight, is also an independent risk factor for functional decline in the elderly. Women have a higher prevalence of functional decline than men at the upper end of the BMI categories (three times greater risk at a BMI of greater than 35), independent of the usual factors, such as depression and polypharmacy (Jensen & Friedmann 2002).

 

PTS:    1

 

  1. ANS:   C

Dehydration is common in the elderly and has serious consequences. The average fluid intake for community-dwelling elderly persons is less than 1,000 mL per day. Thirst is not a reliable indicator of the need for fluids, and most elderly individuals need reminders to drink fluids. The best method for monitoring hydration status is with the blood urea nitrogen/creatinine ratio; anything greater than 20:1 is highly suggestive of dehydration.

 

PTS:    1

 

  1. ANS:   B

Obtain an accurate weight, and make sure the scale is calibrated. For residents of long-term care facilities, always use the same scale for the same patient and, if there is a change in scale, make sure to note that beside the weight. Document what the patient is wearing, and always weigh in that same state. Significant weight loss is a quality indicator measure, and a pattern of weight loss in any facility will trigger an investigation by state and federal regulatory agencies. Ask the patient’s usual body weight if possible. Calculate ideal body weight using the same formula as for any other population.

 

PTS:    1

 

  1. ANS:   A

Women have a higher prevalence of functional decline than men at the upper end of the BMI categories (three times greater risk at a BMI of greater than 35), independent of the usual factors, such as depression and polypharmacy (Jensen & Friedmann 2002).

Dehydration is common in the elderly and has serious consequences. The average fluid intake for community-dwelling elderly persons is less than 1,000 mL per day. Thirst is not a reliable indicator of the need for fluids, and most elderly individuals need reminders to drink fluids. The best method for monitoring hydration status is with the blood urea nitrogen/creatinine ratio; anything greater than 20:1 is highly suggestive of dehydration.

The Tinetti Performance-Oriented Mobility Assessment (POMA) scale is a more sensitive and specific test of gait, balance, and mobility (Box 20.9). The gait and mobility components of the POMA include opportunities to evaluate the initiation of gait, adequacy of step length and height, step and path symmetry and continuity, and ability to turn and pick up speed. Balance is tested by observing immediate standing balance; balance during tandem, one-leg, heel, and toe standing; and a nudge to the sternum or tug from behind. The POMA is sensitive and reproducible and can be used to measure improvement over time; thus, it is often used in clinical trials of exercise interventions.

 

PTS:    1

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