Case Study Age Related Risks

Open Exit Meet the Client An older adult with a history of type 2 diabetes mellitus. The client schedules a visit with the healthcare provider (HPC) because they developed a non-healing ulcer on their right heel. After several weeks of home remedies, the client decides they need to see the HCP. Upon arrival at the clinic, the client's vital signs are taken and a physical assessment completed. The HCP discusses the diagnosis with the client and explains that it is necessary to admit the client to the inpatient medical-surgical unit immediately to treat the heel ulcer. Important to Know 1. Your first answer is the one that counts towards your score, but you’ll be prompted to try again if you get the wrong answer. When you get the right answer, you’ll go to the next section. 2. If you choose to re-take a Case Study, you will no longer be able to see your previous score. Previous Section Open Exit Section 1 Diabetes The client was diagnosed last year with type 2 diabetes mellitus. They explain that they are experienced with self-administration of insulin injections three times per day. They state that their eating habits are not great, but they never miss their insulin injections. The client lives alone and doesn’t like to eat alone, so rarely cooks. The client explains that other than an occasional walk, they do not exercise. Question 1 of 32 With the understanding that the client's eating habits lack consistency, which physiological facts about the client’s nutrition are most concerning to the nurse? (Select all that apply.) The stage II non-healing ulcer on the client’s right heel could require amputation. The development of hypoglycemia could be life-threatening. Lack of exercise and activity require less nutritional nutrients. Dehydration exacerbated by lack of nutrition. Lack of appetite and not wanting to eat alone could lead to malnutrition. Submit The nurse performs a focused assessment, checks the client's blood glucose with a glucometer, then administers the prescribed dose of insulin during morning medication administration rounds. Question 2 of 32 Which information about the client is of most concern to the nurse? Blood glucose rises from 120 mg/dL (6.66 mmol/L) to 125 mg/dL (6.94 mmol/L) in 8 hours. Washes hands with soap and water and allows alcohol swab wipe to dry before performing chemstick. Reports a new onset of blurry vision. Depends on handwritten notes to recall his last blood glucose reading. Submit Previous Section Open Exit Section 2 The nurse reports the client's blurry vision to his HCP, who then evaluates and treats the client for worsening diabetic retinopathy. Question 3 of 32 Which other symptoms should the nurse expect to find in a client with a diagnosis of diabetic retinopathy? (Select all that apply.) Reports of floaters. Loss of vision. Jaundice of the sclera. Difficulty with color perception. Pupil fixation. Submit During the client’s hospital stay, the HCP prescribes an insulin pen to replace the client's insulin syringes and insulin vials. The client is taught by the nurse to dial the pen to the prescribed amount and to use a magnifying glass to ensure that the amount of insulin is correct with each injection. The nurse ensures that the two insulin pens are clearly marked as glargine or lispro so the client can identify them easily. Question 4 of 32 The nurse understands that which information is correct regarding the prescribed insulin? Glargine is rapid-acting insulin typically administered 15 minutes before meals. Lispro is intermediate-acting insulin that peaks in 4 to 10 hours. Glargine does not have a peak interval. Lispro is typically given at bedtime on an empty stomach. Submit Previous Section Open Exit Section 3 The nurse making rounds finds the client unresponsive. The client's vital signs are temperature 100.4° F (38.0° C), heart rate (apical) 135 beats/minute, blood pressure 92/60 mmHg. The client's chemstick reading is high. Question 5 of 32 What conditions, other than hyperglycemia, might the client have? (Select all that apply.) Hypernatremia. Hypervolemia. Ketonuria. Osmotic diuresis. Glycosuria. Submit Based on the information gathered during the nurse’s assessment, the HCP prescribes low doses of regular insulin by continuous IV infusion. Question 6 of 32 In addition to the insulin, which of the following immediate measures would be indicated in the treatment of the client? (Select all that apply.) Prednisone. Epinephrine. Potassium supplements. Sodium bicarbonate. Sodium chloride 0.9%. Submit The HCP writes a prescription to follow hospital protocol for an insulin drip to begin for the client, who currently weighs 226 lbs (102.7 kg) and whose blood glucose level is 312 mg/dL (17.32 mmol/L). Per hospital protocol, the blood glucose is monitored hourly for titration of the insulin infusion. The pharmacy sends a pre-mixed insulin drip with 100 units of regular insulin in 100 mL of sodium chloride 0.9%. Insulin Infusion Protocol Blood Glucose (BG) Units/hr 110 to 119 mg/dL (5.55 to 6.60 mmol/L) 0.5 120 to 149 mg/dL (6.66 to 8.27 mmol/L) 1 150 to 179 mg/dL (8.32 to 9.93 mmol/L) 1.5 180 to 209 mg/dL (9.99 to 11.60 mmol/L) 2 210 to 239 mg/dL (11.65 to 13.26 mmol/L) 2 240 to 269 mg/dL (13.32 to 14.93 mmol/L) 3 270 to 299 mg/dL (14.98 to 16.59 mmol/L) 3 300 to 329 mg/dL (16.65 to 18.26 mmol/L) 4 330 to 359 mg/dL (18.32 to 19.92 mmol/L) 5 Question 7 of 32 Fill in the blankThe nurse sets the insulin drip to deliver how many mL/hr? (Enter numeric value only. If rounding is necessary, round to the whole number.) 4 Submit Previous Section Open Exit Section 4 The client is placed on an EKG monitor because of a concern about hypokalemia. Question 8 of 32 Which pattern should the nurse report immediately to the HCP? ST depression and “U” waves. After insulin therapy, hypokalemia is expected because the potassium shifts back into the cell. Hypokalemia is a serum potassium level less than 3.5 mEq/L and can be life threatening. Flat or inverted T waves or increased “U” waves can occur with hypokalemia. Sinus tachycardia. This EKG pattern is not life threatening, but would still need to be addressed if it continues. Sinus bradycardia. The EKG changes in hyperkalemia (not hypokalemia) are bradycardia. Sinus arrhythmia. The EKG pattern is not life threatening, but can be addressed if it continues. Submit The HCP prescribes arterial blood gases to be drawn as well as serum electrolytes. Question 9 of 32 Which lab value needs to be reported immediately? Serum creatinine 1.2 mg/dL (91.5 mcmol/L). Serum creatinine 0.6 to 1.3 mg/dL (45.75 to 99.13 mcmol/L) is a normal lab value. Arterial pH 7.05. An arterial pH below 7.35 indicates an abnormal blood gas and indicates a shift to an acidotic state. This is an emergency situation. Negative ketones. Negative ketones is a normal lab value. Serum osmolality 285 mOsom/kg (285 mmol/kg). The normal range for serum osmolality is 275 to 295 mOsm/kg (275 to 295 mmol/kg) and is determined by Na+ and its anions Cl- and HCO3. Submit Previous Section Open Exit Section 5 Neuropathies The nurse formulates the client's plan of care and notes that teaching should be initiated related to the client's diabetic peripheral neuropathy. Question 10 of 32 The nurse understands that which symptoms are associated with diabetic peripheral neuropathy? (Select all that apply.) Reduced ability to feel pain or temperature in the extremities. Peripheral neuropathy is the most common form of diabetic neuropathy affecting the ends of the nerves in the feet and legs first, followed by neuropathy affecting the hands and arms in a stocking- like pattern. Frequent UTIs or incontinence. This is a type of diabetic autonomic neuropathy that can affect nearly all body systems; it is a condition in which the nerves of the autonomic system are impaired. Muscle weakness and difficulty walking. These symptoms are associated with motor neuropathy, a type of peripheral neuropathy, which can cause damage to the nerves that control muscles and movement in the body, such as moving your hands and arms or talking. Problems with erectile dysfunction. This is a type of diabetic autonomic neuropathy, a condition in which the nerves of nearly all body systems (autonomic system) are impaired. Extreme sensitivity to touch. Peripheral neuropathy is the most common form of diabetic neuropathy affecting the ends of the nerves in the feet and legs first, followed by neuropathy affecting the hands and arms. Submit The client tells the nurse that they likes to take warm baths because it helps their joints feel better. The nurse is concerned that peripheral neuropathy may cause them to unintentionally burn themself when they are discharged to the assisted living facility. Question 11 of 32 Which instruction related to bath safety is best? Use toes or elbow to make sure that the water is not too hot. Let hot bathwater sit for 10 minutes before entering the bath. Use equal amounts of hot and cold water when preparing the bath. Use a bath thermometer to ensure that the temperature is below 102° F (38.8° C). Submit Before the client's bath, the nurse examines their right heel and documents a stage II non-healing ulcer. A dressing change is prescribed. Question 12 of 32 Prior to changing the dressing on the client’s right heel ulcer, the nurse should first take which actions? Inspect the feet carefully for temperature, sensation, and drainage. Elevate the affected foot. Avoid weight-bearing activities. Administer broad-spectrum antibiotics. Submit Previous Section Open Exit Section 6 The nurse developes a plan of care to prevent the client's feet from further skin breakdown. Question 13 of 32 Which actions will help to maintain skin integrity? (Select all that apply.) Use heel protectors. Use special mattress or foot cradles. Apply drying agents, such as alcohol, to the skin. Apply skin moisturizers to prevent cracking. Instruct the client to wear clean white socks. Submit The nurse notes that the client takes PO gabapentin every day when he is at home to treat his peripheral neuropathy. Question 14 of 32 It is most important for the client to report which potential adverse or side effect associated with gabapentin? Restlessness. Tarry stool. Dry mouth. Flatulence. Submit The nurse reviews potential adverse and side effects of gabapentin with the client, who denies experiencing them at the present time. Previous Section Open Exit Section 7 Urinary Elimination The nurse asks the client a series of questions related to their urinary and bowel elimination patterns. Question 15 of 32 Which response by the client is of most concern to the nurse? “I usually have to get up during the night at least once to urinate.” “It takes me longer to urinate than it did when I was younger.” “My urine had a foul smell this morning.” “My urine is yellow and pale in color.” Submit The nurse asks the client additional questions related to their urinary symptoms. They report mild pain with urination and their temperature is 98° F (36.7° C). The nurse reports the foul smelling urine to the HCP who prescribes a random dipstick urinalysis test. Question 16 of 32 The nurse should instruct the client to take which action first when collecting a urine sample? Collect 1 or 2 ounces of urine. Wipe the genital area clean. Dry any excess urine from the outer specimen cup. Hold the cup a few inches from the urethra. Submit Question 17 of 32 Which results of the dipstick urinalysis does the nurse recognize as abnormal? (Select all that apply.) +1 Ketones. pH 5.0. Absence of glucose. Scant sediment. Trace leucocytes. Submit Previous Section Open Exit Section 8 The nurse reports the abnormal findings to the HCP, who orders a urinalysis and urine for culture and sensitivity. The nurse obtains a clean catch specimen and sends it to the lab for analysis. The lab report states that there is greater than 100,000 E. coli bacteria, and the client is diagnosed with a UTI. The HCP prescribes an oral antibiotic to treat the UTI. Question 18 of 32 Fill in the blankThe pharmacist delivers the client's dose of ampicillin in a 100 mL bag of sodium chloride 0.9%. In order to deliver the medication over 30 minutes, the nurse sets the pump to deliver how many mL/hr? (Enter numeric value only. If rounding is necessary, round to the whole number.) 200 Submit The client is prescribed ampicillin one gram every six hours for his urinary tract infection. The client develops a maculopapular rash on their torso. The nurse notifies the HCP and the ampicillin is discontinued. Question 19 of 32 Which antimicrobial medications are safe alternatives for clients with penicillin allergies? (Select all that apply.) Vancomycin. Cephalexin. Clindamycin. Ticarcillin. Erythromycin. Submit Previous Section Open Exit Section 9 The nurse is carefully monitoring the client's laboratory values. Question 20 of 32 Which results can affect drug distribution and influence drug-to-drug interactions? Elevated BUN. Low serum albumin levels. Reduced glomerular filtration rate. Elevated creatinine levels. Submit Question 21 of 32 The nurse considers which pharmacological age-related principles when administering medications or monitoring the effects of medications in the elderly client? (Select all that apply.) Gastric pH is often decreased in the elderly. Decreased cardiac output increases the risk for adverse drug reactions. Mucosal edema can increase the absorption of drugs. Drugs administered intravenously have a faster absorption rate than oral drugs. Dehydration can decrease the half-life of drugs. Submit Previous Section Open Exit Section 10 Dehydration The nurse suspects that the client is dehydrated and encourages them to increase their oral intake of fluids, especially during their treatment for a UTI. Question 22 of 32 Along with clinical manifestations, which common laboratory findings indicate dehydration? (Select all that apply.) Elevated hemoglobin and hematocrit. Decreased BUN. Increased serum osmolarity. Increased urine specific gravity. Increased serum glucose. Submit Question 23 of 32 The nurse understands that which physiological age-related change is often responsible for dehydration in the elderly? Taste buds are more sensitive, leading to a decreased desire for liquids. Thirst decreases, contributing to less fluid intake. Increased glomerular filtration rate. Constriction of the esophagus prevents fluid metabolism. Submit The nurse understands that the elderly client should drink at least 30 mL/kg of fluid each day with a minimum of 1500 mL/day. They weigh 226 lbs (102.7 kg). Question 24 of 32 Fill in the blankHow many mL of fluid should the client drink per day? (Enter numeric value only. If rounding is necessary, round to the whole number.) 3081 Submit Previous Section Open Exit Section 11 Question 25 of 32 Fill in the blank When using an 8-ounce drinking glass, the client should drink how many glasses per day to ingest 3081 mL of fluid in 1 day? 13 (Enter numeric value only. If rounding is necessary, round to the whole number.) Submit In the older adult, the mechanism for thirst is impaired. The nurse assesses the client for common signs of extracellular fluid loss. Question 26 of 32 Which of the following objective signs indicate dehydration? (Select all that apply.) Hematuria. Increased urine output. High creatinine levels. Postural hypotension. Heart rate greater than 100 bpm. Submit The client completes their round of antibiotics. They report that their UTI symptoms have resolved, and follow-up urinalysis results are normal. Previous Section Open Exit Section 12 Nutrition The nurse creates a care plan for the client and records a nursing diagnosis for knowledge deficit related to signs and symptoms of hypoglycemia. Question 27 of 32 Which teaching points should be included in this plan of care? (Select all that apply.) Report a blood glucose reading of 70 mg/dL (3.89 mmol/L). Notify the HCP if there is headache or irritability. Report excessive hunger and/or weakness. Report cold and clammy skin. Notify the HCP of hot, dry skin. Submit The client lost 4 lbs (1.82 kg) in 1 month prior to their hospital admission. The nurse assesses them for signs of nutritional problems. Question 28 of 32 Which data is most important to report to the HCP? Dyspnea. Constipation. Heartburn. Pallor. Submit Question 29 of 32 The nurse understands that which concept is important when addressing the client’s physiological and psychosocial needs? Socialization is important, but community dining should be avoided because the timing is restrictive and could lead to adverse reactions of medications. The client’s need for a special diabetic meal plan overrides the benefits of community dining; therefore meals should be prepared in the apartment. The client’s diabetes mellitus should not present a problem for community dining. The nurses in the community dining center should take any food containing sugar away from clients who have diabetes mellitus. Submit Previous Section Open Exit Section 13 The nurse reports the findings to the HCP, who orders serum laboratory assessments. The nurse draws the client's blood and sends it to the laboratory. Question 30 of 32 Which laboratory finding is of most concern to the nurse? Potassium 3.9 mEq/L (3.9 mmol/L). Sodium 140 mEq/L (140 mmol/L). Phosphorous 4.1 mg/dL (1.32 mmol/L). Hemoglobin 11.2 g/dL (112 g/L). Submit The nurse notifies the HCP of the laboratory findings and the client is diagnosed with pernicious anemia. Question 31 of 32 The nurse anticipates that the client will receive which treatment for pernicious anemia? Iron supplements by mouth daily. Increase in vitamin C in the diet. Intramuscular injection of vitamin B-12. Prescription strength folic acid supplements. Submit Previous Section Open Exit Section 14 The nurse prepares to administer the first dose of vitamin B-12 via intramuscular injection. Question 32 of 32 Which technique is correct? Inject into the dorsogluteal site, the preferred injection site. Use of the dorsalgluteal site is not recommended because it has been associated with sciatic nerve and superior gluteal artery damage. Aspirate after injecting medication into the muscle. Aspiration should be performed prior to injecting the medication. Inject into the fatty tissue of the abdomen. This the technique used for a subcutaneous injection. Use a 1 to 1 ½ inch needle. For a male client who weighs 130 to 260 lbs (59 to 118 kg), a 1 to 1½ inch needle is recommended. Submit The client's pernicious anemia improves after treatment, and they are taught that they will most likely need this treatment for the rest of their life. Previous Section Open Exit Section 15 Case Outcome The nurse and other members of the client's healthcare team continue to care collaboratively for the client when they are discharged to the assisted living facility. They are given instructions to follow up on treatment and to watch for signs and symptoms of a re-occurrence of their UTI. The nurse completes discharge education about diabetes and instructs the client on the importance of diabetic control with well-balanced meals, frequent blood glucose checks, and selfadministration of insulin. The client is feeling better and appreciates all of the care that the nurses have provided in the management of his diabetic complications. Once discharged, the client is looking forward to an increased independence that the assisted living facility allows and to having better control of their diabetes. Previous Section