1.
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The FANCAPES assessment tool focuses on the older adult’s:
Correct Answer
A. A. ability to meet personal needs to identify the amount of assistance needed
Explanation
ANS: A
The FANCAPES assessment tool focuses on physical functioning and evaluates the individual’s ability to meet his or her needs and how much assistance is needed to meet the needs. FANCAPES evaluates physical functioning. IADLs involve more than just physical functioning. FANCAPES does not assess cognitive function, nor does it assess dementia.
2.
A limitation of the Katz index of activities of daily living (ADLs) is that:
Correct Answer
B. B. all ADLs are weighted equally, and the cutoff score is arbitrarily determined
Explanation
ANS: B
The Katz index assigns an equal weight to all of the ADLs. The determination of a cutoff score is completely arbitrary. It is commonly accepted that a score of 4 indicates moderate impairment and a score of 2 or less indicates severe impairment. Any health care professional can complete the Katz index, although input from the interdisciplinary team is valuable. The Katz index does not address the cognitive abilities necessary to perform ADLs. It is not a self-report instrument; it is completed by the health care professional.
3.
A 78-year-old man is being evaluated in the geriatric clinic. His daughter reports that he has been very forgetful lately, and she is concerned that he might be “senile.” The advanced practice nurse administers the clock drawing test and the patient draws a distorted circular shape and places the numbers all on one side of the shape. Based on his performance, the nurse concludes that the patient:
Correct Answer
B. B. needs further evaluation
Explanation
ANS: B
Errors on the clock drawing test, such as grossly distorted contour, are rarely produced by cognitively intact persons. A low score on the clock drawing test requires further evaluation. Alzheimer’s disease is not a diagnosis using a mental status assessment tool. It is definitively diagnosed with a brain biopsy. The clock drawing test does not assess for delirium. A low score on the clock drawing test does not necessarily warrant a functional status assessment
4.
What is true about instruments to assess for depression in older adults?
Correct Answer
B. B. The shortened Geriatric Depression Scale does not contain a question to evaluate suicide potential.
Explanation
ANS: B
The 15 and 5 item Geriatric Depression Scales do not include an assessment item focused on the suicidal intent or thoughts. Older adults tend to score inaccurately high (indicating more depression) than younger adults because of the number of physical complaints that are associated with aging and because of the number of frequently used medications rather than because of true depression. The Beck Depression Inventory was not designed specifically for use with gerontological patients. The Geriatric Depression Scale is administered as a self-report by the older adult.
5.
An 88-year-old, being admitted to rule out lung cancer, is assessed using the short form of the Geriatric Depression Scale tool. When it is determines that the earned score is 9, the nurse initially:
Correct Answer
A. A. asks if they have any thoughts of committing suicide
Explanation
ANS: A
The shortened version of this assessment tool does not specifically address the presence of suicidal ideations. With a score of 9, which generally indicates depression, this limitation of the tool must be addressed with a specific question. It is not to be considered usual for an older to score such a high score. The heath care provider needs to be made aware of the results of the assessment but the focused question regarding suicide should be asked first.
6.
When comparing the Older American’s Resources and Services (OARS) with the Katz index of ADLs, what is true?
Correct Answer
B. B. the OARS is a comprehensive assessment tool that measures ability in five areas; the Katz index measures only ADL performance
Explanation
ANS: B
The OARS evaluates ability, disability, and capacity at which the person is able to function. Five dimensions are assessed: social resources, economic resources, physical health, mental health, and ADLs. The Katz index only evaluates ADL ability. Both instruments are used in a variety of care settings and are valid for use with cognitively impaired older adults.
7.
When using the Fulmer SPICES assessment tool the nurse expects to ask:
Correct Answer
D. D. “Who helps you when you can’t do something by yourself?”
Explanation
ANS: D
The Fulmer SPICES assess six syndromes that are common to older adults and require nursing intervention. The syndromes are sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown. Social support is not assessed with this tool.
8.
A nurse shows an understanding of the appropriate administration of a Mini-Cog assessment tool when: Select all that apply.
Correct Answer(s)
A. A. Informing the client that, “I’m going to say three (3) words; cat, coffee, and smile.”
C. C. Asking the client, “Can you repeat the words we talked about a little while ago?”
D. D. Explaining to the client that, “I’d like you to draw a clock for me on this paper.”
Explanation
ANS: A, C, D
The Mini-Cog assessment tool requires that the client be introduced to three unrelated words and then immediately asked to repeat them; draw a clock; again repeat the original 3 words. Questions concerning memory loss or the ability to recognize time on a clock are not a part of this assessment process.