Eliopoulos - CH 29- Living in Harmony with Chronic Conditions

1. A nurse is well aware of the high incidence and prevalence of chronic conditions among older adults. The nurse would recognize which of the following phenomena as currently contributing to this high rate of incidence? (Select all that apply.)

A) Longevity is increasing.

B) Many previously fatal diseases are now treatable.

C) Increasing numbers of older adults can afford medical care.

D) Older adults have increased expectations for treatment.

E) New chronic conditions are being identified by medical researchers.

Ans: A, B

Feedback:

The combination of increased lifespan with the availability of treatment options for previously fatal conditions has contributed to the increased incidence of chronic conditions in the elderly. Answers C, D, and E are not noted to contribute to the phenomenon.

2. A nurse planning a health workshop for senior citizens wants to provide discussion topics that will interest everyone. In a typical group of seniors, which disorder will afflict the greatest number?

A) Hypertension

B) Hearing impairment

C) Heart condition

D) Arthritis

Ans: D

Feedback:

All these disorders are common in elderly people, but arthritis will afflict almost half of them. More than one-third will have hypertension, nearly one-third will have a hearing impairment, and more than one-fourth will have a heart condition. These are the "top four" conditions a nurse in this situation would want to present to the group.

3. Mr. W has recently been diagnosed with rheumatoid arthritis, a chronic condition that is having a significant impact on his daily routines and his quality of life. Which one of the nurse's following statements best reflects recognition of the importance of healing rather than curing Mr. W's condition?

A) "A combination of physical therapy and corticosteroid treatment holds a strong chance of mitigating the effects of your arthritis."

B) "The best way for us to foster your overall well-being is to eliminate the symptoms that are most affecting your daily routines."

C) "There are changes that I can help you make that can help you live a full life in spite of this health problem."

D) "There are lifestyle changes, coupled with promising new therapies, that hold out hope for being free from this problem."

Ans: C

Feedback:

Answer C best reflects a focus on living a satisfying life in spite of the presence of the chronic condition. The other answers prioritize treatment aimed at eliminating the chronic condition itself.

4. Which of the following statements about the goals for persons with chronic illnesses are appropriate? (Select all that apply.)

A) Chronic illnesses can be cured with proper and persistent treatment.

B) Healing requires the mobilization of the body, mind, and spirit.

C) Appropriate care measures focus on helping patients live in harmony with chronic disease.

D) Controlling symptoms, promoting a sense of well-being, and enhancing the quality of life are appropriate goals for persons with chronic illnesses.

Ans: B, C, D

Feedback:

Healing requires the mobilization of the body, mind, and spirit. Appropriate care measures focus on helping patients live in harmony with chronic disease. Controlling symptoms, promoting a sense of well-being, and enhancing the quality of life are appropriate goals for persons with chronic illnesses. Chronic illnesses cannot be cured.

5. A homecare nurse has begun providing care for an older adult male in the community who has recently been diagnosed with type 2 diabetes. The nurse is responsible for creating a care plan for the client and has consequently identified a number of goals for his care. Which of the following goals of care is most in need of reexamination or modification?

A) "The client will gain the knowledge and skills necessary to manage his diabetes independently and effectively within 3 months."

B) "The client will remain free of common complications of diabetes."

C) "The client will maintain a high quality of life despite his diabetes."

D) "The client will no longer require blood sugar monitoring or oral antihyperglycemic medications within 12 months."

Ans: D

Feedback:

While answers A, B, and C stress the management of the condition, freedoms from complications, and a high quality of life, answer D essentially makes curing the disease the goal.

6. Despite the fact that the patient is now receiving palliative care because of the progression of her congestive heart failure (CHF), a nurse views the care that was provided for the patient as a success. Which of the following aspects of the patient's situation would most likely lead the nurse to this conclusion?

A) The client was able to live independently and care for herself until very late in the progression of her disease.

B) The client maintained an acceptable cardiac output for the majority of the time that she lived with CHF.

C) The client was able to teach other older adults about the experience of living with CHF and the way it affected her life.

D) The client remained largely pain-free from the time of diagnosis until the present.

Ans: A

Feedback:

The fact that the client was able to live independently and perform self-care represents success in a holistic nursing model. A focus on cardiac output and the ability to teach others is less indicative of a healing paradigm. While controlling pain in and of itself is a laudable goal, it is less closely associated with the quality of life that is the true goal.

7. A nurse is providing care for an 82-year-old woman on the palliative care unit of a hospital. The woman has a long-standing diagnosis of diabetes that has manifested in serious cardiac problems and she is not expected to survive the weekend. How can the nurse best understand this course of events in light of the chronic care that the patient has long received?

A) Death represents the ultimate failure of the provision of care.

B) Dying in comfort and dignity is the final component of high-quality chronic care.

C) The period of death represents the transition from chronic care to acute care.

D) Holistic, chronic care requires that the nurse limit care to psychosocial interventions.

Ans: B

Feedback:

Dying a "good death" is a component of sound chronic care. It does not necessarily represent a failure of care nor does the near-death period mark the end of chronic care. Chronic care includes, but is not limited to, psychosocial interventions. Pain control and comfort care, for example, require pharmacological interventions that are still congruent with chronic care and the focus on healing and quality of life.

8. Mr. E, an elderly man who lives alone, has hypertension and diabetes but seems to manage both conditions quite well. Three times a week he drives to a dialysis center for dialysis. He injects himself with insulin and is in charge of his medications and meals. Because Mr. E is lonely, he often has lunch or dinner in restaurants where he may eat and drink unwisely, but he takes his medicines with him. What could a nurse at the dialysis center suggest that would most help Mr. E in managing his conditions?

A) Eat at home most of the time

B) Take a list of approved foods to the restaurants

C) Find some social activities that do not involve eating

D) Test your blood pressure and blood sugar after returning home

Ans: C

Feedback:

Mr. E's loneliness is leading to dietary problems, and a nurse can use a motivational strategy to help him. Even if Mr. E keeps track of his blood pressure readings and blood sugar levels, unwise eating and drinking will eventually affect his conditions. If he has a social life, he may find it easier to eat at home more often, where it is easier to manage his diet. When he does eat out, taking a list of approved foods and measuring his blood pressure and blood sugar afterward will be helpful.

9. An elderly woman had a series of lab tests that indicate she is healthy, but she has had several colds lately and often feels fatigued (although she is not depressed). She eats lightly but has a healthful diet. Which is the best advice a nurse could give her for improving her health?

A) Increase total food intake.

B) Take mega-doses of vitamins.

C) Exercise more.

D) Have psychotherapy.

Ans: C

Feedback:

Eating more is inadvisable; current research indicates that a light but nourishing diet is best for most people. Although a daily vitamin/mineral supplement is a healthful practice, mega-doses of vitamins are seldom needed, and use of them should be supervised by a physician. Psychotherapy does not seem to be indicated; the woman is not depressed, and no other mental problem is mentioned. Exercise should help her general health, making her feel more awake during the day and helping her sleep at night. That, in turn, will increase her resistance to colds.

10. Mr. P, a 70-year-old retired engineer, has diabetes and is on dialysis. He is a gourmet who takes pride in cooking delicious meals. His physical condition is quite good, but he is unhappy and bored with the restricted life he must lead. An old friend has invited him to travel across the country to San Francisco and spend a week there. Dialysis treatments can be arranged through a network of dialysis providers. How should Mr. P's charge nurse respond to this situation?

A) Discourage the idea, as he is likely to eat and drink too much on vacation

B) Discourage the idea, but provide as much helpful information as possible

C) Encourage him to go, and provide as much helpful information as possible

D) Encourage him to go, and advise him to relax regarding his condition for a week

Ans: C

Feedback:

A visit to San Francisco, a city known for its many fine restaurants, certainly poses risks for a patient who must follow a restricted diet, and could even shorten Mr. P's life. His unhappiness with his current situation, however, probably makes it desirable for him to take that risk. Even in San Francisco, it may be possible for him to eat sensibly, and in any case he is likely to be much happier than he is now. He needs to decide whether his quality of life will improve enough to risk any dangers. A nurse or social worker should help with setting up the dialysis arrangements ahead of time and with giving him any available information about restaurants, medical centers, and other places he may need to know about.

11. A nurse in a cardiac fitness unit is helping an elderly man set health goals for the coming year. The patient has had one heart attack and two coronary artery bypass operations, and can now walk only one city block (1/8 mile) before tiring. Which goal seems most reasonable for him?

A) Walk 10 blocks every day

B) Jog 4 blocks every day

C) Walk 24 blocks every day

D) Continue to walk 1 block every day

Ans: A

Feedback:

Although setting such a goal depends very much on the patient and the course of his recovery, it seems reasonable to set a goal of walking 10 blocks (a little more than a mile) every day within a year. That is not so much as to seem unreachable, or so little as to seem worthless. If the patient tries to make progress toward that goal but fails, the goal can be revised after a few months.

12. Which of the following older adults with chronic conditions is most likely to have the greatest care needs?

A) An 80-year-old woman with varicose veins who has just been diagnosed with osteoarthritis.

B) A 74-year-old man with macular degeneration and type 1 diabetes.

C) A 77-year-old man who has long-standing hypertension and is displaying early signs of chronic renal failure.

D) An 84-year-old woman who lives with severe hearing loss and recurrent hemorrhoids.

Ans: B

Feedback:

Visual impairment is likely to impact significantly the ability to monitor blood glucose levels and administer insulin. These challenges likely supersede those of the other older adults in answers A, C, and D.

13. How can a visiting nurse best ensure proper care for a patient when she is not present but can be reached by a telephone or pager?

A) Instruct that all the family's questions should be filtered through the primary caregiver.

B) Provide detailed written instructions for all procedures.

C) Train the patient carefully in all procedures.

D) Train all caregivers carefully in all procedures.

Ans: B

Feedback:

Patients and caregivers can usually follow instructions well when a nurse is present, but the stress of illness and caregiving can make it easy to forget instructions later, especially if a procedure involves several steps or has changed from a recent procedure. Written instructions make it possible for a patient or caregiver to review procedures; if there is still confusion, the nurse can be called for advice.

14. Mr. Q has heart disease, and his wife needs to learn about the cooking methods and recipes she can use to help his condition. Which of the following sources is probably her best source of information?

A) Cardiologist

B) General practitioner

C) Nurse

D) Support group

Ans: D

Feedback:

Other caregivers in a support group can probably provide many cooking tips and recipes. The other sources can provide more theoretical information and general guidance.

15. A 77-year-old woman has recently been diagnosed with type 2 diabetes. The gerontological nurse who is working with the woman has emphasized the need for the woman to make smart lifestyle choices in the management of her chronic condition. The woman has retorted, "Choices! I didn't choose to get diabetes and there's not much that I can do about it!" Which of the following statements best underlies the response that the nurse will provide?

A) Many of the factors that contribute to increased quality of life are within the woman's direct control.

B) The woman has the ability to adopt or reject behaviors that have the potential to cure her disease.

C) The woman can identify treatment options in consultation with the physician who is providing her care.

D) Lifestyle choices exist only in older adults with strong support networks and sufficient resources.

Ans: A

Feedback:

Lifestyle choices are within the locus of control of most older adults with chronic conditions and they have the potential to increase quality of life, though not cure chronic disease. Lifestyle choices supersede the direction of her physician, and while support and resources may indeed open up more lifestyle options, lifestyle choices are not exclusive to patients with these resources.

16. Mrs. S has a serious chronic condition that requires her seeing a physician several times a year (or more, if she is hospitalized). She is considering four physicians, all of whom are well qualified. Which physician is likely to be her best choice?

A) Dr. A is the top expert in his field and is highly respected at the local hospital.

B) Dr. B is a woman with an office in Mrs. S's neighborhood.

C) Dr. C is a woman who makes Mrs. S feel comfortable and allows plenty of time for talking.

D) Dr. D communicates well with her and is in high demand.

Ans: C

Feedback:

Finding a doctor with whom the patient feels comfortable is of major importance. She will also want a physician who makes her feel comfortable in the office. These considerations are likely to outweigh others, especially when the patient is elderly. A physician in high demand may be less accessible.

17. A 76-year-old man has had his quality of life significantly affected by chronic obstructive pulmonary disease (COPD), a condition that has brought a steady decline in his activity tolerance, his mobility, and ultimately his independence. In light of the apparent ineffectiveness of conventional treatment, the man is eager to forego conventional treatments and explore alternative and complementary treatment options. How can the man's nurse best direct him?

A) "This is a wise decision, since conventional treatments are motivated by profit and the interests of pharmaceutical companies, not patients."

B) "These are good options to explore, but you will need to set aside your physician's advice in the short term in order to get accurate information."

C) "Try not to think of your options as choosing either conventional treatment or alternative therapies, but rather choosing the best of both."

D) "Your care team is probably ignorant of alternative therapies, so you'll have to go elsewhere for any information you need."

Ans: C

Feedback:

Patients should be able to use the best of both complementary/alternative and conventional health care practices. It would be inaccurate to wholly write off conventional treatments as serving only the interests of pharmaceutical companies and while various information sources are likely necessary, it would be inappropriate to recommend ignoring the advice or potential information from the care team and physicians.

18. Mr. Y, who lives with his wife in their home of 50 years, has a diagnosis of osteoarthritis. Which of the following factors is most likely to have the largest impact on Mr. Y's ability to manage his illness?

A) The availability of new treatment options for his condition

B) The financial resources available to Mr. Y and his wife

C) The course and progression of his condition

D) The openness of Mr Y to complementary and alternative medicine (CAM)

Ans: C

Feedback:

The course and progression of Mr. Y's arthritis is likely to affect his ability to manage it more than new treatment options, finances, or his openness to CAM treatments.

19. The daughter of an 80-year-old female patient with a diagnosis of severe ischemic heart disease has been her mother's sole care provider for over a year. The daughter is tearfully telling the homecare nurse about the onerous burden that she bears by struggling to meet her mother's ever-increasing needs. How can the nurse best respond to the daughter?

A) "There are promising new treatments for heart disease that hold a great potential for your mother."

B) "It's very normal for you to feel this way, given how much you do for your mother; perhaps we can explore other living options together."

C) "It sound like it is probably time to place your mother into long term care."

D) "This must be difficult for you; many others in a circumstance similar to yours find it useful to remind themselves of how much their parents did for them when they were young."

Ans: B

Feedback:

Answer B acknowledges the family members burden and tactfully introduces alternatives in a way that is more respectful than in answer C. Answer A overemphasizes curing rather than the daughter's burden of responsibility and answer D is likely to foster guilt rather than a solution.

20. Mrs. D, a resident in a nursing home, is considered noncompliant by many of the staff because she refuses to eat some of the food, which is nourishing and has been carefully planned by a dietitian. Most other residents have no objection to the meals. In addition, Mrs. D sometimes skips exercise classes. On the other hand, she takes all her medicines, and she gets along well with the other residents, to whom she tells risqué jokes. In what area is Mrs. D coping successfully?

A) Diet

B) Assertiveness

C) Exercise

D) Compliance

Ans: B

Feedback:

The staff may be annoyed by Mrs. D's noncompliant behavior, and her diet and exercising may be imperfect, but she is exhibiting a healthy assertiveness in refusing to eat food she dislikes and to exercise when she doesn't want to.

21. Mr. A says that he does not need his medicine for hypertension. He also claims that it makes him feel weak and he suspects that it sometimes makes him impotent. When his wife tries to remind him to take the drug, he becomes enraged. How can a nurse best help in this situation?

A) Suggest that Mr. A vent his frustrations

B) Insist that Mr. A force himself to take the medicine

C) Advise Mr. A's wife to supervise him

D) Exhort Mr. A repeatedly that a chronic condition like hypertension requires self-care

Ans: A

Feedback:

Mr. A is in denial about his need for the medicine and is angry about the effects. He needs extra support, not criticism. Venting his frustrations, perhaps by yelling or punching a pillow, may give him some relief.

22. An elderly woman has lived with her son and his family for about 10 years. When she came to live with them, she was independent and healthy, but now she has rheumatoid arthritis and is nearly blind. To take care of her, her daughter-in-law took early retirement from a job she enjoyed. Although the daughter-in-law did so voluntarily, she now feels resentful about staying home, and the family's income has lessened. Recently, the family hired a part-time home care worker to help out. This gives the daughter-in-law more freedom but adds to the financial burden. The marriage is beginning to suffer. What might a marriage counselor tell the couple?

A) Set firmer boundaries with the mother

B) Arrange for additional in-home care

C) Consider finding an assisted-living facility for the mother

D) Make their own decisions without outside input

Ans: C

Feedback:

This couple is trying hard to provide good care for the mother, but it has become too much of a burden for them. The counselor must tread lightly to avoid making them feel guilty, but needs to suggest an assisted-living arrangement so that the daughter-in-law can work. More in-home care would add to their current expense and would not allow the daughter-in-law to return to full-time work.

23. What is one of the steps in the COACHING acronym?

A) Assist

B) Help

C) Caution

D) Instill

Ans: B

Feedback:

The letters in COACHING: C, Contact; O, Observe; A, Affirm; C, Clarify; H, Help; I, Inspire; N, Nurture; and G, Guide.

24. An elderly man is dying of cancer, and a hospice nurse comes to his home every day to oversee his care and comfort. What is the most important thing the nurse can provide?

A) Stress management

B) Help with tasks that may sap the patient's energy

C) Assurance of support

D) Help with basic needs such as eating and bathing

Ans: C

Feedback:

All these tasks are important for a hospice nurse, but the most important is instilling in a dying patient a feeling that the nurse can be depended on for support through this period.