Gerontological Nursing Flashcards

An 80-year-old patient scores 18/30 on the Mini-Mental State Examination (MMSE). This score indicates:

Answer: Moderate cognitive impairment

MMSE scores of 10–18 indicate moderate cognitive impairment; scores ≥24 are considered normal.

A 78-year-old has a pressure injury with full-thickness skin loss exposing subcutaneous tissue without exposed bone, tendon, or muscle. This is classified as:

Answer: Stage 3

Stage 3 pressure injuries involve full-thickness skin loss with visible subcutaneous tissue but no exposed bone, tendon, or muscle.

Which intervention is most effective for preventing falls in hospitalized older adults?

Answer: Hourly rounding with toileting and call light within reach

Regular rounding with scheduled toileting and ensuring call lights are accessible are evidence-based fall prevention strategies.

Which of the following medications is considered high-risk in older adults due to anticholinergic effects?

Answer: Diphenhydramine (Benadryl)

Diphenhydramine has strong anticholinergic effects causing confusion, urinary retention, constipation, and fall risk in older adults.

When assessing pain in a non-verbal older adult with dementia, which scale is most appropriate?

Answer: PAINAD Scale

The PAINAD (Pain Assessment in Advanced Dementia) scale uses behavioral indicators to assess pain in non-verbal patients.

Elder mistreatment screening should be performed using which validated tool in outpatient settings?

Answer: Elder Abuse Suspicion Index (EASI)

The Elder Abuse Suspicion Index (EASI) is a validated 6-item tool used by clinicians to identify elder mistreatment.