Polypharmacy is a leading cause of morbidity in the older adult population. Advanced practice nurses (APRNs) can improve medication safety in their older adult patients by doing all the following EXCEPT:

Shoulder injuries following trauma are evaluated using specific physical examination maneuvers that help localize the affected anatomical structure. The crossover test (also known as the horizontal adduction or scarf test) is used to assess pathology of the acromioclavicular (AC) joint. Pain elicited when the arm is moved across the chest indicates stress or inflammation of this joint. Accurate interpretation of special tests helps differentiate AC joint injury from rotator cuff, biceps tendon, or glenohumeral pathology.

Rationale:
A. Rotator cuff injuries typically present with pain during abduction, especially between 60–120 degrees (painful arc), and weakness with shoulder movement. These injuries are associated with positive drop arm or empty can tests rather than pain specifically with horizontal adduction across the chest. The crossover test is not specific for rotator cuff pathology.

B. Bicipital tendon pathology presents with anterior shoulder pain and tenderness over the bicipital groove. Pain is typically reproduced with Speed’s or Yergason’s tests rather than the crossover maneuver. The localization of pain in this case does not match the anterior tendon involvement typical of biceps tendinitis.

C. Glenohumeral joint injury involves deep shoulder pain, reduced range of motion, and instability, often worsened by active and passive movement in multiple planes. It is not specifically reproduced by horizontal adduction across the chest. The crossover test is more targeted to the AC joint rather than the glenohumeral articulation.

D. Acromioclavicular joint is the most likely site of injury because the crossover test places stress directly on this joint by horizontally adducting the arm across the body. Pain reproduced with this maneuver indicates AC joint irritation or separation, commonly seen after falls onto the shoulder. This test is highly specific for AC joint pathology, making it the correct answer.

Progressive visual impairment in older adults can result from several age-related ocular conditions that affect different parts of the eye. Glaucoma is a chronic optic neuropathy characterized by increased intraocular pressure leading to progressive optic nerve damage. This damage initially affects peripheral vision, often unnoticed by patients until significant loss has occurred. Changes such as increased cup-to-disc ratio and visual field defects are key diagnostic indicators of glaucomatous damage.

Rationale:
A. Cataracts involve clouding of the eye’s lens, leading to blurred vision, glare, and difficulty seeing in low-light conditions. They primarily affect central vision rather than peripheral vision and do not cause an increased cup-to-disc ratio. The optic nerve remains unaffected in cataracts, making this diagnosis inconsistent with the findings described.

B. Glaucoma is the most likely diagnosis because it is characterized by progressive optic nerve damage associated with increased intraocular pressure. It initially causes peripheral vision loss, leading to “tunnel vision,” which explains the patient’s difficulty noticing cars in adjacent lanes. The increased cup-to-disc ratio on examination is a hallmark sign of optic nerve atrophy due to chronic pressure-related damage.

C. Macular degeneration primarily affects central vision due to deterioration of the macula, the part of the retina responsible for sharp, detailed vision. Patients typically report difficulty reading or recognizing faces rather than peripheral vision loss. The presence of peripheral vision defects and optic disc changes does not align with this condition.

D. Presbyopia is an age-related decline in the eye’s ability to focus on near objects due to lens stiffening. It results in difficulty with reading or close work but does not affect peripheral vision or cause optic nerve changes. The physical examination findings of increased cup-to-disc ratio are not associated with presbyopia.