Exam 2 - Chapter 19

Question 1

what happens to the plantar fat pad in old age?

Answer 1

shrinks and degenerates

Question 2

what happens to the skin on the feet of older adults?

Answer 2

• drier
• less elastic
• cooler
• thinner

Question 3

what are the are-related changes expected in toenails of older adults?

Answer 3

• more brittle
• less resistant to fungal infection
• thicker

Question 4

subcutaneous tissue on dorsum and sides of foot becomes thinner in old age

Answer 4

true

Question 5

what is a possible reason for an older adult to have decreased ROM?

Answer 5

degenerative joint disease

Question 6

what are common foot problems among older adults?

Answer 6

• calluses
• bunions
• hammer toe
• onchomycosis

Question 7

what are calluses?

Answer 7

thick compacted skin formed from prolonged pressure

Question 8

what are bunions?

Answer 8

bony deformities that form on the great toe from chronic squeezing

Question 9

define hammer toe

Answer 9

permanently flexed toe

Question 10

what is onchomycosis?

Answer 10

a condition of the nails that makes it thick, yellow, brown, brittle, and opaque

fungal infection

Question 11

how are calluses treated?

Answer 11

• padding in footwear
• OTC callus remover (avoid sharp tools)
• daily lubrication of feet
• use well-fitted shoes

Question 12

how are bunions treated?

Answer 12

• surgery
• steroid injections
• anti-inflammatory pain medications
• custom-made shoes that provide forefront space

Question 13

how are hammer toes treated?

Answer 13

• surgery
• well-fitted shoes
• professional orthotics

Question 14

how is onchymycosis treated?

Answer 14

• oral medications
• photodynamic therapy
• keep toes clean, dry, and regularly exposed to sun and air

Question 15

why is onchymycosis hard to treat?

Answer 15

• limited circulation to toenails
• oral medications have limited effectiveness & may be highly toxic to heart and liver

Question 16

what are the factors that increase fall risk?

Answer 16

• unsteady gait
• cognitive impairment
• reduced vision and hearing
• medications
• chronic illness
• orthostatic hypotension

Question 17

what are things to include in educating about proper foot care?

Answer 17

• annual foot examination
• care of toenails
• diabetic foot care
• proper footwear
• orthotic shoes

Question 18

what is indicated in an annual foot examination?

Answer 18

• identify risk factors for ulcers and amputations
• assess for loss of protective sensation and pedal pulses

Question 19

what is best practice for cutting nails?

Answer 19

• best time to cut after bath
• soak for 20-30 minutes
• clip straight across
• filing to make straight edge

Question 20

which group people should not have pedicures in commercial establishments?

Answer 20

• diabetics
• those with PVD

Question 21

what is a leading consequence of falls?

Answer 21

hip fractures

Question 22

what is a consequence of having fallophobia?

Answer 22

restricts an individual’s perception of their own function

which leads to increased fall risk

Question 23

how does fallophobia affect an older patient’s life?

Answer 23

• decreases mobility, safety and function
• increases fall risk

Question 24

how do nurses contribute to enabling fallophobia?

Answer 24

• telling patients not to get up by themselves
• using restrictive devices (promotes dependence)

Question 25

what are the major assessment tools for falls?

Answer 25

• Hendrich II
• Morse

Question 26

what test does the Hendrich II include?

Answer 26

Get Up and Go

Question 27

what are the components of the Hendrich II model?

Answer 27

• male gender
• vertigo
• depression
• confusion
• altered elimination
• antiepileptics
• bezodiazepines
• “get up and go”

Question 28

what makes Morse Fall Scale different from Hendrich II?

Answer 28

more appropriate for use in acute care settings rather than LTC

Question 29

what are the components of the Morse Fall Scale?

Answer 29

• fall history
• secondary diagnosis
• ambulatory aid
• IV access
• gait
• mental status

Question 30

major risk factors of falls

Answer 30

• orthostatic hypotension
• cognitive impairment
• medications
• weakness and fraility
• environmental factors
• impaired vision and hearing

Question 31

what is included in the “fall bundle”?

Answer 31

• arm bands
• signs
• education
• risk assessment
• footwear
• assisted toileting

Question 32

interventions for falls

Answer 32

• environmental modifications
• assistive devices
• wheelchairs
• alarms
• motion sensors
• safe client handling

Question 33

what are the measures for fall prevention?

Answer 33

• vision screening
• medication reduction
• assess for syncope and postural hypotension
• provide hip protectors
• fall prevention education

Question 34

types of restraints

Answer 34

• vest
• belt
• mitten
• bedrails
• geriatric chairs
• medication

Question 35

when are restraints typically used in the hospital setting?

Answer 35

• ICU
• on patients with dementia & medical devices

Question 36

why do nurses use restraints in ICU?

Answer 36

prevent tube dislodgment related to greater frequency of invasive lines & mechanical ventilation

Question 37

physical restraints should NOT be used to manage behavioral symptoms

Answer 37

true

Question 38

daily evaluation of the necessity of medical devices (catheter, IV, tubes) is a nursing responsibility

Answer 38

true

Question 39

best practice for restraints

Answer 39

• remove when deemed unnecessary
• preoperative teaching regarding devices
• use mitts instead of wrist restraints
• roll belts rather than vests
• remove restraints while working with the patient
• have IV lines out of sight

Question 40

cons for restraints

Answer 40

• do not prevent falls
• might exacerbate problems
• asphyxiation
• pressure ulcer
• agitation
• cognitive decline
• depression

Question 41

how can the nurse prevent falls related to restraint-free care?

Answer 41

• anticipate patient’s needs
• assess for incontinence/ nocturia
• reduce injury potential
• provide visual/ physical cues
• reduce sleep disturbances