mod 1 info

Question 1

5 rights of delegation

Answer 1

Right taskRight circumstancesRight personRight communicationRight supervision

Question 2

Information and technology

Answer 2

Information and technology is used to:CommunicateManage knowledgePrevent errorsSupport decision-making

Question 3

Tanner

Answer 3

Tanner (2006)Assessment: NoticingAnalysis: InterpretingPlanning and Implementation: RespondingEvaluation: Reflecting

Question 4

Ethics

Answer 4

Addresses issues and questions about morality
ANA Code of Ethics
Attributes
Autonomy
Beneficence
Nonmaleficence
Fidelity
Veracity
Social justice

Question 5

Health care disparities cause by

Answer 5

poor communicationhealth care accesshealth literacyhealth care provider biases and discrimination

Question 6

Which nursing documentation demonstrates the integration of patient-centered care?

Answer 6

A.Social worker paged for consultationB.Steady gait observed when ambulatingC.Discussed dietary preferences with clientD.Nursing literature reviewed for best practice approaches

Question 7

The nurse is delegating ambulation for a client to an experienced Patient Care Technician (PCT). Which teaching will the nurse provide to the UAP? (Select all that apply.)

Answer 7

A.“Come and get me for lunch.”B.“Ambulate the client every four hours.”C.“Each ambulation should last 10 minutes.”D.“Please let me know how the client does after each ambulation.”E.“Be certain to use a gait belt when performing this activity.”

Question 8

The nurse observes that numerous clients on a medical-surgical respiratory unit seem to have increasingly frequent readmissions. What quality improvement step could the nurse implement to explore the readmission rate?

Answer 8

A.Inform the unit manager of the concern.B.Evaluate trends and develop a plan for improvement. C.Contact the hospital quality improvement nurse to create an improvement strategy. D.Post a journal article on the unit that addresses national readmission rates for respiratory disorders.

Question 9

Subgroups of Late Adulthood

Answer 9

Young old—65 to 74 yearsMiddle old—75 to 84 yearsOld old—85 to 99 yearsElite old—100 years+

Question 10

Common Health Issues and Concerns

Answer 10

Performance of ADLsParticipation in social activitiesLossesHealth promotion needs

Question 11

Common Health Issues andConcerns (Cont.)

Answer 11

Impaired NUTRITION and hydrationImpaired MOBILITYStress, loss, and copingAccidentsDrug use and misuseImpaired COGNITIONSubstance useElder neglect and abuse

Question 12

Impaired Nutrition and Hydration

Answer 12

Increased need for calcium, Vitamins A/C/D, fiberDiminished taste and smell, tooth loss, poor dentures can impact nutrition statusConstipation concernsLoneliness

Question 13

Geriatric Failure to Thrive (GFTT)

Answer 13

Complex syndromeUnder-nutritionImpaired physical functioningDepressionCognitive impairment

Question 14

Impaired Mobility

Answer 14

Physical activity advantagesFocus on functional ability

Question 15

Stress, Loss, and Coping

Answer 15

Rapid environmental changesChanges in lifestyleAcute or chronic illnessLoss of significant otherFinancial hardshipRelocation (especially relocation stress syndrome)

Question 16

Accidents

Answer 16

Fall preventionDriving safetyChart 3-3

Question 17

Drug Use and Misuse

Answer 17

Polymedicine, polypharmacyDrugs, food, herb, disease interactionsIntolerance to standard drug dosagesPhysiologic changes affect absorption, distribution, metabolism, excretion

Question 18

Effects of Drugs

Answer 18

Often intolerant of standard dosesAge-related changesAffect absorptionAffect metabolismReduce liver blood flow and serum enzyme activityChanges in kidneys result in high plasma drug concentrations

Question 19

Creatinine Clearance Test

Answer 19

Measures glomerular filtration rate of kidneys(140 – age in years) × lean body weight in kg divided by serum creatinine in mg/dL × 72== Creatinine Clearance in Men

Creatinine Clearance in Men × 0.85 = Creatinine Clearance in Women=

Question 20

Medication Assessment and Health Teaching

Answer 20

Assess medication use per Healthy People 2020recommendationsHighlight all drugs that are part of Beers criteriaPerform medication assessment every 6 months or more often as neededCollaborate with patient, family, providers, pharmacist
Give verbal and written informationPromote adherence to drug therapy regimen exactly as prescribedEncourage lifestyle changes and nonpharmacologic interventionsRemind not to share/borrow drugs

Question 21

Impaired Cognition

Answer 21

If an older adult is not legally competent, a guardian may be appointed

Question 22

Veterans’ Health Considerations

Answer 22

DepressionPTSDSevere anxietySubstance use (especially alcoholism)Homelessness

Question 23

Depression

Answer 23

Mood disorder having cognitive, affective, physical manifestationsPrimary or secondaryGeriatric Depression Scale—Short Form (GDS-SF) (see next slide)Treatment includes drug therapy, psychotherapyReminiscence or reflective therapies useful with older adults

Question 24

Geriatric Depression Scale

Answer 24

x

Question 25

Dementia

Answer 25

Syndrome involving slow, progressive cognitive decline (also known as chronic confusion)Global impairment of intellectual function; generally chronic and progressiveTypesAlzheimer’s diseaseMulti-infarct dementia

Question 26

Delirium

Answer 26

Acute state of confusion, fluctuating onsetUsually short-term; reversible within 1 month or lessOften experienced by older adults in unfamiliar settings Can include physical and emotional manifestations (including psychosis)

Question 27

Examples of Causes of Delirium

Answer 27

Drug therapyFluid and electrolyte imbalancesInfectionsFecal impaction or severe diarrheaSurgeryMetabolic problemsNeurological, circulatory, renal, pulmonary disordersNutrition deficienciesHypoxemia

Question 28

Screening for Delirium

Answer 28

Confusion Assessment Method (CAM)Delirium Index (DI)NEECHAM Confusion ScaleMini-Cog

Question 29

Substance Use

Answer 29

Excessive use (alcohol and illicit drugs)Impairs cognition
Isolation, depression, delirium can resultNational Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends no more than one drink per day or seven drinks per week for people over 65

Question 30

Short Michigan Alcoholism Screening Test – Geriatric Version

Answer 30

Short Michigan Alcoholism Screening Test – Geriatric Version10 yes/no questionsEach “yes” answer = 1 pointTotal score of 2 or more points = individual has problem with alcoholExamples of questionsDo you drink to take your mind off of your problems?When you feel lonely, does having a drink help?

Question 31

CAGE Test

Answer 31

Four questionsHave you ever tried to cut down on your drinking?Have people annoyed you by criticizing your drinking?Have you ever felt bad or guilty about your drinking?Have you ever had a drink first thing in the morning to settle your nerves? (eye-opener)

Question 32

Elder Neglect and Abuse

Answer 32

Neglect: Caregiver failure to provide basic needsAbusePhysical—Use of physical force that results in bodily injuryFinancial—Mismanagement or misuse of property or resources Emotional—Intentional use of threats, humiliation, intimidation, isolation

Question 33

Health Issues for Older Adults in Hospitals and Long-Term Care Settings

Answer 33

Hartford Institute for Gerontological NursingWorks to ensure that all hospitalized patients 65 years of age and older be given quality care

Question 34

Gender Health Considerations

Answer 34

Health disparitiesFulmer SPICES frameworkSleep disordersProblems with eating or feedingIncontinenceConfusionEvidence of fallsSkin breakdown

Question 35

Sleep, Nutrition, and Continence

Answer 35

Sleep disordersProblems with eating or feedingElimination issuesVery common in hospital and long-term care settings

Question 36

Confusion, Falls

Answer 36

Confusion, Falls Acute and chronic confusion can contributeAvoid multiple drugsPromote sleep Reorient as neededProvide comfortNPSG—fall risk assessment tools and fall reduction plan

Question 37

Restraints

Answer 37

Device or drug that prevents patient from moving freelyMust be prescribed by a health care providerAlternatives to restraints should always be used firstIf restraints are usedUse least restrictive deviceCheck patient every 30–60 minutesRelease restraint every 2 hoursTurn, reposition, toilet

ChemicalAntipsychoticsAntianxiety drugsAntidepressantsSedative-hypnotics

Question 38

Skin Breakdown

Answer 38

NPSG—must have program to prevent agency-associated pressure injuriesNutrition supportAvoid friction, shearingReposition and provide support surfacesIncrease mobility and activity (when appropriate)Clean skin, use moisture barriers

Question 39

Care Coordination and Transition Management

Answer 39

Older adults experience high readmission rates and ED visits if care coordination is poorAssess patients’ communication needsFollow up after discharge“Health coach” can help ensure understanding of discharge instructions

Question 40

The home care nurse is caring for a 78-year-old patient who is normally alert and oriented. Today, the patient is confused and running a high fever. What condition does the nurse anticipate?

Answer 40

*A.Delirium B.DementiaC.DepressionD.Alcohol withdrawal

Question 41

The Emergency Department nurse is assessing a patient brought in by law enforcement. The patient slurs words and smells like alcohol, yet denies drinking alcohol. When the patient is able to communicate clearly, which assessment question will the nurse ask? (Select all that apply.)

Answer 41

“Why do you drink?”B.“Did you lie about drinking earlier tonight?”C.“Who have you been drinking with this evening?”D.“Have you ever tried to cut down on your drinking?”E.“Have you ever had a drink first thing in the morning to settle your nerves?”

Question 42

The nurse is caring for a patient who is considered “frail elderly”. Into which category does the nurse place the patient?

Answer 42

A.65 to 74 years of age (the young old)B.75 to 84 years of age (the middle old)C.
*85 to 99 years of age (the old old)D.100 years of age or older (the elite old)

Question 43

ch6Assessment: Noticing

Answer 43

HistoryHistory of present conditionCurrent medicationsTreatment in progressUsual schedule, habits of everyday livingFunctional abilities

Question 44

ardiovascular and Respiratory Assessment

Answer 44

Assess for decrease in cardiac outputChest painWeakness and fatiguePlan care to maximize limited energy resourcesFrequent rest periodsMajor tasks in morningDetermine level of activity that can be done without invoking symptoms

Question 45

GI and Nutritional Assessment

Answer 45

AssessOral intake and pattern of eatingFactors that may interfere with oral intakeUse of dentures (and fit)Height, weightHemoglobin/hematocritSerum prealbumin and albuminBlood glucose levelsWeight loss or gainElimination

Question 46

Renal and Urinary Assessment

Answer 46

AssessBaseline urinary patternsFluid intake patterns and volumeFrequent concernsNocturia Urinary incontinence or retentionMonitor for UTIConfusion may be only indicator

Question 47

Neurological and Musculoskeletal Assessment

Answer 47

AssessMotor functionSensory perceptionCommunication abilitiesParesis, paralysisCognitionROM Endurance level

Question 48

Skin and Tissue Integrity Assessment

Answer 48

Assess skin integrityActual or potential interruptions in skin and tissue integrityPressure injury: Assess problem and possible causesMeasure depth, diameter of open skin areasPhotographs may be taken based upon agency policy and consent obtained

Question 49

Assessment of Functional Ability

Answer 49

Assess ability to perform ADLsInstrumental activities of daily living (IADLs)—phone use, shopping, preparing food, housekeepingFunctional independence measure (FIM)

Question 50

Psychosocial Assessment

Answer 50

Body image and self-esteemUse of defense mechanismsResponse to lossPresence of stress-related physical problemsDepression, fatigue, appetite changes, powerlessness

Question 51

Cultural and Spiritual Considerations

Answer 51

Availability of support systems for the patientAsk patients what is important to them; what gives meaning to their livesCultural, spiritual/religious needsSexuality and intimacy needs

Question 52

Vocational Assessment

Answer 52

Inform patients about Americans with Disabilities Act (1991)Reasonable assistance Collaborate with vocational counselorsJob modificationsVocational rehabilitation

Question 53

Analysis: Interpreting

Answer 53

Priority collaborative problemsPhysical mobility concernsDecreased functional abilitySkin and tissue integrity concernsUrinary concernsConstipation

Question 54

Improving Physical Mobility

Answer 54

Coordinate care with PT and OTProvide assistance with transfersAssess patient’s mobility levels using standardized toolGait trainingAmbulatory aidsROM exercises

Question 55

Increasing Functional Ability

Answer 55

Collaborate with OTAssistive/adaptive devicesAssistive or robotic technology

Question 56

Maintaining Skin Integrity

Answer 56

Frequent position changes with adequate skin care, sufficient nutritional intakeTurn and reposition at least every 1 to 2 hoursProvide adequate skin careEnsure sufficient nutritionUse pressure-relieving or pressure-reducing devices

Question 57

Establishing Urinary Continence

Answer 57

Establishing Urinary ContinenceOveractive spastic bladder versus underactive flaccid (areflexic) bladderIntermittent catheterizationConsistent toileting routinesDrug therapy

Question 58

Bowel Continence

Answer 58

Bowel ContinenceReflex (spastic) bowelUpper motor neuron disease/injury•Defecation occurs suddenly without warningFlaccid bowelLower motor neuron disease/injury•Defecation occurs infrequently and in small amountsUninhibited bowelBrain injury•Frequent defecation•Urgency•Hard stool

Bowel retraining programs include combination methodsBisacodyl (Dulcolax)FluidsFiberBedside commode or bathroom toilet

Question 59

Care Coordination and Transition Management

Answer 59

Begins at time of admissionHome care preparationSelf-Management EducationHealth care resources

Question 60

Evaluation: Reflecting

Answer 60

Collaboratively evaluate efficacy of interprofessional interventionsMobilitySelf-care/self-management skillsIntact skin and tissuesUrinary elimination Stool evacuation

Question 61

The nurse has provided teaching about rehabilitation goals to a patient whose right hand was injured in a skiing accident. Which patient statement requires further nursing intervention? (

Answer 61

A.“Rehabilitation will completely heal me.”B.“I will work on functioning to my best ability.”C.“My left hand will have to do everything now.”D.“Rehab is only for cardiac or respiratory patients.”E.“I will try to talk with a vocational counselor about my job.”

Question 62

The nurse is preparing to care for a patient who recently underwent a below-the-knee amputation. Which nursing intervention is appropriate to anticipate meeting the patient’s cultural and spiritual needs?

Answer 62

A.Contact a chaplain.B.Conduct a thorough assessment.C.Ask the health care provider to order a vegetarian diet.D.Assume that the patient is experiencing depression.

Question 63

Which nursing intervention is appropriate to assist a patient to manage overactive bladder incontinence?

Answer 63

*A.Establish a toileting routine.B.Leave a urinal by the bedside.C.Encourage use of incontinence pads.D.Delegate to unlicensed assistive personnel to check on the patient every 2 hours.