Adult & Elder Health Exam: Fall Prevention, Sensory Changes, Skin & Wound Care, Exams of Nursing

Download Adult & Elder Health Exam: Fall Prevention, Sensory Changes, Skin & Wound Care and more Exams Nursing in PDF only on Docsity! Adult & Elder Exam Questions 1 With 100% Correct Answers 2024 fall - Correct Answer-an unexpected event in which the participant comes to rest on the ground, floor, or lower level; not a normal part of aging What is the percentage of older adults living in institutional long term care settings experience a fall each year? - Correct Answer-50-75% What percentage of older adults who fall suffer from serious injuries? - Correct Answer-20-30% intrinsic - Correct Answer-non-modifiable risk factor extrinsic - Correct Answer-modifiable risk factor; occurs in the environment How do falls come to the attention of the healthcare team? - Correct Answer-Medical History Physical Assessment pg. 1 professoraxel Mental Status Labs and diagnostic Results Home Safety Assessment dementia - Correct Answer-chronic confusion; associated to physiologic issues delirium - Correct Answer-acute confusion ; associated with external factors such as drugs or injury common causes of delirium - Correct Answer-drugs, elimination, liver and other organs, infection, respiratory, injury, unfamiliar environment, metabolic Confusion assessment method - Correct Answer-1) acute onset and fluctuating course 2) inattention 3) disorganized thinking 4) altered level of consciousness pg. 2 professoraxel True - Correct Answer-T/F: The proportion of older persons in each state varies heart disease, cancer, stroke - Correct Answer-What are the three major causes of death among US adults aged 65 years or older? True - Correct Answer-T/F: Much of all health care is devoted to care of older adults What are the select physiologic changes in neurologic/sensory during aging? - Correct Answer-loss of axons and neurons slowing of coordinated movements decreased sensation visions changes with age - Correct Answer-decreased ability to focus and deal with glare and nighttime vision hearing changes with age - Correct Answer-high frequency hearing loss (presbycusis), thickening of tympanic membrane, sclerosis of inner ear, build up of earwax pg. 5 professoraxel taste changes with age - Correct Answer-diminished taste recommendations for communicating with older adults - Correct Answer-recognize the tendency to stereotype older adults; avoid "elder speak"; maximize strategies to improve face-to-face communication; optimize opportunities to engage older adults to participate in their care and health care decision-making including those who have impaired cognition integumentary system changes with age - Correct Answer-loss of collagen fibers and decrease in glandular functions; decreased moisture and thinning of the dermis; increase in skin lesions and 'age spots' thorax and lung changes with age - Correct Answer-decrease in respiratory muscle strength, anteroposterior diameter increases, increased incidence of kyphosis, drier mucous membranes heart and cardiovascular changes with age - Correct Answer- decreased cardiac contractile strength; baroreceptor sensitivity decreases; decreased arterial compliance pg. 6 professoraxel gastrointestinal system and abdomen changes with age - Correct Answer-increased amount of fatty tissue in the trunk; slowing of peristalsis; altered gastric and intestinal secretions urinary changes with age - Correct Answer-decrease in the number of nephrons; hypertrophy of the prostate; increased incidence of stress incontinence in older women musculoskeletal system changes with age - Correct Answer- muscle mass is lost, decline rapidly if not used; increased incidence of bone issues related to aging and osteoporosis chronic diseases - Correct Answer-What are the leading cause of death that cause more than 2/3 of deaths each year? arthritis, hypertension, heart disease, cancer - Correct Answer-What are the most frequently diagnosed conditions? issues with chronic diseases - Correct Answer-reduce quality of life, limit activity, require assistance, increase healthcare costs, increase hospitalizations, impact emotional health pg. 7 professoraxel implementation evaluation assessment - Correct Answer-collection and verification of data; sources of data: primary and secondary; data: subjective or objective data; analysis and clustering of data nursing diagnosis - Correct Answer-clinical judgment about individual, family, or community responses to actual or potential health problems or life processes that the nurse is licensed to treat; use of standardized nursing language (NANDA-I) planning - Correct Answer-establishes priorities; helps nurses to anticipate and sequence nursing interventions; ID of short term and long term outcomes; classification of priorities: high, intermediate, and low implementation - Correct Answer-carry out the plan True - Correct Answer-T/F: Evaluation is an ongoing process pg. 10 professoraxel pressure injury - Correct Answer-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear pressure intensity pressure duration tissue tolerance - Correct Answer-What are the major elements in the cause of pressure injury? risk factors for pressure injuries - Correct Answer-impaired sensory perception impaired mobility alteration in level of consciousness shear and friction moisture/macerations decreased general health history of healed ulcers uses of braces, collars, oxygen tubes, and other pressure- forming devices stage I - Correct Answer-defined area of redness or discoloration pg. 11 professoraxel stage II - Correct Answer-partial loss of skin thickness involving epidermis/and or dermis, abrasion, blister, shallow crate stage III - Correct Answer-full thickness skin loss involving damage or necrosis of subcutaneous tissues and might extend through fat layer and underlying fascia; deep crater stage IV - Correct Answer-full thickness skin loss, down to muscle, bone - undermining and tracts are associated with these unstageable - Correct Answer-too much slough or eschar to determine the depth deep tissue injury - Correct Answer-characterized by deep reddish, purple color; it's serious because the skin is not open IAD - Correct Answer-exposure to urine or stool; diffuse, in skin folds; not necrotic; pain and itch pg. 12 professoraxel sanguineous - Correct Answer-fresh blood that comes from a recent wound, and is characterized by a bright red color documentation of pressure ulcers - Correct Answer-Accurate pressure ulcer stage classification Location of pressure ulcer Size of pressure ulcer (L x W x D) Tunneling Undermining Exudates - color, odor, consistency Pain/tenderness What is the highest score you can achieve on the Braden Risk Assessment Scale - Correct Answer-23 What 6 things are taken into consideration when doing a Braden Risk Assessment scale? - Correct Answer-sensory perception moisture activity pg. 15 professoraxel mobility nutrition friction and sheer purulent - Correct Answer-thick, yellow, green, tan, or brown discharge from a wound Pressure ulcers are always avoidable - Correct Answer-False pressure ulcer wound care - Correct Answer-Use non-toxic cleansers such as Normal Saline for clean ulcers and those with anti-microbials for pressure ulcers that have debris, infected or suspected high levels of bacterial colonization debridement - Correct Answer-For wounds that seem stable: Mechanical such as Wet-to-Dry Dressing Enzymatic For those wounds with cellulitis or signs of deterioration: Surgery Do not debride stable and dry eschar in ischemic limbs (such as the heel) pg. 16 professoraxel Use of Dressing Type of dressing used/wound care is based on stage of the ulcer and the objective of the dressing Types of Dressings (more than 200 are available) hydrocolloids - Correct Answer-for clean stage 2 or shallow stage 3 pressure injuries transparent film dressing - Correct Answer-could be used for autolytic debridement hydrogel - Correct Answer-for shallow minimally exudating pressure ulcer that are not infected and are granulating alginate dressing - Correct Answer-for moderate to heavily exudating ulcers silver-impregrated dressing - Correct Answer-silver sulfadiazine for infected wound honey-impregnated dressing - Correct Answer-use of medical- grade honey for stage 2 and 3 pressure ulcers (injury) pg. 17 professoraxel diagnostic/lab inaccuracies equipment failure blood transfusion error systems failure National Patient Safety Goals - Correct Answer-joint commission established this to promote specific improvements in patient safety. The requirements highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. How to Improve Patient Safety? - Correct Answer-1) User- centered Design 2) Avoid Reliance on Memory 3) Attend to Work Safety 4) Avoid Reliance on Vigilance 5) Training Concepts for Teams 6) Involve Patients in Their Care 7) Anticipate the Unexpected 8) Improve Access to Accurate, Timely Information pg. 20 professoraxel Quality and Safety Eduction in Nursing - Correct Answer- Funded by the Robert Wood Johnson Foundation (RWJF) to prepare nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously deliver quality and safe patient care. What should you do in case that restraints are used? - Correct Answer-Follow agency policies Use appropriate-size restraints Assess patient (circulation and ROM) Document (in real time) What is the impact of mobility/immobility? - Correct Answer- Functional ability activities of daily living (ADL) instrumental activities of daily living (IADL) economic avoid the sequelae of immobility What is mobilization? - Correct Answer-Turning Bed to chair ambulation pg. 21 professoraxel migration What are the systemic effects of immobility on the metabolic system? - Correct Answer-negative nitrogen balance altered GI function altered fluid and electrolyte balance What are the systemic effects of immobility on the CV? - Correct Answer-orthostatic hypotension thrombus formation What are the systemic effects of immobility on urinary elimination? - Correct Answer-urinary stasis renal calculi What are the systemic effects of immobility on the respiratory? - Correct Answer-atelectasis hypostatic pneumonia What are the systemic effects of immobility on the muscular changes? - Correct Answer-loss of endurance and muscle mass pg. 22 professoraxel emotional support anticipate - Correct Answer-What are the interventions for psychosocial system (in terms of systemic effects of immobility)? Patient-Centered Care Evidence-Based Practice Quality Improvement Informatics Safety Teamwork and Collaboration - Correct Answer-What six competencies do the quality and safety education in nursing address? pharmacology pharmacokinetics life sciences human anatomy mathematics - Correct Answer-What knowledge do you need to safely and accurately administer medications? pg. 25 professoraxel 1) stored in locked secure cabinet 2) count narcotics with every opening 3) document use of narcotics - Correct Answer-What are the guidelines for safe narcotic administration? How are brand name drugs written? - Correct Answer- Capitalized first letter small case first letter - Correct Answer-How are generic name drugs written? l What are the four main medication forms? - Correct Answer- solid liquid topical parenterna pharmacokinetics - Correct Answer-describes how medications are absorbed, distributed, metabolized into cells, tissues, or organs, and how they are excreted pg. 26 professoraxel absorption - Correct Answer-the passage of medication molecules into the blood from the site of administration 1) route of administration 2) ability to dissolve 3) blood flow to site of administration 4) lipid solubility of medication - Correct Answer-What are the factors that influence absorption? distribution - Correct Answer-after absorption, this occurs within the body to tissues, organs, and to specific sites of action What does distribution depend on? - Correct Answer-1) circulation 2) membrane permeability 3) protein binding metabolism - Correct Answer-medications are metabolized into a less potent or an inactive form; biotransformation occurs under the influence of enzymes that detoxify, degrade, and remove active chemicals pg. 27 professoraxel lengthen half-life for renally excreted drugs; antidiabetic drugs, among others, stay in the body longer age and distribution of drugs - Correct Answer-lean body mess falls. adipose stores increase; total body water declines raising the concentration of water-soluble drugs, such as digoxin, which can cause diminishes, reducing site available for protein-bound drugs and raising blood levels of free drug therapeutic effect - Correct Answer-expected or predictable adverse effect - Correct Answer-severe response to medications idiosyncratic reaction - Correct Answer-over- or under- reaction to a medication side effect - Correct Answer-unintended, secondary effect allergic reaction - Correct Answer-unpredictable response to a medication pg. 30 professoraxel toxic effect - Correct Answer-medication accumulates in the blood stream onset - Correct Answer-time it takes for a medication to produce a response trough - Correct Answer-minimum blood serum concentration before next scheduled dose duration - Correct Answer-time medication takes to produce greatest result serum half-life - Correct Answer-time for serum medication concentration to be halved peak - Correct Answer-time at which a medication reaches its highest effective concentration plateau - Correct Answer-blood serum concentration is reached and maintained after repeated fixed doses pg. 31 professoraxel completem medication order - Correct Answer- acetaminophen (Tylenol) 500 mg orally once daily for pain routes of administration - Correct Answer-oral (sublingual, buccal) parenteral (intradermal, subcutaneous, intramuscular, intravenous) inhalation topical intraocular standing or routine - Correct Answer-administered until the dosage is changed or another medication is prescribed PRN - Correct Answer-(pro re nata) given when the client requires it single one-time - Correct Answer-given one time only for a specific reason STAT - Correct Answer-given immediately in an emergency pg. 32 professoraxel the complex process of prescribing, dispensing, and administration - Correct Answer-What are the reasons medication error occurs? ventilation - Correct Answer-the process of moving gases into and out of the lungs perfusion - Correct Answer-the ability of the CV system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs diffusion - Correct Answer-exchange of respiratory gases in the alveoli and capillaries respiratory muscles lung compliance and elasticity lung volumes pulmonary circulation oxygen and carbon dioxide transport - Correct Answer-What does ventilation require? cardiac chambers/myocardial blood flow pg. 35 professoraxel conduction system coronary blood flow systemic circulation - Correct Answer-What does perfusion require? hypoventilation - Correct Answer-taking in more CO2 (retention) hypoxia - Correct Answer-lack of oxygen to an area Nursing history focus for oxygenation - Correct Answer- explore factors or conditions associated with impaired oxygenation physical assessment for oxygenation - Correct Answer-assess level of consciousness, general appearance, breathing pattern, etc. auscultate for lungs and heart sounds assess capillary refill, edema, etc. pulse oximetry - Correct Answer-What provides an instant feedback about the patient's level of oxygenation? pg. 36 professoraxel reduces pulmonary stasis, maintains ventilation and oxygenation - Correct Answer-What does positioning do for patients with cardiopulmonary issues? encourages voluntary deep breathing - Correct Answer-What does incentive spirometry do for patients with cardio pulmonary issues? bronchoscopy - Correct Answer-procedure that allows your doctor to look at your airway through a thin viewing instrument called a bronchoscope; your doctor will examine your throat, larynx , trachea , and lower airways thoracentesis - Correct Answer-is a procedure to remove excess fluid in the space between the lungs and the chest wall. This space is called the pleural space. Normally, the pleural space is filled with a small amount of fluid (about 4 tablespoons) pg. 37 professoraxel