Course Point Edith Jacobson (Health Assessment Case 9) Post-Quiz

A patient has reported dizziness that has been associated with orthostatic hypotension. What information will the nurse provide to the patient that is directly associated with this condition?

A patient has reported dizziness that has been associated with orthostatic hypotension. What information will the nurse provide to the patient that is directly associated with this condition?

To assess an adult patient suspected of experiencing increased intracranial pressure (ICP), the nurse will implement which intervention?

Your Response: Check pupillary activity Rationale:Changes in pupillary activity (pupil size, shape, equality, and response to light) may signal increased intracranial pressure (ICP). Impaired swallowing (known as dysphagia) is not associated with increased ICP. Changes in vital signs alone (including blood pressure) rarely indicate neurologic compromise; therefore, any changes should be evaluated in light of a complete neurologic assessment. Disorientation can be a result of a variety of factors.

Mrs. Jacobson was prescribed raloxifene hydrochloride 18 months ago. She is concerned the dizziness she felt just before she fell is a result of the medication. How does the nurse best address her concerns?

Your Response: Assure her that dizziness is not one of the recognized side effects of that medication Rationale:The nurse needs to assure Mrs. Jacobson that dizziness is not one of the recognized side effects of that medication. Raloxifene hydrochloride has been associated with triggering central nervous system reactions such as depression, insomnia, fever, and migraine headache, but is not associated with either vertigo or dizziness. Although the medication would be discontinued until Mrs. Jacobson is mobile again, it is because the medication increases the risk of venous thromboembolism formation, especially in the first 4 months of therapy.

The nurse's patient, Edith Jacobson, is being monitored after a fall that resulted in a fractured hip. Her initial assessment included a Glasgow Coma Scale assessment that showed she had no observable deficiencies involving consciousness. Following the provider's orders she is being monitored with the administration of the Glasgow Coma Scale every 4 hours. When the current assessment indicates that the patient has scored a 14, what will the nurse's initial response be?

Your Response: Document the latest Glasgow Coma Scale results as 14 Rationale:The scoring scale for the Glasgow Coma Scale ranges from 3 (lowest score indicating no responses in any of the focus areas) to 15 (highest score indicating no observable deficiencies in any of the focus areas). The orders supported the provider's desire to be notified of any changes in the patient's neurologic status. Since a score of 14 indicates that no observable deficiencies are noted, the nurse will document the results in the patient's medical record. There is no need to document that the assessment will be done again in 4 hours.

An older adult patient is being assessed for potential fall risks. Which statements by the patient would the nurse identify as risk factors? (Select all that apply.)

Your Response: I celebrated my 81st birthday last month., My cataract surgery is scheduled in 6 weeks., I've started to have some trouble getting to the bathroom in time., I'm less depressed since I've moved in with my daughter. Rationale:Advanced age (over 80), vision deficits, depression, and incontinence are personal risk factors for falls. Neither medication is typically associated with an increase for falls. Using more than four prescription medications is considered a risk factor.

Which statement by a patient would cause the nurse to suspect that a pattern of falling exists?

Your Response: I fell twice when I was visiting my daughter 2 months ago. Rationale:The nurse would be most concerned about the falls that occurred over a 1-month period. The history should determine the circumstances surrounding the falls of the past 3 months to determine whether a pattern exists. The other options are not necessarily characteristic of a pattern of falls.

What suggestions will the nurse include in the education materials regarding falls prevention at home for an older adult with a history of falls? (Select all that apply.)

Your Response: Keep floors clear of paper clutter, Store often-used items on shelves that are at waist level, Keep halls and stairs well lighted, Wear rubber-soled shoes Rationale:Decluttering, keeping potentially dangerous areas well lighted, wearing rubber-soled shoes, and minimizing the need to climb or stretch to reach commonly used items will all help to prevent falls. Because reading glasses tend to distort far vision, they should not be worn when ambulating.

A patient who fell and hit her head and fractured her femur is scheduled for surgery in the morning. The patient has had a complete neurologic assessment and is currently in stable condition. How will the nursing staff best monitor the patient's neurologic status?

Your Response: Perform a neurologic check every 4 hours Rationale:A neurological check, or neuro check, is useful in an emergency situation and when frequent assessments are needed during an acute phase of illness to detect rapid changes in neurologic status. It is also useful for a patient who has already had a complete neurologic examination but needs to be rechecked for changes related to therapy or other conditions. The neuro check includes assessment of consciousness; pupil checks; extremity assessment for strength, movement, and sensation; and vital signs. The question asks for the best way to monitor the patient. Although the other actions are associated with monitoring a patient's neurologic status, none would provide as complete an assessment of the patient's neurologic function as the neuro check, nor would they serve as a baseline for future assessments.

What behavior would the nurse document as lethargy related to Mrs. Jacobson's level of consciousness (LOC)?

Your Response: Remains awake only long enough to answer questions Rationale:When considering levels of consciousness, lethargy would be demonstrated by a patient who opens her eyes, answers a question, and then falls back asleep. Awakening to only loud noises and appearing confused are associated with the term "obtunded," whereas stupor is associated with awakening that requires being physically shaken.

An older adult is being prepared for discharge to her daughter's home after completing rehabilitation following surgery to repair a hip fracture. What information will the nurse include in discharge teaching to best help minimize the patient's risk for falls? (Select all that apply.)

Your Response: Use a walking device to help with proper balance, Sit down and rest when feeling dizzy, Turn on lights at night when getting out of bed to go to the bathroom, Drink enough fluids to keep your urine pale and clear Rationale:The risk of falls can be minimized best by attempting to manage some of the most common reasons for falls: dizziness, poor balance, poor visibility, and dehydration resulting in hypotension. It is not necessary to limit movement; actually, movement and reasonable exercise will help strengthen the muscles and bones and improve balance.