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

An older adult patient who lives alone is hospitalized after falling and sustaining a broken arm. Which nursing action will best determine whether the patient is experiencing any cognitive dysfunctions that may have contributed to the fall?

Your Response: Administer an assessment tool such as the Mini-Cog Rationale:Assessment tools that focus on mental status, such as the Mini-Cog, validate and provide objective early warning of possible deterioration of mental function. Although the family can be a source of information, they may be uninformed, or may underreact or overreact to the patient's behaviors. The Glasgow Coma Scale focuses on evaluation of a person's state of consciousness. Asking the patient to explain the meaning of a phrase evaluates abstract thinking, which is only one component of cognitive function

Which nursing actions demonstrate an understanding of the components required when conducting the objective portion of a neurologic assessment? (Select all that apply.)

Your Response: Evaluate cranial nerve XI function by asking the patient to shrug the shoulders, Test for tactile discrimination using a door key Rationale:A complete neurologic examination consists of evaluating the following five areas: mental status, cranial nerves, motor and cerebellar systems, sensory system, and reflexes. The evaluation of cranial nerve XI can involve demonstrating the ability to shrug one's shoulders. Tactile discrimination can involve identifying a door key by touch. The mental status exam is conducted first to assess the patient's ability to provide valid subjective information, not to minimize anxiety. The Romberg test evaluates balance, not coordination. A reflex hammer is used to elicit deep tendon reflexes, not superficial responses.

1During a routine visit, an older patient shares that recently he has had "trouble remembering things; little things like where I put my keys." Which interview question will the nurse ask to best identify a possible physical cause for the lapses in memory?

Your Response: Have you ever had any kind of head injury during your lifetime? Rationale:Head injuries, even minor ones, can cause long-term neurologic deficits and affect cognitive functioning. Assessing for such an event would provide a possible cause for the patient's memory lapses. Although it is appropriate to ask about when the memory lapses began and what medications the patient is taking, these questions are not focused on a physical cause of the patient's memory issues. The term "major traumatic events" is broad and can include emotional events as well as physical.

The nurse is reviewing patient data from a neurological assessment and notes that the patient's history includes several recent falls. Which nursing action will the nurse take immediately to address the patient's risk for injury?

Your Response: Implement the facility's universal fall precautions Rationale:Safety is the primary concern. The implementation of universal fall precautions is the initial intervention. The other options are appropriate but do not have priority over addressing safety needs.

Which nursing actions would be effective when managing an older adult patient's risk for injury related to falling? (Select all that apply.)

Your Response: Present the patient with fluids regularly throughout the day, Measure the patient's blood pressure both when sitting and upon standing, Encourage the patient to wear prescription glasses, Offer to take the patient to the toilet every 2-3 hours Rationale:Falls may be the result of intrinsic factors, such as orthostatic hypotension, dizziness, failing eyesight, or incontinence. Hydration is important to the older adult patient and can be a factor in the development of dizziness; fluids should not be limited.

A patient undergoing a neurological assessment fears a serious diagnosis. Which action by the nurse will best ensure that the patient will comply with the assessment process?

Your Response: Treat the patient's concerns and fears with both sensitivity and empathy Rationale:Patients experiencing symptoms associated with the neurologic system may fear that they have a serious condition (such as a metastatic brain tumor) or a difficult-to-treat disease (such as Alzheimer's). Fear of losing control and independence and threatened self-esteem or role performance are common. The examiner needs to be sensitive to, and address, these fears and concerns or else the patient may decline to share important information. All assessments should be approached in a positive, professional manner with attention being paid not only to the interview and history but also the examination. Although dizziness and headaches are commonly reported, they are not necessarily the most common complaints.

An older adult patient has fallen and sustained a bruise to the forehead. Although there appears to be no significant injury, the family is concerned when the provider orders a Mini-Cog assessment and asks, "Why are you testing her memory and mental abilities?" Which explanation best meets the family's expressed needs?

Your Response: Your mother's fall may have hurt the frontal lobe of her brain. That is the part that controls memory, reasoning, and judgment. Rationale:The frontal lobe of the brain directs a variety of functions, both physical and nonphysical. Communication, emotions, intellect, reasoning, judgment, and behavior can be influenced by trauma to that portion of the brain. The Mini-Cog assessment is a simple but effective screening tool that can identify such cognitive impairment in its earliest stages. The explanation of why a Mini-Cog assessment has been ordered for this particular patient will best answer the family's question. Although it is appropriate to provide the family with an opportunity to express their concerns, doing so doesn't answer their question. The patient's age is not pertinent to the reason for conducting the Mini-Cog, as this assessment would be performed on anyone who sustained such a head injury. It is not appropriate to suggest to the family that the assessment will not identify a cognitive dysfunction, since there is no way to make such a guarantee.

Which nursing actions are associated with conducting a Glasgow Coma Scale assessment on a patient who has fallen and sustained a possible brain injury? (Select all that apply.)

Your Response: Ask the patient to identify where he or she is, Request that the patient squeeze the nurse's hand, Observe which stimuli cause the patient to open his or her eyes Rationale:The Glasgow Coma Scale, which is used to evaluate a patient with possible neurologic deficiencies, focuses on eye opening response, verbal response, and motor response. The assessment of pain or of vital signs is not included in the screening.

An older patient reports feeling dizzy right before falling. Which action by the nurse indicates an understanding of how dizziness can be triggered? (Select all that apply.)

Your Response: Ask, "Had you been taking any nonprescription medications before the fall?", Review the patient's medical history for previous head injuries, Assess the patient's blood pressure Rationale:Dizziness has many causes, including hypertension, previous head injury, and the side effect of certain medications. There is a correlation between dizziness and niacin, folic acid, or vitamin B12 deficiency, but not between dizziness and dietary calcium deficiency. Vertigo is described as a sensation in which a person's environment is moving or spinning. It differs from dizziness, which is usually described as lightheadedness. The distinction has no bearing on the cause of the sensation.