High Acuity- Section Review Questions

Which measures are useful in fall prevention?(select all that apply)

-rounds to address toileting needs -assessment of fall risk -identification of orthostatic hypotension

Which nursing skills demonstrate cultural competence?(select all that apply)

-showing respect -assessing and affirming differences -showing sensitivity -providing care with humility

Which factors contribute to medical errors?(select all that apply)

-staffing ratios -overtime -excessive documentation

When gathering a nursing history on an older adult client, what information from the client would indicate an increased risk for peptic ulcer disease?

"I take non steroidal anti-inflammatory drugs daily"

How may complementary and alternative therapies be used?(select all that apply)

-In lieu of standard medical treatment -as a complement to standard medical treatment

The nurse understands that there is an increased risk of neurologic side effects or toxicity from drug therapies in the older client, related to which age-related change?(select all that apply)

-a smaller brain volume -a more permeable blood-brain barrier -dilation of the ventricles

The atypical presentation of urinary tract infection often seen in the older adult client includes which symptoms?(select all that apply)

-abdominal pain -incontinence -nausea and vomiting -confusion

Age-related changes may affect which factors of pharmacodynamics?(select all that apply)

-absorption -metabolism -excretion -distribution

Critical incident stress debriefings can be used for which purposes?(select all that apply)

-address staff symptoms of stress -provide staff with a sense of closure -assess the need for follow ups

Which conditions are contraindications to massage therapy?(select all that apply)

-advanced osteoporosis -bone fractures -burns -DVT

Guided imagery may be a useful strategy for clients with which conditions?(select all that apply)

-anxiety -depression -pain

Which changes of aging decrease the older adult's ability to conserve body heat?(select all the apply)

-decreased muscle mass -decreased peripheral vasoconstriction

Why are medications not absorbed as well in the older adult?(select all that apply)

-decreased splanchnic blood flow -altered gastric pH

Which nursing interventions would support the client's REM sleep?(select all that apply)

-dimming lights during normal sleep time -reducing environmental noise -providing opioid analgesia at bed time -limiting visitation during quiet time

The nurse is aware that REM sleep has which effects on the client?(select all that apply)

-facilitates protein anabolism -promotes healing -restores the immune system

The atypical presentation of some older clients experiencing acute myocardial ischemia/infarction may include which manifestations?(select all that apply)

-falls -flu like symptoms -acute confusion

What are the hazards inherent in the use of technology?(select all that apply)

-fragmenting clients into subpopulations -increasing the nurse's stress level -increasing nurse dependence on machines for decision making

Which atypical signs of infection may be present in older clients?(select all that apply)

-functional decline -altered mental status -recent history of falls -unexplained hypo- or hyperglycemia

What are the ethical concerns surrounding resuscitation?(select all that apply)

-futility -likelihood of failure -decision making

What is a common characteristic of delirium?(select all that apply)

-inability to attend to environmental stimuli -acute onset -disorganized thinking -agitation

What are some risk factors for the development of sepsis in older clients?(select all that apply)

-institutionalization -pressure ulcers -altered mental status -indwelling urinary catheters

What is the proper procedure to ensure client safety when the nurse is preparing a med that will be administered to the client by another person?(select all that apply)

-labels should be verbally verified by two healthcare providers -labels should be visually verified by two healthcare providers

The term "burnout" refers to which feelings?(select all that apply)

-personal and professional frustration -physical and emotional exertion -job dissatisfaction

Which factors can help buffer the negative effects of stress?(select all that apply)

-positive social climate -managerial support -cohesiveness among staff

When teaching high acuity clients, what are the initial goals?(select all that apply)

-reduce stress -promote comfort

Which statements are correct regarding the use of technology devices in high acuity care?(select all that apply)

-they present mechanical impediments to touching -they make evoke fear in clients -they lead to a feeling of depersonalization -they may increase client anxiety

Why are older adults more likely to present with a common problem in an uncommon way?(select all that apply)

-they take more medications -they have more comorbidities -they are at a greater risk for infection

What are the components of a healthy work environment?(select all that apply)

-true collaboration -appropriate staffing -authentic leadership -skilled communication

In mechanically ventilated older clients, weaning is often more difficult for which major reason?(select all that apply)

-weak respiratory muscle function -altered respiratory mechanics -changes in hemodynamics

Which changes can induce anxiety in the high-acuity patient? (select all that apply)

-weaning from a mechanical vent -increasing mobility -changing monitoring

About what percentage of older adults were living in institutional settings in 2013?

3.4%

A client was involved in a MVC.... client is drawing plans for remodeling his porch to accommodate a wheelchair. This behavior reflects which stage of illness?

Acceptance

What is the best tool for assessing delirium in the high-acuity older adult?

CAM-ICU

Evidence suggests that which of the following factors reduces mortality and life-threatening complications in the hospitalized client?

Constant surveillance of clients by nurses

When interacting with a client in denial, what is the nurse's best strategy?

Function as a noncritical listener

As a general statement, it would be correct to say that older adults have which characteristic?

Increasingly diverse

What should be the focus of care of the high-acuity client?

Individual client needs

Which strategy should the nurse use to reduce transfer anxiety?

Introduce the client and family to the receiving nurse before the transfer occurs

A hospital with an ICU that has the capability of providing comprehensive care to most critically ill clients, but not to trauma clients, meets the criteria for which level ICU?

Level 2

In the U.S. what is the fastest growing age group(by decade)?

People over 85

According to some, ICU resources should be used for which clients?

Those who have the greatest possibility of benefitting

Which statement is accurate concerning unlicensed assertive personnel?

UAP performs only those tasks delegated to them by a professional nurse

Why are older adults prone to abdominal injury with very little force?

abdominal wall is weakened

Family presence during CPR contributes to which result?

ability of family to say goodbye

What do the current client safety and healthy work environment cultures in the high acuity environment promote?

an increase in error reporting and systems improvement

How often should the nurse conduct a skin assessment?

at least weekly

Which statement best describes cultural diversity?

cultural diversity plays an important role in the care of the high acuity client

Dehydration and hyponatremia in the older adult are often associated with which physiologic alteration in the kidneys?

declining renal tubule function

Which age related change in urinary system function should the nurse anticipate in the older adult?

decreased glomerular filtration rate

The nurse expects which age-related change when checking the pupils in the older client?

decreased response to light

The nurse understands that, in the older adult client, the diminished rate of neurotransmitter synthesis leads to which condition?

decreased sympathetic nervous system response

When caring for the older client, which intervention should be a nursing priority for prevention of airway clearance and gas exchange complications?

deep breathing and coughing exercises

When caring for the older client, which common nursing intervention is most likely to result in skin breakdown?

elevating the head of the bed 30 degrees

Which term describes a set of social, cultural, and political beliefs held by a group of individuals?

ethnicity

What is the effect of unrestricted visiting hours on some clients?

fewer hallucinations

How do the effects of burn injury in an older adult compare to those in a young person?

greater depth and size of burn, prolonged healing, and decreased scarring

Nurses are challenged with the task of blending which types of care to enhance the quality of life of older adults at the end of life?

high-tech and high-touch

Which statement best describes the use of humor as a therapy?

humor is a CAT that can be used w/ high acuity clients

The nurse understands that age-related changes in the thyroid gland increase the risk for development of which thyroid related problem in the older client?

hypothyroidism

Why is subdural hematoma a common complication of brain injury in the older client?

increase in intracranial space between the brain and dura

Which statement is correct regarding the improvement of the death and dying experience?

it is a goal of modern medicine

Which statement is correct regarding hypoactive delirium in the older adult?

it is sometimes misdiagnosed as depression

Which description of Alzheimer disease is most accurate?

it is the most common cause of progressive dementia

Why is the risk of pulmonary infections higher in the older client?

loss of pulmonary epithelial cell function

Which assessment finding is the client with depression most likely to exhibit?

low mood

The older client may not develop a fever as an early sign of infection due to which factor?

lower basal temperature

What is the expected cognitive status of older adults?

memory retention

Which brief and easy test is used to evaluate a high-acuity older client for dementia?

mini-cog mental status test

The nurse recognizes that older clients can have delayed manifestations of intracranial bleeding due to which age-related change?

more dead space in the cranium

What should the nurse use to validate the technologic data?

nursing assessment data

Which musculoskeletal condition is most prevalent among older adults?

osteoarthritis

The nurse is aware that in the older adult high acuity client, altered gastric pH increases the risk of which complication?

pneumonia

Which priority level indicates that the client is acutely ill and unstable and requires intensive treatment and monitoring that can not be provided outside the ICU?

priority 1

What is an appropriate nursing intervention for a client experiencing shock and disbelief about his or her diagnosis?

providing accurate information

When an older adult requires pain medication, how should it be administered?

routinely

Which factor increases the older adults risk of traumatic injuries?

sensory changes

How can the nurse enhance communication with clients?

speaking in small units of speech

Which noise do high-acuity clients report as being most annoying?

staff's loud voices

Which consideration is most important when assessing for the presence and severity of pain?

the client's account of the pain

What must be done to ensure client safety before a percutaneous tracheostomy is placed at the bedside?

the correct client, site and procedure should be identified during a "time-out"

In caring for the older adult experiencing high levels of stress, the nurse would expect which heart rate response?

the heart rate remains below what would be expected in a younger adult with an equal stress level

What does the designation of magnet status indicate?

the hospital uses practice models that promote professional nursing

Which statement about IMC is correct?

they provide an efficient distribution of resources

The older client is more susceptible to skin breakdown for which reasons?(select all that apply)

thinning of the skin