Edith Jacobson v-sim
The nurse performs a focused musculoskeletal assessment on a patient with a hip fracture. Which should the nurse include for this type of assessment? (Select all that apply.)
Pain, Joint tenderness, Range of motion, Muscle weakness -A focused musculoskeletal assessment on a patient with a hip fracture would include assessing pain, joint tenderness, range of motion, and muscle weakness. In addition, many practitioners assess the neuromuscular, musculoskeletal, and peripheral vascular systems as an integrated assessment. Although gait is part of a complete musculoskeletal assessment, this is not an anticipated assessment at this time.
An older adult is admitted for a hip fracture and is confined to bed. What is the priority action by the nurse to decrease the risk of pressure ulcer?
Reposition the patient every two hours. - A pressure ulcer may form in as little as one to two hours if the patient has not moved or been repositioned to allow circulation to flow to dependent areas. Patients who are immobile or confined to bed are at high risk for a pressure ulcer. Sitting up a patient with a hip fracture would not be an appropriate intervention. All patients should receive rest and comfort measures; however, these measures are not a priority to decrease the risk for pressure ulcer. Never slide a patient with a draw sheet; lift the patient, so as not to increase the risk for friction shear.
Devices such as pillows, trapeze bars, special mattresses, and trochanter rolls are used for what primary purpose?
To alleviate pressure and maintain proper body alignment - These devices are commonly used to help maintain proper alignment and alleviate pressure on various parts of the body while a patient is confined to a bed. The devices might provide some comfort for the patient, but that is not their primary purpose. The devices are not used for the purpose of facilitating activities of daily living or range of motion.
Which age-related change(s) increase the risk for complications after illness or injury in the older adult? (Select all that apply.)
Decreased skin elasticity, Fragile blood vessels, Altered pain and pressure perception, Decreased muscle strength and bone demineralization. - An older adult is more likely to develop complications and to recover more slowly following illness or injury. In addition, age-related changes place the older adult at risk for complex reactions to illness. Skin changes such as decreased elasticity and fragile blood vessels, along with pain and pressure perception changes, can put the older adult at risk for pressure ulcers. Bone demineralization, along with decreased muscle strength, can put the older adult at risk for fractures. Senses such as taste and smell are diminished, which can cause poor nutrition and can influence wound healing.
Which subjective questions by the nurse demonstrate a familiarity with commonly occurring disorders that can put an older patient at risk for unnecessary iatrogenesis? (Select all that apply.)
How well do you usually sleep?, Have you had any difficulty eating?, Is this the first time you have fallen? - The Fulmer SPICES tool is used to obtain information related to the following prevalent problems experienced by older adults: sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown. The SPICES tool should be used with any older adult to gather baseline information for more in-depth investigation. Asking about activity level or independence related to driving would not help the nurse prevent or detect complications prevalent to an older adult in the hospital.
