Edith Jacobson - VSIM - Pre-Questions

Which age-related change(s) increase the risk for complications after illness or injury in the older adult? (Select all that Apply.) a) Fragile blood vessels b) Altered pain and pressure perception c) Heightened senses of taste and smell d) Decreased skin elasticity e) Decreased muscle strength and bone demineralization

a, b, d, e

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.) a) Is this the first time you have fallen? b) Have you had any difficulty eating? c) Are you still able to drive? d) How active are you? e) How well do you usually sleep?

a, b, e

An older adult patient has been admitted for a hip fracture. The nurse is assessing fall risk with a fall risk tool. What essential elements should the tool assess? (Select all that apply.) a) Mental and emotional status b) High-risk medications c) Nutritional status d) Symptoms of dizziness e) Altered elimination

b, d, e

A provider orders docusate sodium 100 mg, PO twice a day for an older patient. The pharmacy provides docusate sodium liquid 150 mg/mL. How much medication should the nurse administer? a) 30 mg b) 0.6 mL c) 10 mg d) 10 mL

d

Prior to surgery, the nurse is discussing expected outcomes with Mrs. Jacobson after surgery. The nurse recognizes that Mrs. Jacobson requires further education when she makes which of the following statement(s)? (Select all that apply.)

'While taking opioid analgesics, I may experience diarrhea.', ' Because I have osteoporosis, I should limit my activity.' Rationale:The nurse should instruct the client that constipation, not loose stools, is common when taking opioid analgesics. The client should not restrict her activity but should strive to attain the highest activity level possible for her injury. The nurse should anticipate the need to teach the client how to use any assistive devices she will be using at home and, after that education, should ask the client to correctly demonstrate their use. Fall prevention education would include potential risks associated with certain medications and the use of assistive devices. She should also be given information regarding home modifications such as adding stair railings or grab bars in the bathroom, which will decrease her risk of falls at home. Vitamin D is commonly recommended for clients with osteoporosis to strengthen bones and increase the absorption of calcium.

The nurse caring for Mrs. Jacobson completes her initial assessment. Which of the following assessment finding(s) are significant in establishing the plan of care for the client? (Select all that apply.)

Last repositioned 3 hours ago, Pain 5/10 with movement of the left leg, Lives alone with two small dogs Rationale:Standard of care requires that clients are repositioned every 2 hours to assist in preventing skin breakdown and injury. Ensuring that Mrs. Jacobson is repositioned as soon as possible will be an important part of her plan of care. Although expected, pain in the left leg should be monitored frequently and treated as needed to provide comfort to the client and support less painful repositioning efforts. The care plan should also include providing education about fall risks; to do so, the nurse will need to consider Mrs. Jacobson's living status and complete a home assessment to evaluate potential hazards, including the possibility of her tripping over her dogs. The capillary refill, blood pressure, mental status, and pedal pulses are all within normal limits and do not require focused planning at this time.

The nurse preparing to care for Mrs. Jacobson is reviewing the information provided in the SBAR report and recognizes that which of the following require a priority evaluation during the initial shift assessment? (Select all that apply.)

Mental status, Circulation, Pain level, Fall precaution status, Musculoskeletal status Rationale:The report provided does not indicate if Mrs. Jacobson is alert and oriented. This in combination with a history of recent dizzy spells indicates the need for a focused mental status assessment. Because of the hip fracture and Mrs. Jacobson's decreased mobility, it will be important to assess circulation, particularly to the lower extremity of the injured side. Assessment of the pain level in a client with recent trauma should be initiated early and repeated often. Ensuring that all necessary fall precautions are in place will be important to include in the client's plan of care. Based on the diagnosis of hip fracture and plan for surgery, a focused musculoskeletal assessment should be performed, to include inspecting and palpating the muscles and joints, as well as evaluation of range of motion (ROM) and muscle strength. The current position of Mrs. Jacobson is not as important as the length of time since she was last repositioned.

While waiting for assistance in repositioning Mrs. Jacobson, the nurse initiates a neurovascular assessment. Which of the following should be included in an appropriate neurovascular assessment for this client? (Select all that apply.)

Assessing for paresthesia, Comparing assessment of the left and right lower extremities, Assessing for capillary refill, Assessing skin temperature above and below fracture site, Assessing for movement of the toes

The nurse has established a plan of care for Mrs. Jacobson and recognizes that the priority intervention for this client will be

Blank-1administering pain medication Blank-2increase comfort during repositioning Rationale:Mrs. Jacobson will require pain medication first, so that she can better tolerate repositioning. Once this has been completed, other tasks, such as repositioning or fall prevention education, can occur. Obtaining surgical consent is not a priority at this time.

Assistance has arrived to reposition Mrs. Jacobson. Which of the following action(s) are included while working together in repositioning the client? (Select all that apply.

Support the body with pillows, Demonstrate proper body alignment for client, Demonstrate proper body alignment for nurses, Place call light within reach, Educate on fall risk Rationale:During and after repositioning, the body should be supported with pillows to provide comfort and support maintenance of proper alignment. Safety during the procedure is maintained by demonstrating proper body alignment for both the client and the nurses. After the client is repositioned, the call light should be placed in a location easily accessible to the client. Education regarding the risk of falls and injury should be provided to the client. The height of the bed should be raised to a level that allows the nurses to maintain proper body mechanics while repositioning and is then lowered after the procedure is completed. Mrs. Jacobson has a fractured hip and should only be positioned on the unaffected side.

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? a) Reposition the patient every 2 hours b) Use a draw sheet to slide the patient c) Sit the patient up in a chair d) Provide rest and comfort measures

a

Which nursing interventions should a nurse anticipate for an older patient with a hip fracture? (Select all that apply.) a) Use logrolling techniques to turn the patient in bed. b) Prevent skin breakdown by frequent repositioning. c) Maintain non-weight bearing status. d) Reassess the affected extremity. e) Increase the patient's activity level before surgery.

a, b, c, d

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.) a) Joint tenderness b) Pain c) Gait d) Muscle weakness e) Range of Motion

a, b, d, e

Devices such as pillows, trapeze bars, special mattresses, and trochanter rolls are used for what primary purpose? a) To facilitate ROM b) To alleviate pressure and maintain proper body alignment c) To provide patient comfort d) To facilitate activities of daily living

b