vSim Fundamentals | Edith Jacobson (Patient Safety, Fall Risks, & the Older Adult)

Which complications is Edith Jacobson at risk for because of her age and hip fracture?

C.) Pressure Ulcer D.) Pneumonia E.) Mental deterioration

Which fall precautions should the nurse establish for Edith Jacobson after repositioning? (Select all that apply)

A.) Remind the patient that she is at high risk for falls due to her medications. B.) Educate the patient to use the call light if she needs to get up. E.) Make call light easily accessible.

The nurses comes into the room and observes Edith Jacobson moaning and guarding her leg. What should the nurse do next?

Administer pain medication Rationale: Administer after pain and respiratory assessment

What would be a priority nursing diagnosis for Edith Jacobson related to her psychosocial needs?

Anxiety

Which statement by the nurse indicates a need for further education related to a focused neurovascular assessment on Edith Jacobson?

I am going to check the pulses in your unaffected limb. Rationale: Assessing for changes in circulation, oxygenation, and nerve function; check peripheral pulses for presence, rate, and quality on both limbs and compare. Components of neurovascular assessment include pain, pallor (perfusion), peripheral pulses, paresthesia (sensation), paralysis (movement), and pressure.

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 d) Muscle weakness e) Range of Motion

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 d) Symptoms of dizziness e) Altered elimination

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.