Fundamentals: Edith Jacobson
The nurse comes into the room and observes Edith Jacobson moaning and guarding her leg. What should the nurse do next? a) Administer an antibiotic b) Notify the provider c) Reassure the patient d) Administer pain medication
Administer pain medication Morphine sulfate was prescribed for management of pain and for sedation. Therefore, the nurse should administer the medication after completing a pain and respiratory assessment, The nurse should perform a respiratory assessment before administration because respiratory depression can occur in older patients. The provider has already ordered pain medication; the nurse should notify the provider after administration of the medication of the pain is not alleviated. Antibiotics are often given prior to surgery, but administering an antibiotic would not be the correct answer to this questions. Reassuring the patient is appropriate therapeutic communication but it is not the priority action.
What would be a priority nursing diagnosis for Edith Jacobson related to her psychosocial needs? a) Risk for Infection b) Impaired Physical Mobility c) Impaired Skin Integrity d) Anxiety
Anxiety Anxiety is the correct priority nursing diagnosis for the patient's psychosocial needs. An expected outcome would be for the patient to express feelings of decreased anxiety after the nurse encourages her to verbalize her feelings, especially any fear that she might have. The other options do not relate to psychosocial needs of the patient; they refer to physical needs.
Which statement by the nurse indicates a need for further education related to a focused neuromuscular assessment on Edith Jacobson? a) I see that you can move your toes. b) I am going to check the pulses in your unaffected limb. c) I have compared the skin on both legs and do not find any shiny areas. d) The skin temperature above and below your fracture is the same.
I am going to check the pulses in your unaffected limb. A neuromuscular assessment on Edith Jacobson would include assessing for changes in circulation, oxygenation, and nerve function. The nurse should check peripheral pulses for presence, rate, and quality on both limbs and compare. Components of a neurovascular assessment include pain, pallor (perfusion), peripheral pulses, paresthesia (sensation), paralysis (movement), and pressure.
Anti-embolism stockings often have an inspection window. Which statement by the nurse indicates understanding of the purpose of the inspection window. a) I will place the inspection window on top of the foot so I can easily assess capillary refill, temperature, and pulses of the patient's feet. b) I will place the inspection window on the bottom of the foot so when the patient walks, she does not slip and fall. c) I can use the inspection window to pull on and off the stockings. d) I will use the inspection window as a way to wash the patient's feet without taking off the stockings.
I will place the inspection window on top of the foot so I can easily assess capillary refill, temperature, and pulses of the patient's feet. The nurse should place the inspection window on the top of the foot so that the toes ca be inspected for capillary refill, temperature, and presence of a pulse. The other options do not indicate knowledge of the primary purpose of the inspection window.
Which fall precautions should the nurse establish for Edith Jacobson after repositioning? (Select all that apply.) a) Put the side rails up. b) Ask her daughter to help her out of bed if she needs assistance. c) Educate the patient to use the call light is she needs to get up. d) Make the call light easily accessible. e) Remind the patient that she is at high risk for falls due to her medications.
Make the call light accessible; Remind the patient that she is at high risk for falls due to her medications; Educate the patient to use the call light if she needs to get up. The nurse should make the call light is in reach of the patient. The nurse should teach the patient to use the call light to request assistance if she needs to get out of bed. The patient is at risk for falls due to the medications she is taking for pain management. Her daughter should not help her out of bed unless she feels comfortable doing so and has been educated on specific aspects; otherwise, she or her mother could injure themselves. Side rails are considered a restraint and should be raised only at the patient's request.
Which complications is Edith Jacobson at risk for because of her age and hip fracture? (Select all that apply). a) Osteoarthritis b) Mental deterioration c) Pneumonia d) Pressure Ulcers e) Gout
Mental deterioration, Pneumonia, Pressure Ulcers Pneumonia, pressure ulcers, and mental deterioration are all risk factors for the patient due to her hip fracture. Interventions to prevent complications would include frequent repositioning, deep breathing, incentive spirometry, adequate hydration, and frequent monitoring of her level of consciousness. Osteoarthritis would not be a complication from her hip fracture as the patient already has a history of the disease. Although gout is a disease that many older adults present with, it is not a correct answer for this question.
Edith Jacobson has been taking raloxifene for her osteoporosis. What is the priority nursing consideration for raloxifene related tot he patient's current hip fracture? a) Monitor lab results for high triglycerides. b) Monitor for increased efforts of hormone replacement therapy with concurrent use. c) Monitor for increased breast cancer risk. d) Monitor for blood clot formation.
Monitor for blood clot formation. The nursing consideration for raloxifene includes the need to watch for signs of blood clots. The greatest risk of thromboembolic events occurs during the first four months of treatment. Although raloxifene does not protect against breast cancer and increased triglycerides, these options would not be the priority nursing consideration with this patient. The drug should not be used in conjunction with hormone replacement therapy.
What is the priority outcome for Edith Jacobson in relationship to her hip fracture. a) The patient will be able to walk with an assistive device without the fear of falling. b) The patient will ave no signs or symptoms of infection while in the hospital. c) The patient will move in with her daughter, who will assist the patient with activities of daily living. d) The patient will be able to perform activities of daily living, such as dressing herself, before discharge/
The patient will be able to walk with an assistive device without the fear of falling. The older adult has a better chance of staying independent and free of illness if she can attain the highest degree of mobility possible within the confines of her injury. The goal of nursing care should be to facilitate this expected outcome. The other answer options could be anticipated outcomes, but they are not the priority outcome.
Edith Jacobson needs to be frequently repositioned. Why should the task take two people? a) To provide comfort for the patient b) To comply with hospital policy c) To prevent additional injury to the patient d) To allow complete assessment of the skin
To prevent additional injury to the patient. The patient needs to be kept in proper body alignment to prevent additional injury. Proper body mechanics should be utilized so that the health care workers do not also get injured. An assessment of the skin can be completed while repositioning, but this is not the reason for two people. Comfort measures would not require two people. Hospital policies can indicate how much a health care worker is allowed to lift but is not the correct answer for this question.
What should the nurse anticipate needing to teach Edith Jacobson before discharge in relationship to her hip fracture and mobility. a) Use of assistive devices such as a walker b) Restriction of activity c) Measures to reduce the risk of osteoporsosis d) Risk for loose stools with opioid analgesics
Use of assistive devices such as a walker The nurse should anticipate the need to teach the patient how to use any assistive devices she will be using at home and, after that education, should ask the patient to correctly demonstrate their use. It would not be appropriate for the nurse to teach Edith Jacobson about measures to reduce the risk of osteoporosis. The patient should restrict her activity but should strive to attain the highest activity possible for her injury. The nurse should instruct the patient that constipation, not loose stools, is common when taking opiod analgesics.