VSIM 1 Edith Jacobsen

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

What is the priority outcome for Edith Jacobson in relationship to her hip fracture?

The patient will be able to walk with assistive device without fear of falling.

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

Administer pain medication

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?

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.

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

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

Pressure Ulcer Pneumonia Mental deterioration

Which fall precautions should the nurse establish for Edith Jacobson after repositioning?

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. Make call light easily accessible.

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.

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.)

Symptoms of dizziness High-risk medications Mental and emotional status Altered elimination

Edith Jacobson needs to be frequently repositioned. Why should the task take two people?

To prevent additional injury to the patient

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

Anxiety

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

Antiembolism stockings often have an inspection window. Which statement by the nurse indicates understanding of the purpose of the inspection window?

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.

Which nursing interventions should a nurse anticipate for an older patient with a hip fracture? (Select all that apply.)

Maintain non-weight bearing status. Prevent skin breakdown by frequent repositioning. Use logrolling techniques to turn the patient in bed. Reassess the affected extremity.

Edith Jacobson has been taking raloxifene for her osteoporosis. What is the priority nursing consideration for raloxifene related to the patient's current hip fracture?

Monitor for blood clot formation.

What should the nurse anticipate needing to teach Edith Jacobson before discharge in relationship to her hip fracture and mobility?

Use of assistive devices such as a walker