Clinical V-Sim Week 1

Increased risk for respiratory infections is directly related to which age-related change? 1. Reduction of body fluids 2. Decrease in the number of alveoli 3. Altered pain sensations 4. Overinflation of lung bases

1 (Rationale: A reduction in body fluid and reduced fluid intake can cause drier mucous membranes, impeding the removal of mucus and leading to the development of mucus plugs and infections. Altered (diminished) perception of pain sensation can cause existing infections to go unnoticed. A decrease in alveoli would contribute to activity indolence. Underinflation of the lung bases occurs with aging and would affect gas exchange.)

When preparing to conduct a mental status assessment, which initial statement would be appropriate for the nurse to make? 1. The questions I'm about to ask are a part of the assessment that is done on all patients. 2. Are you familiar with the questions asked as part of a mental health assessment? 3. I'm sorry that these questions are of a very personal nature, but they must be asked. 4. Please let me know if any of my questions are embarrassing to you.

1 (Rationale: Approach the evaluation in a matter-of-fact manner, not in an apologetic or intimidating one, with reassurance that this evaluation is part of every patient's assessment. Because patients may be anxious, embarrassed, unfamiliar, or insulted by having their mental status reviewed, explain the importance of and the reasons for the examination. Addressing such issues as embarrassment, familiarity, or discomfort with the topic should occur only when the nurse identifies a need.)

Which statement made by an older adult patient is associated with the most common mental health problem experienced by that population? 1. I get depressed when I think about all of my friends who have died. 2. I can't help but think that my children only want my money. 3. At my age I should be able to drink as much alcohol as I want. 4. I occasionally forget names and telephone numbers.

1 (Rationale: Depression is the most common problem that psychiatrists treat in older adults; some estimate that as much as 25% of the older adult population is depressed. Although major depression declines with age, minor depression increases in incidence with age. Older adults confront many problems that challenge their emotional well-being, which may predispose them to paranoia or alcohol abuse, but these conditions are not as frequently diagnosed as depression. Some degree of forgetfulness is an accepted outcome of aging.)

Which nursing intervention will help to minimize anxiety in an older adult patient during hospitalization? 1. Involving the patient in selecting preferences regarding care-focused decisions to support the need for stability 2. Providing only basic information regarding the treatment plan so as to minimize information overload 3. Encouraging the patient to form new friendships with other patients to provide needed interpersonal contacts 4. Promoting patient involvement in spontaneous activities during free time in order to support the need for socialization

1 (Rationale: Anxious people need their lives to be simplified and stable, with few unpredictable occurrences. Encouraging and respecting the patient's decisions over matters affecting his or her life would be the best intervention for minimizing the patient's anxiety initially. In order to provide stability, the patient should be fully educated concerning his or her treatment plan. The patient requires adequate preparation for all activities, while the introduction of new people should be minimal in order to reduce anxiety-producing stressors.)

What is the proper order of nursing actions when preparing to administer oxygen to a patient via nasal cannula? - Perform hand hygiene. - Verify the provider's order for oxygen therapy. - Assess and document the patient's vital signs. - Explain the procedure to the patient. - Confirm the patient's identity. - Gather the equipment.

1)Verify the provider's order for oxygen therapy. 2)Perform hand hygiene. 3)Gather the equipment. 4)Confirm the patient's identity. 5)Assess and document the patient's vital signs. 6)Explain the procedure to the patient. (Rationale: In order of priority, the nurse should first verify the provider's order for oxygen therapy (because oxygen is considered a medication or therapy and should be prescribed), perform hand hygiene, gather the equipment, confirm the patient's identity (using at least two identifiers according to the facility's policy), obtain a baseline physical assessment (including vital signs, breath sounds, oxygen saturation, and physical assessment), and finally explain the procedure and the reason for oxygen to the patient (he or she will need to be able to cooperate with oxygen administration).)

Which of the following classifications of medications are known to trigger depression? (Select all that apply.) 1. Corticosteroids 2. Psychotropics 3. Central nervous system (CNS) stimulants 4. Antianxiety agents 5. Antihypertensives

1,2,4,5 (Rationale:Certain drugs can cause or aggravate depression. These drugs include antihypertensives and cardiac drugs; hormones such as corticotropin, corticosteroids, and estrogens; central nervous system depressants (not stimulants); antianxiety agents; and psychotropics, among others.)

Which patient statements support the nurse's initial assessment that the patient is experiencing an adverse reaction to albuterol? (Select all that apply.) 1. I've been getting headaches since I started this medicine. 2. I can't understand why constipation has become a problem. 3. I get leg cramps so bad; they wake me up at night. 4. I've had heartburn every day this week. 5. I don't know why I'm getting so many nosebleeds.

1. I've been getting headaches since I started this medicine. 3. I get leg cramps so bad; they wake me up at night. 4. I've had heartburn every day this week. 5. I don't know why I'm getting so many nosebleeds. (Rationale: Adverse reactions to albuterol include headache, epistaxis, heartburn, and muscle cramps. Constipation is not a recognized adverse reaction to albuterol.)

What is the major indication for the use of albuterol sulfate? 1. Treatment of bronchospasms in patients with reversible obstructive airway disease 2. Maintenance therapy to control asthma symptoms 3. Prevention of bronchospasms in patients also diagnosed with cardiovascular disorders 4. Substitution for poorly tolerated corticosteroid therapy

1. Treatment of bronchospasms in patients with reversible obstructive airway disease (Rationale: Albuterol sulfate is prescribed to prevent or treat bronchospasms in patients with reversible obstructive airway disease. Regular use for maintenance therapy to control asthma symptoms isn't recommended. Bronchodilators and corticosteroids have different effects; therefore, these therapies are not interchangeable. Bronchodilators like albuterol sulfate must be used cautiously in patients with cardiovascular disorders, hyperthyroidism, or diabetes mellitus and in those who are unusually responsive to adrenergics.)

During a respiratory assessment of an older adult experiencing an exacerbation of chronic obstructive pulmonary disease (COPD), what abnormality would be detected by auscultation? 1. Wheezes 2. Cyanosis 3. Minimal chest movement 4. Tactile fremitus

1. Wheezes (Rationale: Auscultation involves listening to the lungs, typically with the aid of a stethoscope. Wheezes are breath sounds heard in patients experiencing respiratory distress associated with COPD. Chest movement and tactile fremitus are palpated or felt, whereas cyanosis, a bluish tinge of the skin resulting from poor oxygenation, is observable or seen.)

A diagnosis of respiratory acidosis is supported by which laboratory data? (Select all that apply.) 1. pH 7.34 2. PaCO2 34 3. PaCO2 50 4. pH 7.45 5. HCO3- 28

1. pH 7.34 3. PaCO2 50 5. HCO3- 28 (Rationale: Respiratory acidosis is characterized by a pH below 7.35, PaCO2 above 45, and HCO3- above 26. Normal pH is 7.35 to 7.45 and normal PaCO2 is 35 to 45.)

When older adults experience disruptions in their usual routines, which emotion are they most likely to experience? 1. Guilt 2. Anxiety 3. Despair 4. Resentment

2. Anxiety (Rationale: Distractions from ritualistic activity (daily, familiar routines) can provoke anxiety or agitation in the older adult. Unexpected disruptions are often difficult for the older adult to cope with and can cause anxiety and fear. Guilt is usually associated with the feeling of remorse over some action taken, while resentment is often associated with a loss. Despair is generally a reaction associated with depression.)

A deficiency in which blood factor is likely to indicate a possible cause of shortness of breath (dyspnea)? 1. Leukocytes 2. Hemoglobin 3. Sodium 4. Glucose

2. Hemoglobin (Rationale: In men, the level of hemoglobin (Hb) is normally 14 to 17.4 g/dL. A low Hb level may indicate anemia, recent hemorrhage, or fluid retention. Inadequate Hb results in diminished ability to attach oxygen to red blood cells and can result in shortness of breath, especially triggered by activity. A deficiency in leukocytes (white blood cells) would possibly increase the risk for infection. Low sodium can affect neurological functioning, and low serum glucose levels can cause hypoglycemia.)

Which factor(s) is considered a risk factor for the development of depression? (Select all that apply.) 1. Male gender 2. Recent retirement 3. Prescribed beta-adrenergic blocker therapy 4. Personal history of alcohol abuse 5. Chronic illness diagnosis

2. Recent retirement 3. Prescribed beta-adrenergic blocker therapy 4. Personal history of alcohol abuse 5. Chronic illness diagnosis (Rationale: Risk factors for depression include: female gender, family history of major depression or bipolar disorder, chronic illness, chronic pain, substance abuse, and an adverse reaction to medication such as beta-adrenergic blockers.)

Why is it most important that an older adult caregiver be assessed for both physiological and psychological stressors? 1. A caregiver's ability to provide effective care is most dependent upon psychological and physiological wellness. 2. Advanced age increases an individual's susceptibility to stress-related disorders. 3. Stressors associated with caregiving increase the risk for physical and psychological disorders. 4. Thoroughly assessing the caregiver for any indications of illness or risk of illness is the nurse's responsibility.

3 (Rationale: Providing care places caregivers at risk for the development of depression, grief, fatigue, financial hardship, and changes in social relationships. They may also experience physical health problems due to psychological stressors and their effect on the immune system. These factors are enhanced when the caregiver is also affected by the normal process of aging. Although assessment is a nursing responsibility, identifying the potential or existing health-related risks of the caregiver is the basis for such an assessment. Being well physically and psychologically is important, but other considerations, like the presence of an effective support system, are also factors that influence the effectiveness of caregiving.)

A patient diagnosed with chronic obstructive pulmonary disease (COPD) is wakened from sleep demonstrating behaviors that indicate difficulty breathing. Which intervention should the nurse implement immediately? 1. Place an intravenous (IV) line. 2. Call the provider to obtain medication and fluid orders. 3. Raise the head of the bed at least 30°. 4. Introduce oxygen at 2 L via nasal cannula.

3 (Rationale:Raising the head of bed will improve the patient's lung expansion. This improvement in lung capacity will allow more effective inhalation and exchange of the oxygen being administered. The provider should be notified and an IV line may be needed, but assessment of the patient must occur first in order to determine the need for a hydrating IV. In this situation, the patient's obvious respiratory distress must be addressed before an assessment can be done. The provider should be called only after the nurse makes a reasonable evaluation of the patient's needs.)

Which statement represents the foundational premise for the use of the SPICES assessment tool? 1. The older adult has existing health-related conditions and injuries that require nursing care. 2. Dysfunctional sleep patterns are at the core of the risks that the older adult patient faces. 3. Normal aging leads to inevitable changes that cause geriatric syndromes and risk for injury and illness in older adults. 4. The early identification of fall risk is vital to the well-being of the older adult patient.

3 (Rationale:Use of the SPICES assessment tool is based on the premise that normal aging brings about inevitable and irreversible changes that result in specific areas identified by the acronym SPICES (Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown). The need for nursing care is not specifically associated with the SPICES assessment tool.)

The SPICES assessment tool is intended to focus on which older adult population? 1. Frail older adults 2. Acutely ill older adults 3. All older adults 4. Chronically ill older adults

3. All older adults (Rationale: The problems assessed through SPICES occur commonly among the entire older adult population. Therefore, the assessment tool may be used for all older adults. Its use should not be limited to frail, chronically ill, or acutely ill older adults.)

Which factor is most likely to affect a person's perception of the impact of his or her caregiving role both physically and psychologically? 1. Degree of acceptance shown by the care recipient 2. Caregiver's age 3. Caregiver's ethnic and cultural background 4. Relationship to the care recipient

3. Caregiver's ethnic and cultural background (Rationale: The ways in which caregivers express strain can vary and depends in part on ethnic and cultural influences. Perception is based on personal views and beliefs that are influenced by one's culture and ethics. The caregiver's age is a factor that affects ability to provide care but is not as influential on the perceived degree of stress that results. Relationship and acceptance are factors that may influence willingness to provide care, but they are not factors in how stressful the role is.)

Which assessment question will provide the most reliable information regarding the current respiratory function of an older adult patient? 1. Have you ever been diagnosed with a respiratory condition? 2. Can you describe the difficulty you have with your breathing? 3. Do you believe that you have any problems breathing? 4. How many pillows do you usually use when sleeping?

4 (Rationale:Some older adults may give unreliable accounts of their past respiratory symptoms or have grown so accustomed to living with their symptoms that they do not consider them unusual. Specific questions can assist in revealing disorders. More specific questions of behaviors like the number of pillows used when sleeping increase the likelihood of obtaining a full and accurate history of factors related to respiratory health.)