Vernon Russell Health assessment VSIM
the nurse is assessing a patient for fall risk. Which factor(s) would place the patient at a higher risk for falls?(select all that apply)
depression, gait or balance impairment, use of more than four prescription medications
the nurse is assessing a patient's joints. What should the nurse include in this assessment (select all that apply)
Color, Symmetry, Size
the nurse is assessing a patient's range of motion and notes a limitation in the movement of the elbow joint. which tool would the nurse use to measure the degree of movement in the joint
Goniometer
the nurse is completing a health history on a patient reporting musculoskeletal pain. Which question(s) would be appropriate for the nurse to inlcude in the interview?
Have you experienced any previous injuries to your joints, do you exercise regularly, what type of job do you have, have you had any recent weight gain, what medications are you currently taking
the nurse is assessing a patient's gait. Which factors should the nurse observe as the patient ambulates in the room? (select all that apply)
base support, stride, arm swing, posture
the nurse is completing passive range-of-motion (ROM) exercises and bends the patient's foot so that the toes point upward. Which skeletal muscle movement has the nurse performed?
dorsiflexion
falls make up the single largest category of hospital-reported adverse events. Name at least fiver interventions that the nurse can implement to reduce falls in the hospitalized patient.
orient the patient to his or her surroundings, maintain the patients bed in the lowest position with wheels locked, keep room free of excessive clutter. ensure that hallways are clear of obstacles, place the patient's call light and assistive devices within reach, raise side rails as appropriate. perform hourly rounding on patients