vSim 1: Edith Jacobsen
An older adult patient is being assessed for potential fall risks. Which statements by the patient would the nurse identify as risk factors?
- I celebrated my 81st birthday last month - I'm less depressed since ive moved in with my daughter - i've started to have some trouble getting to the bathroom in time - my cataract surgery is scheduled in 6 weeks
A patient undergoing a neurological assessment fears a serious diagnosis. Which action by the nurse will best ensure that the patient will comply with the assessment process? A. treat the patient's concerns and fears with both sensitivity and empathy B. approach the assessment in a positive and professional manner C. focus the assessment on an in-depth nursing history and interview D. be aware that dizziness and headaches are the most commonly reported complaints
A
During a routine visit, an older patient shares that recently he has had "trouble remembering things; little things like where I put my keys". Which interview question will the nurse ask to best identify a possible physical cause for the lapse in memory? A. have you ever had any kind of head injury during your lifetime? B. what medications are you currently prescribed for chronic illnesses? C. how long have you been experiencing these memory lapses? D. have you had any major traumatic events in your life lately?
A
The nurse is reviewing patient data from a neurological assessment and notes that the patient's history includes several recent falls. Which nursing action will the nurse take immediately to address the patient's risk for injury? A. implement the facility's universal fall precautions B. review the patient's medication for possible triggers that could cause falls C. instruct the patient to rise slowly from a supine position D. alert the staff to the patient's increased risk for injury due to falls
A
which nursing actions are associated with conducting a GCS assessment on a patient who has fallen and sustained a possible brain injury? (Select all that apply) A. ask the patient to identify their name B. request that the patient squeeze the nurses hand C. assess the patient's vital signs D. observe which stimuli cause the patient to open his/her eyes E. request that the patient rate his/her pain level
A B D
Which nursing actions would be effective when managing an older adult patient's risk for injury related to falling? (Select all that apply) A. present the patient with fluids regularly throughout the day B. offer to take the patient to the toilet every 2-3 hours C. limit the patient's fluid intake after the last meal of the day D. measure the patient's blood pressure both when sitting and upon standing E. encourage the patient to wear prescription glasses
A B D E
Which nursing actions demonstrate an understanding of the components required when conducting the objective portion of a neurologic assessment? (Select all that apply) A. test for tactile discrimination using a door key B. use a reflex hammer to elicit superficial tendon responses C. evaluate cranial nerve XI function by asking the patient to shrug the shoulders D. conduct the mental status exam as the initial part of the assessment to minimize anxiety E. asssess the patient's coordination by conducting the Romberg test
A C
An older patient reports feeling dizzy right before falling. Which action by the nurse indicates an understanding of how dizziness can be triggered? (Select all that apply) A. ask, "had you been taking any nonprescription medications before the fall" B. ask, "did it feel like the room was spinning when you experienced your dizziness?" C. assess the patient's blood pressure D. review the patient's diet for sufficient calcium intake E. review the patient's medical history for previous head injuries
A C E
Mrs. Jacobsen was prescribed raloxifene hydrochloride 18 months ago. She is concerned the dizziness she just felt before she fell is a result of the medication. How does the nurse best address her concerns?
Assure her that dizziness is not one of the recognized side effects of that medication
An older patient who lives alone is hospitalized after falling and sustaining a broken arm. Which nursing action will best determine whether the patient is experiencing any cognitive dysfunction that may have contributed to the fall? A.evaluate the patient using GCS B. administer an assessment tool such as the Mini-Cog C. inquire of family members as to whether they are comfortable with the patient living alone D. ask the patient to explain what "raining cats and dogs" means
B
An older adult patient has fallen and sustained a bruise to the forehead. Although there appears to be no significant injury, the family is concerned when the provider orders a Mini-Cog assessment and asks "Why are you testing her memory and mental abilities?". Which explanation best meets the family's expressed needs? A. the test results have shown no significant trauma to your mother's head, so I am confident that the Mini-Cog will show no dysfunction, either B. this has been a traumatic experience for all of you. Let's talk about your concerns related to your mother's health C. your mother's fall may have hurt the frontal lobe of her brain. That is the part that controls memory, reasoning, and judgment D. the provider is concerned about how the head injury has affected your mother's mental status, considering her advanced age
C
To assess an adult patient suspected of experiencing increased ICP, the nurse will implement which intervention?
check pupillary activity
A patient has reported dizziness that has been associated with orthostatic hypotension. What information will the nurse provide to the patient that is directly associated with this condition?
dehydration can be a trigger for the dizziness
What suggestions will the nurse include in the education materials regarding falls prevention at home for an older adult with a history of falls?
keep floors clear of clutter keep halls and stairs well lighted store often-used items on shelves that are at eye-level wear rubber-soled shoes
A patient who fell and hit her head and fractured her femur is scheduled for surgery in the morning. The patient has had a complete neurologic assessment and is currently in stable condition. How will the nursing staff best monitor the patient's neurologic status?
perform a neurologic check every 4 hours
What behavior would the nurse document as lethargy related to Mrs. Jacobsen's LOC?
remains awake only long enough to answer questions
An older adult is being prepared for discharge to have her daughter's home after completing rehab following surgery to repair a hip fracture. What information will the nurse include in discharge teaching to best help minimize the patient's risk for falls?
sit down and rest when feeling dizzy use a walking device to help with proper balance turn on the lights at night drink enough fluids to keep urine pale and clear
