VSim Jacobson

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?

-Altered elimination -Mental and emotional status -Symptoms of dizziness

The nurse performs a focused musculoskeletal assessment on a patient with a hip fracture. Which should the nurse include for this type of assessment?

-Range of motion -Joint tenderness -Pain -Muscle weakness

Which nursing interventions should a nurse anticipate for an older patient with a hip fracture?

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

What would be a priority nursing diagnosis for Edith Jacobson related to her psychosocial needs? A.) Anxiety B.) Impaired physical mobility C.) Risk for infection D.) Impaired skin intergrity

A.) Anxiety

Antiembolism 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

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.

Which fall precautions should the nurse establish for Edith Jacobson after repositioning? (Select all that apply) A.) Remind the patient that she is at high risk for falls due to her medications. B.) Educate the patient to use the call light if she needs to get up. C.) Put side rails up. D.) Ask her daughter to help her out of bed if she needs assistance. E.) Make call light easily accessible.

A.) Remind the patient that she is at high risk for falls due to her medications. B.) Educate the patient to use the call light if she needs to get up. E.) Make call light easily accessible

What should the nurse anticipate needing to teach Edith Jacobson before discharge in relationship to her hip fracture and mobility? A.) Measures to reduce the risk of osteoporosis B.) Use of assistive devices such as a walker C.) Risk for loose stools with opioid analgesics D.) Restriction of activity

B.) Use of assistive devices such as a walker

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

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

Which age related change(s) increase the risk for complications after illness or injury in the older adult?

-Decreased skin elasticity -Fragile blood vessels -Decreased muscle strength -Altered pain and pressure perception

The nurses 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

D. 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?

-How well do you usually sleep? -Have you had any difficulty eating? -Is this the first time you have fallen?

A provider orders docusate sodium 100mg PO twice a day for an older patient. The pharmacy provides docusate sodium liquid 150mg/mL. How much medication should the nurse administer?

10mL

Which statement by the nurse indicates a need for further education related to a focused neurovascular assessment on Edith Jacobson? A.) The skin temperature above and below the fracture is the same. B.) I have compared the skin on both legs and do not find any shiny areas. C.) I am going to check the pulses in your unaffected limb. D.) I see that you can move your toes.

C.) I am going to check the pulses in your unaffected limb.

Which complications is Edith Jacobson at risk for because of her age and hip fracture? A.) Gout B.) Osteoarthritis C.) Pressure Ulcers D.) Pneumonia E.) Mental deterioration

C.) Pressure Ulcer D.) Pneumonia E.) Mental deterioration

What is the priority outcome for Edith Jacobson in relationship to her hip fracture? A.) The patient will be able to preform activities of daily living, such as dressing herself, before discharge. B.) The patient will move in with her daughter, who will assist the patient with activities of daily living. C.) The patient will be able to walk with assistive device without fear of falling. D.) The patient will have no signs or symptoms of infection while in the hospital.

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

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? A.) Monitor lab results for high triglycerides. B.) Monitor for increased effects of hormone replacement therapy with concurrent use. C.) Monitor for increased breast cancer risk. D.) Monitor for blood clot formation.

D.) Monitor for blood clot formation.

Edith Jacobson needs to be frequently repositioned. Why should the task take two people? A.) To comply with hospital policy B.) To allow complete assessment of the skin C.) To provide comfort for the patient. D.) To prevent additional injury to the patient

D.) To prevent additional injury to the patient