One-Minute Nurse

Which statements about delirium and dementia are correct? Select all that apply.

Delirium has an abrupt onset, and dementia has a gradual, progressive onset.

Delirium has a gradual, progressive onset, and dementia has an abrupt onset.

Delirium can be caused by hypertension, and dementia can be caused by lack of sleep.

Delirium can be caused by lack of sleep, and dementia can be caused by hypertension.

Delirium is reversible, and dementia is irreversible.

Delirium has an abrupt onset, and dementia has a gradual, progressive onset., Delirium can be caused by lack of sleep, and dementia can be caused by hypertension., Delirium is reversible, and dementia is irreversible.

Rationale:Delirium has an abrupt onset and can be caused by lack of sleep; it is reversible. Dementia has a progressive onset, can be caused by hypertension, and is irreversible.

Which tool can nurses use to screen for delirium?

Delirium assessment tool (DAT)

Confusion assessment method (CAM)

Confusion analyzing measurement (CAM)

Delirium analyzing test (DAT)

Confusion assessment method (CAM)

Rationale:To screen for delirium, nurses use the confusion assessment method (CAM).

What is not a risk factor for delirium?

Genetics

Hospitalization

Lorazepam

Lack of sleep

Genetics

Rationale:Genetics is not a risk factor for delirium. Risk factors for delirium include preexisting cognitive impairment, head injury, use of medications such as benzodiazepines, hospitalization, and lack of sleep.

Which medication is used to slow the progression of dementia?

Donepezil hydrochloride

Fluoxetine

Carbidopa/levodopa

Norepinephrine

Donepezil hydrochloride

Rationale:Medications such as donepezil hydrochloride are used to enhance acetylcholine uptake in the brain, which helps patients with Alzheimer disease maintain memory skills for a longer period of time.

How is vascular dementia best treated?

Control of blood pressure and diabetes

Admission to a long-term care unit

Cognitive-behavioral therapy

Exposure therapy

Control of blood pressure and diabetes

Rationale:Keeping blood pressure and diabetes controlled, as well as lowering cholesterol levels, can slow the progression of vascular dementia.

Which is true about palliative care?

It is based on the patient's wishes.

It only considers doctors' prescriptions.

It is focused on finding trials to extend life.

It does not consider quality of life to be important.

It is based on the patient's wishes.

Rationale:Palliative care is based on the patient's wishes. It may consider doctors' prescriptions but defers to what the patient desires. Palliative care is not focused on extending life through clinical trials. Promoting quality of life is a goal of palliative care.

What is the primary goal of hospice?

Providing comfort and support

Determining goals of care

Admitting the patient to a facility

Giving the family space for bereavement

Providing comfort and support

Rationale:Hospice care is a subset of palliative care that is focused solely on providing comfort and support.

What is the role of the nurse when a patient in hospice care is actively dying? Select all that apply.

Administer medications that will promote comfort.

Provide emotional support to the support people.

Apply nasal cannula for SpO2 less than 92%.

Turn the patient every 2 hours.

Administer medications to improve blood pressure.

Determine goals of care

Rationale:The goals of the palliative care team are to determine goals of care and promote the patient's quality of life. Obtaining a DNR and starting hospice may be among the team's actions but are not their primary goals. Establishing the patient's will is done by a lawyer.

When is the most appropriate time to consult the palliative care team?

As the patient is actively dying

When the patient has a serious, life-threatening illness

When the patient is active and healthy

During a routine primary care visit

Administer medications that will promote comfort., Provide emotional support to the support people.

Rationale:Administering medications and providing emotional support are within the scope of the nurse's role when the patient in hospice care is actively dying. In this scenario, the care team will not provide any life-saving measures such as applying oxygen, turning the patient, or giving medications to improve blood pressure.

When is the most appropriate time to consult the palliative care team?

When the patient has a serious, life-threatening illness

Rationale:It is too late to consult the palliative care team when the patient is actively dying. The palliative care team is not consulted routinely or for healthy people. The most appropriate time to consult the palliative care team is when the patient has a serious or life-threatening illness.

What health promotion strategies support the older adult through musculoskeletal age-related changes? Select all that apply.

Calcium and vitamin D supplements

Weight-bearing activity

High-impact cardiovascular activity

Bone density screenings

Preventative back braces

Calcium and vitamin D supplements, Weight-bearing activity, Bone density screenings

Rationale:Health promotion strategies related to the musculoskeletal changes of older adulthood include engaging in weight-bearing exercises three times a week, having bone density screenings, and taking calcium and vitamin D supplements as prescribed. Taking measures to prevent falls is also recommended.

Which vaccines should the older adult receive to prevent respiratory complications?

Measles, mumps, rubella (MMR) and polio vaccines

Varicella and hepatitis B vaccines

Influenza and pneumonia vaccines

Tetanus, diphtheria, and pertussis (Tdap) vaccine

Influenza and pneumonia vaccines

Rationale:Adults over the age of 65 should receive annual influenza vaccines and should receive a vaccination against pneumonia.

What is the blood pressure goal for someone over the age of 65?

Less than 110/70 mmHg

Less than 120/75 mmHg

Less than 130/80 mmHg

Less than 140/85 mmHg

Less than 130/80 mmHg

Rationale:For a person over the age of 65, the goal is to keep blood pressure lower than 130/80 mmHg.

Which could indicate that an older adult is having difficulty hearing?

They provide inappropriate responses to questions.

They turn up the television volume during a conversation.

They recall a conversation from the previous week.

They respond to high-pitched tones quickly.

They provide inappropriate responses to questions.

Rationale:If the patient provides inappropriate responses to questions or asks people to repeat words, this may be an indication the person is experiencing hearing loss.

Which makes the older adult more susceptible to respiratory infections such as pneumonia?

Decreased cough efficiency

Increased ability to clear secretions

Increased fluid intake

Decreased number of alveoli

Decreased cough efficiency

Rationale:In the older adult, there is a decrease in gas exchange and diffusing capacity and a decrease in cough efficiency. These factors can lead to immobilized secretions, which make the older adult more susceptible to infection.

How do NSAIDs work?

They elevate the body's pain threshold and remove excess heat.

They bind to opioid receptors.

They block beta receptors in the heart.

They block prostaglandin synthesis.

They block prostaglandin synthesis.

Rationale:NSAIDs work by blocking prostaglandin synthesis to target inflammation. Acetaminophen elevates the body's pain threshold and removes excess heat. Opioids bind to opioid receptors to reduce pain. Beta-blockers block beta receptors in the heart.

What is the maximum dose per day for ibuprofen?

1,200 mg

2,000 mg

3,200 mg

4,000 mg

3,200 mg

Rationale:The maximum dose for ibuprofen per day is 3,200 mg. The maximum dose of acetaminophen is 4,000 mg per day.

In which patient is administering an NSAID contraindicated?

18-year-old with a temperature of 101.2°F being treated for an infection

27-year-old in the first trimester with their second child

48-year-old newly diagnosed with osteoarthritis

56-year-old with nephrolithiasis

1 to 3 hours

Rationale:It takes NSAIDs 1 to 3 hours to reach their peak effectiveness.

For which condition are NSAIDS recommended to alleviate symptoms?

Gastric ulcers

Blurred vision

Menstrual cramps

Cholecystitis

27-year-old in the first trimester with their second child

Rationale:NSAIDs are contraindicated in patients who are pregnant or have bleeding disorders. NSAIDs are appropriate for fever reduction when an infection is known or to relieve pain associated with osteoarthritis and nephrolithiasis.

A patient is awake, alert, and oriented on a surgical unit. Which pain scale is the preferred pain scale for this patient?

Numeric

PAINAD

FLACC

CPOT

Numeric

Rationale:A numeric pain scale is the best for patients who are verbal and oriented. PAINAD can be used for patients with dementia, FLACC can be used for babies, and CPOT can be used for critically ill patients.

A patient had a below-the-knee amputation 24 hours ago and insists that the toes on the affected side are in pain. What is the nurse's best response?

'I think you are hallucinating; there is nothing there to hurt.'

'You are fine, this is normal.'

'Phantom pain occurs where the amputated leg should be and is real pain. Let me see when you are due for pain medication.'

'This is phantom pain, and it goes away in a few hours. It is best to breathe through it and tell yourself it's fine.'

'Phantom pain occurs where the amputated leg should be and is real pain. Let me see when you are due for pain medication.'

Rationale:Phantom pain is pain that occurs where an amputated limb should be; the patient feels extreme pain in the limb that is gone, and the pain is very real. Telling the patient they shouldn't feel pain, that they are fine, and that they should breathe through it are dismissive, nontherapeutic responses.

A patient presents with bone pain related to osteomyelitis. What type of pain is this called?

Acute

Chronic

Cutaneous

Somatic

Somatic

Rationale:Somatic pain originates in the ligaments, bones, blood vessels, and nerves and can be felt throughout the whole body. Acute indicates an abrupt onset, chronic pain lasts beyond the time of expected recovery, and cutaneous pain involves the skin.

Which is an appropriate nonpharmacologic pain intervention?

Applying a cool pack

Applying a tourniquet to the area

Encouraging sleep

Consuming a snack

Applying a cool pack

Rationale:Applying a cool pack is reasonable intervention for pain. A tourniquet will cut off the blood supply and is not indicated. Sleep does not address the pain and may be inhibited by pain. A snack is not indicated specifically for pain.

In addition to a pain scale, what other information should be included when assessing pain? Select all that apply.

What the pain feels like

What made the pain start

Where the pain is located

How long the pain lasts

What helps the pain

What the pain feels like, What made the pain start, Where the pain is located, How long the pain lasts, What helps the pain

Rationale:It is important to assess the quality of the pain, what caused its onset, where it is located, how long it has lasted or is lasting, and what helps relieve it.