A&E Exam 1

major health issues associated with late adulthood in community and inpatient settings

geriatric syndrome

young old

65 to 74

middle old

75 to 84

old old

85 to 99

elite old

100+

a complex syndrome including under nutrition, impaired physical functioning, depression and cognitive impairment

geriatric failure to thrive

the physical and emotional distress that occurs after the person moves from one setting to another

relocation stress syndrome

presbycusis

high frequency hearing loss

fallophobia

fear of falling

presbyopia

farsightedness that worsens with age; makes walking more difficult

polymedicine

describe the use of many drugs to treat multiple health problems for older adults

ageism

discrimination against people because of age

acute confusional state, potentially reversible cognitive impairment that often has a physiological cause like electrolyte imbalance, hypoglycemia, medication effects etc.; sudden/abrupt onset

delirium

generalized impairment of intellectual functioning that interferes with social and occupational functioning; insidious/slow and often unrecognized

dementia

happens with major life changes often abrupt but can be gradual; 1/3 of older adults experience symptoms but not considered a normal part of aging

depression

leading cause of death in older adults

heart disease

second leading cause of death in older adults; Malignant neoplasms

cancer

a stage of age-related physiologic vulnerability, resulting from impaired homeostatic reserve and a reduced capacity of the organism to withstand stress

frailty

phenomenon of rapid decline resulting from frailty, acute illness, and stress of institutional care (most often from acute hospitalization)

geriatric cascade

percentage of older adults in population

13.7%

scientific reasoning that involves: assessment, nursing diagnosis, planning, implementation, and evaluation

nursing process

neurologic/sensory changes

loss of axons and neurons, slowing of coordinated movements and decreased sensation

communicating with older adults

avoid elder speak, maximize strategies to improve face to face communication, and engage older adults to participate in their care and health care decision making (including those with impaired cognition)

vision changes

decreased ability to focus and deal with glare and nigh time vision

hearing changes

high frequency hearing loss, thickening of tympanic membrane, sclerosis of inner ear, build up of ear wax

taste changes

diminished tasting ability, may have hard time tasting salt and sugar and may make food too salty or sweet as a result

integumentary system changes

loss of collagen fibers, decrease in glandular functions, decrease in moisture and thinning of dermis, increased skin lesions and age spots

Thorax and lung changes

decrease in respiratory muscle strength, anterior/posterior diameter increases, increased incidence of kyphosis, drier mucous membranes

heart and cardiovascular system

decreased cardiac contractility, baroreceptor sensitivity decrease, decrease arterial compliance

urinary system

decrease in number of nephrons, hypertrophy of prostate, increase incidence of incontinence in females

musculoskeletal system

muscle mass decreases (declines rapidly if not used), increased incidence of bone issues related to aging/osteoporosis

gastrointestinal system

increased amount of fatty tissue in the trunk, slowing of peristalsis, altered gastric secretions, decrease in liver function

effective instrument for obtaining the information necessary to prevent health

alterations in the older adult patient; acronym for the common syndromes of the elderly requiring nursing intervention including sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown

Fulmer's SPICES

Katz index of Independence in Activities of Daily Living

most appropriate

instrument to assess functional status as a measurement of the client's ability to perform activities of daily living independently; Index ranks adequacy of

performance in the six functions of BATHING, DRESSING, TOILETING, CONTINENCE, AND FEEDING

Katz index of Independence in Activities of Daily Living

includes having a specific knowledge base, experience, competencies, attitudes, and standards

Critical thinking

occurs in the liver; age related changes affect functionality of the liver based on decreased liver size, decreased liver blood flow, and decreased serum liver enzyme activity;

drug metabolism

Fall

an unexpected event in which the participant comes to rest on the ground, floor, or lower level; not a normal part of aging; LEADING CAUSE OF DEATH FROM INJURY IN ADULTS 65 AND OLDER; 1.9 ED VISITS PER YEAR

Hendrich II Fall Risk Model

provides determination for risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk; primary prevention tool for risk of falling and post fall assessments

confusion assessment method

1. acute onset and fluctuating course

2. inattention

3. disorganized thinking

4. altered level of consciousness

diagnosis of delirium by this tool requires the presence of features 1&2 and either 3 or 4

restraints

only use restraints when ALL other alternatives fail; these include the failure of close monitoring, changes in physical space, eval of treatment or medication, use of therapeutic communication and use of diversion

physical restraints

include: mittens, vest and waist restraints, wrist and ankle restraints, everything that inhibits movement

if restraints are used

follow agency policies, use appropriate size restraint, assess circulation, range of motion and document

impact of Mobility/immobility

impacts functional ability, activities of daily living, instrumental activities of daily living; avoid sequelae of immobility, economic/maneuvering through healthcare system

mobilization

includes: turning, bed to chair, ambulation, and migration

The nurse is caring for a patient with the diagnosis of Impaired physical mobility. The nurse understands that the following interdisciplinary services are needed to ensure the patient's best outcome?

A.Respiratory therapy

B.Occupational therapy

C.Physical therapy

D.Cardiac therapy

E.Psychology services

BCE

The nurse needs to reposition a 300 pound patient. Which of the following strategies is most likely to prevent back injury?

A. Turn the patient alone using the lift pad and applying pillows

B. Place the patient in Trendelenburg position and pull from the head of the bed

C. Assess and obtain the number of people needed to help

D. Bend at the waist and pull the lift pad using the arms

C

Of the following nursing goals, which is most appropriate for a patient who has had a total hip replacement?

A. The patient will ambulate by the time of discharge

B. The patient will ambulate briskly on the treadmill by the time of discharge

C. The nurse will assist the patient to ambulate in the hall

D. The patient will ambulate a 1000 feet using her walker by the time of discharge

D

The nurse is caring for a patient who has been diagnosed with a stroke. As part of the ongoing care, the nurse should

A. Provide a complete bed bath to promote patient comfort

B. Place the patient on bed rest to prevent fatigue

C. Encourage the patient to perform as many self-care activities as possible

D. Understand that the patient will not eat owing to a decreased energy need

C

The nurse is caring for a patient who suddenly becomes confused and tries to remove the intravenous infusion from his arm. The nurse begins to develop a plan to care for this patient. Which nursing intervention should take priority?

A. Gather restraint supplies

B. Try alternatives to restraint

C. Assess the patient

D. Call the physician for a restraint order

C

While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first

A. Leave the room and place the patient in isolation

B. Ask the patient to describe the type of reaction

C. Proceed to the termination phase of the interview

D. Document the latex allergy on the medication administration record

B

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse

A. Identifies pertinent nursing diagnosis

B. Completes a comprehensive database

C. Intervenes based on patient goals and priorities of care

D. Determines whether outcomes have been achieved

B

An older client is in the hospital. The client is ambulatory and independent. Which intervention by the nurse would be most helpful in preventing falls in this client?

A. Keep the light on in the bathroom at night

B. Order a bedside commode for this client

C. Put the client on a toileting schedule

D. Use all siderails to keep the client in bed

A

A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this client?

A. Building strength and flexibility

B. Improving exercise endurance

C. Increasing aerobic capacity

D. Providing personal training

A

The nurse understands that the following are true regarding hand washing:

A.Long nails and chipped or old nail polish increase the number of bacteria residing on nails

B.Subungual areas of the hands harbor low concentrations of bacteria

C.Artificial nails are not to be worn because they show high rates of infectious agents

D.Perform hand hygiene using plenty of lather and friction for at least 15 seconds

E.After washing hands, dry hands thoroughly from forearms to wrists and then to fingers with paper towel or warm air dryer

ACD

Describe and discuss common health care issues among community dwelling and hospitalized older adults (5)

nutriton

Impaired Mobility

Stress and Loss

Depression, Dementia and Delirium (3 D's)

Polypharmacy in older adults

polypharmacy

Taking a lot of medications due to multiple comorbid conditions

iatrogenesis (effect) of hospitalization in older adults (3)

Increased length of stay

Nosocomial infections

psychological decomposition

continuum of care

Make sure nothing is left and all of the patient's needs are taken care of

a stage of age-related physiologic vulnerability, resulting from impaired homeostatic reserve and a reduced capacity of the organism to withstand stress

frailty

Phenomenon of rapid decline resulting from frailty, acute illness, and stress of institutional care (most often from acute hospitalization)

geriatric cascade

Chronic illness causes of frailty (5)

Cancer, CV disease, Alzheimer's, MS problems, diabetes

social/psychological causes of frailty (4)

Poverty

social isolation

depression

cognitive impairment

Nursing process acronym ANDPIE

assessment

nursing diagnosis

planning

implementation

evaluation

planning step of nursing process is aimed towards

establishing priorities

Clinical judgment about individual, family, or community responses to actual or potential health problems or life processes that the nurse is licensed to treat.

nursing diagnosis

The nurse knows that the purpose of aspiration on intramuscular (IM) injections is to

A. Ensure proper placement of the needle.

B. Increase the force of the injection.

C. Reduce the discomfort of the injection.

D. Prolong the absorption time of the medication.

A

The nurse knows that patient education regarding medication administration has been effective when the patient states :

A. "I must take all my medications with food."

B. "If I am 30 minutes late taking my medication, I should skip that dose."

C. "I will rotate the location where I give myself subcutaneous injections."

D. "Once I start feeling better, I will stop taking my medication."

C

The nurse knows to assess for signs of medication toxicity within older adults because of which physiological change?

A. Delayed esophageal clearance

B. Reduced glomerular filtration

C. Increased gastric peristalsis

D.

Decreased cognitive function

B

What is the nurse's priority action to protect a patient from a medication error?

A. Administering as many of the medications as possible at one time

B. Checking the patient's room number against the medication administration record

C. Requesting that the prescriber write out an order, rather than giving a verbal order

D. Asking anxious family members to leave the room before giving a medication

C

One of the greatest challenges for the nurse caring for older adults is ensuring safe medication use. One way to reduce the risks associated with medication usage is to

A. Focus only on prescribed medications.

B. Periodically review the patient's list of medications.

C. Inform the patient that polypharmacy does not lead to adverse medication reaction.

D. Be aware that medication is absorbed the same way regardless of patient's age.

B

A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the nurse discharging the patient?

A. Ensure that someone will provide housekeeping for the patient at home.

B. Set up the follow-up appointments with the physician for the patient.

C. Ensure that the home care agency is aware of medication and health teaching needs.

D. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care

C

A provider has ordered a STAT medication to be administered. The nurse knows that the best route of administration is

A. Intravenous (IV)

B. Intramuscular (IM)

C. By mouth (PO)

D. Subcutaneous (SQ)

A

The home care nurse is helping a patient with short-term memory loss how to remember to take multiple drugs throughout the day. The nurse should:

A. Ask a family member to call the patient when the medications are to be taken.

B. Instruct the patient to take the medication at the same time everyday.

C. Create a daily schedule with the patient's family.

D. Instruct the patient to put medications in a weekly organizational pill container.

D

Which of the following are methods to reduce the risk of needlestick injury? (SELECT ALL THAT APPLY).

A. Recap the needle after giving an injection

B. Dispose of needle using one hand.

C. Never force a needle into the sharps disposal.

D. Clearly mark sharps disposal containers.

E. Use needleless devices whenever possible.

BCDE

An older adult states that he has trouble seeing his medication bottles clearly to determine when to take his prescription. What should the nurse do? (SELECT ALL THAT APPLY?)

A.

Tell the patient what is in each container

B. Provide a dispensing container for each day of the week

C. Have a family member administer the medication

D.

Provide larger, easier to read labels

E. Consult with the health care provider to discontinue all medications

F. Ask the patient when was the last time he went to see the eye doctor

BDF

A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercises regiment would be most beneficial to this client?

Building strength and flexibility.

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps?

Install contrasting strips at the edge of each step.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client.

Keep the light on in the bathroom at night

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse

Completes a comprehensive database

To gather information about a patient's home and work surroundings, the nurse will need to utilize which method of data collection?

Perform a thorough nursing health history

While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first

Ask the patient to describe the type of reaction

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous infusion. The nurse begins to develop a plan to care for the patient. Which nursing action should take priority?

Assess the patient

The nurse educator is planning to educate long term care nurses on the use of restraints. It is important to emphasize that restraints are:

place the client at risk for injury and possible death

Although isometric contractions do not result in muscle shortening, the nurse understands that isometric contractions

result in increased energy expenditure

Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by

Keeping a low center of gravity

Immobilized patients frequently have hypercalcemia, placing them at risk for

renal calculi

The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should

encourage the patient to perform as many self-care activities as possible

Of the following nursing goals, which is most appropriate for a patient who has had a total hip replacement?

The patient will walk 1000 feet using her walker by the time of discharge

The nurse needs to reposition a 300-lb patient. Which of the following strategies is most likely to prevent back injury?

Assess and obtain the number of people needed to hlep

The nurse is caring for a frail older adult patient who developed a stroke and identifies the priority nursing diagnoses of Impaired physical mobility and Impaired coping. Which discipline or services would the nurse anticipate to work with to prevent potential complications

physical therapy

occupational therapy

psychology services

pressure ulcer

localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear; partial thickness to full thickness, necrosis may be present as well as itching and pain

major elements in the cause of pressure ulcers

pressure intensity, pressure duration and tissue tolerance

risk factors for skin breakdown

impaired sensory perception, impaired mobility, alterations in consciousness, shear/friction, moisture/maceration, decreased general health

incontinence associated dermititis

results from exposure to urine or stool, moisture diffuses into skin folds, not necrotic, patient feels pain and itching

phases of wound healing

hemostasis, inflammatory stage, proliferative stage, and maturation phase

hemostasis

first stage of wound healing; 0 to 2 days in length

inflammatory phase

second stage of healing; the body's protective response to injury, 2 to 4 days in length, characterized by pain, redness, heat, swelling, loss of function at site of injury; if inflammation lasts longer than 48-72 hours look for evidence of new or ongoing tissue damage

proliferative phase

third stage of healing; 4 to 21 days in length, involves rebuilding of tissue

maturation phase

can take up to 2 years; collagen production and reorganization will be ongoing for two years

granulation

tissue that is well formed although fragile; pale not well vascularized