fundamentals exam wednesday old ppl

Reasons why people do not seek or delay health care (geography, economics, education, etc

Lack of education, limited access due to geography, language barrier, stereotyping and unconscious bias, discrimination, misunderstanding

Best response for a person who avoids eye contact: How should you respond?

Show respect and avoid eye contact

How can you fix misunderstandings with non-English speakers? Nursing interventions.

Interpreter, learn common phrases, ask pt what they understand

Types of physical assessments: Know the types and when to perform specific assessments.

Comprehensive health assessment= in depth of whole person physical, mental, emotional, cultural and spiritual aspect of health, performed when pt is admitted

Initial head to toe assessment= quick ovr assessment of pt to establish baseline which will be used for comparisons for later assessments, done at beginning of shift

Focused assessment= examination and assessment of focused body system, performed throughout shift after head to toe follow up on any abnormal findings or areas of concern

Assessments are performed at beginning of shift, new pt admission, pt coc, evaluating effectiveness of nursing interventions, and anytime things don’t feel right

Know the normal findings of the consensual reflex.

Both pupils constrict simultaneously and equally when light is shined

What do you do if you notice a patient with an abnormal respiratory pattern? Nursing action.

Notify provider

Assessing an older adult's eyes: What findings are consistent with aging?

Opaque white ring around outer edge of cornea (Arcus senillis), cloudiness which is a sign of infection, vitamin a deficiency, and opaqueness of lens (cataracts):observe eyelids for dropping or ptosis of one side (paralysis from stroke)

Patient on diuretic therapy: Assessment findings.

Electrolyte depletion, dehydration, weakness, hypotension, renal impairment, hypersensitivities,

Know the Glasgow Coma Scale (GCS) levels and what nursing action you should take if they change.

Assess injured person level of brain damage eye movement 1-4, speech 1-5, motor 1-6, 3-8 severe, 9-12 moderate, 13-15 mild

Know how to perform a focused cardiovascular assessment.

CBC, cardiac enzymes, bleeding and clotting studies, ecg, chest X-ray, activity tolerance, color of mucous membranes, color and temp of extremities, skin color, moisture, temp, edema, clubbing of fingertips, blood pressure, peripheral pulse, pulse, jugular vein, heart sounds, capillary refill

How to document findings of edema: Know when edema is considered +2 and +3. How do you document these findings?

+2= depth of 4mm, lasts no longer than 15sed after removing pressure

+3= depth of 6mm, last full 60sec after removing pressure

Depth of depression determines amount of pitting edema present

What is aphasia

Pt with stroke or brain damage may understand spoken and written words and know what to say but they can’t say the actual words

What is dysphasia

Difficulty wording and organizing words correctly in a sentence

What is PERRLA

Pupils are bilaterally brisk and reactive to light and accommodation

Pupils

Equal

Round

Reactive

Light

Accommodation

Best position for auscultating breath sounds

45-90 degrees, fowlers

Know how to assess the abdomen: There is a correct order.

Inspect, auscultate palpate

Know the components of a focused respiratory assessment.

Respiratory rate and characteristics, respiratory effort, respiratory pattern, symmetry, of excursion, SpO2, breath sounds, use of accessory respiratory muscles, shape of chest, retractions, cough and sputum, skin color, color of nail beds, tolerance for activity, arterial blood gas test, rad test chest X-ray

When taking labetalol, what do you need to assess prior to administration?

Blood pressure, pulse, heart rate

Know the signs of elder abuse.

Excessive bruising in unexpected places, bruises in multiple stages of healing, bite marks, burns, lacerations, fractures or dislocations, sedation, dehydration or malnutrition, excessively poor hygiene or unsuitable clothing

An older patient is talking to you about their medication; they describe their medications as different colored pills. What’s the best way to respond to this patient?

Teach pts and family to maintain list of ALL meds and doses taken. Take to hcp, hospital, and get all meds from same pharm so they can be cross referenced for cross meds

symptoms of hemorrhagic stroke

Bleeding in brain, sudden severe headache, confusion, seizure, neck pain

symptoms of ischemic stroke

Blood clot in brain, symptoms are sudden and persistent

symptoms of TIA.

Decrease in blood flow to brain “mini stroke” symptoms appear suddenly but are temporary and disappear within minutes-hr

Interventions to minimize skin breakdown.

Encourage protection of skin such as wearing closed toed shoes, assess and cover all skin tears or open areas, apply creams and lotions to prevent cracking of skin, keep toenails trimmed and consult a podiatrist for diabetes prn

Know the correlation between cognitive changes in the elderly and UTIs.

Confusion, delirium, disorientation

High Morse fall scale: Know nursing interventions.

Tell pt not to get up unassisted, check on pt q30min, encourage pt use of call light, ensure that pt knows where call light is and how to use it, keep needed items within reach, answer call lights promptly, respond to bed/chair/leg monitor alarms immediately after fall, assist pt to ambulate to chair or bathroom when needed, don’t leave pt alone while in bathroom or bedside commode

A patient with decreased urinary output and has adequate hydration: How will this patient present? They hydrated, but not peeing. Key assessment findings.

Renal impairment, urinary obstruction, low urine output, fluid retention (edema, crackles, weight gain, hypertension), elevated renal labs

Home health visit: What environmental factors would alert the nurse to intervene when visiting an elderly patient with osteoporosis?

Loose rugs, poor lighting, cluttered walkways, lack of grab bars, slippery floors, absence of assistive devices