Renal/GI
What do you look at when giving vancomycin to a patient?
Creatinine
True or false
The older you get the more likely a person develops diabetes.
True
Decreased insulin secretion
Peripheral tissues become insulin-resistant
True or False
Older adults have a compromised thermoregulation?
True
Fewer neurons to delver signals to the hypothalamus leading to compromised thermoregulation.
Which of the following are most likely to be an early sign of cardiac problems in older persons?
a. Agitation
b. Intermittent claudication with exercise
c. Altered sensation to touch
d. changes in the GI system
A. Agitation
Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting?
a. Keep all of the side rails up.
b. Review prescribed medications.
c. Complete the "get up and go" test.
d. Place the bed in the lowest position.
Place the bed in the lowest position.
Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of bed is at an appropriate height
A 80 year old female is admitted to the hospital for AMS changes. What could be the cause of the AMS?
UTI
How often should nurses check a patient's blood glucose?
Also follow physician orders.
Difficulty speaking and understanding speech is termed?
Aphasia
Results from damage to the portion of the brain involved in creating and interpreting language. Aphasia is not a disease. It is a symptom of a neurological disorder or injury, such as stroke, brain tumor, or head injury.
A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?
A. Activity intolerance related to fatigue
B. Anxiety related to actual threat to health status
C. Risk for infection related to retained secretions
D. Impaired gas exchange related to airflow obstruction
Impaired gas exchange related to airflow obstruction
A. patent airway and an adequate breathing pattern are the top priority for any client, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis.
A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
a. Restrain the client in bed.
b. Ask a family member to stay with the client.
c. Check the client every 15 minutes.
d. Use a bed exit safety monitoring device
Use a bed exit safety monitoring device.
An intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance
An older male patient visits his primary care provider because of burning on urination and production of urine that he describes as "foul smelling." The health care provider should assess the patient for what factor that may put him at risk for a urinary tract infection (UTI)?
BPH
The nurse is planning care for a client with hyperthyroidism. Which of the following nursing interventions are appropriate?
a. provide rest periods
b. keep environment cold
c. provide 3 large meals daily
d. encourage frequent visitors and conversation
Provide rest periods
The client is usually exhausted due to restlessness and agitation
A 65 year old patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding
A
Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization
A nurse is caring for a patient with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
A.
Hypoxia
B. Delirium
C. Hyperventilation
D. Semi consciousness
Hypoxia
Produces wheezing, bradycardia, and a decreased respiratory rate
An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury?
a. Leave the bathroom light on.
b. Withhold the client's diuretic medication.
c. Provide a bedside commode.
d. Keep the side rails up.
Provide a bedside commode.
Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls.
Which of the following causes the majority of UTI’s in hospitalized patients?
a. Lack of fluid intake
b. Inadequate peri care
c. Immunosuppression
d. Invasive procedures
Invasive procedures
Such as catheterization can introduce bacteria into the urinary tract. A lack of fluid intake could cause concentration of urine, but wouldn’t necessarily cause infection.
For the first 72 hours after thyroidectomy surgery, nurse Jamie would assess the female client for Chvostek's sign and Trousseau's sign because they indicate which of the following?
Hypocalcemia
The client with hypocalcemia will exhibit a positive Chvostek's sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated for a few minutes).
The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?
A. Loosening restrictive clothing
B. Restraining the client’s limbs
C. Removing the pillow and raising padded side rails
D. Positioning the client to side
B. Restraining the client’s limbs
The limbs are never restrained because the strong muscle contractions could cause the client harm
A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next?
a. Review the intake and output records for the last 2 days
b. Change the time of diuretic administration from morning to evening
c. Request a sodium restriction of 1 g/day from the physician.
d. Order daily weights starting the following morning.
Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight
Which is the most common type of falls with injury in the older adult population?
a. elbow fracture
b. hip fracture
c. knee fracture
d. spinal fracture
b. Hip fracture
Mr. Williams a 65 year old was diagnosed with proteinuria. He has HTN, CHF, and decreasing GFR. He takes Lasix (80mg) PO daily. He is admitted to the ED with SOB. What physical assessment finding would a nurse expect?
Hypotension
Epigastric pain
Dry mucous membranes
Pulmonary edema
Pulmonary edema
Occurs when a patient is fluid overloaded
Which nursing diagnosis takes highest priority for a female client with hyperthyroidism?
a. Risk for impaired skin integrity
b. Risk for imbalanced nutrition: More than body requirements
c. Body image disturbance
d. Risk for imbalanced nutrition: Less than body requirements
Risk for imbalanced nutrition: Less than body requirements
In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism
Narcolepsy is a disorder characterized by:
a. Narcotic abuse
b. Grand mal seizures
c. Reliance on drugs
d. Inability to regulate sleep-wake cycles
D.
Narcolepsy is a neurological disorder that causes affected individuals to experience irresistible bouts of sleep, causing them to fall asleep for periods ranging from seconds to minutes throughout the day
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to:
a. Check the client status and lead placement
b. Call a Swat
c. Call the physician
d. Call a code blue
a. Check the client status and lead placement
Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention.
At UF Health Shands, how many falls occur in March 2019? Out of those falls, how many were falls with injuries?
a. 50 falls/ 10 with injuries
b. 48 falls/ 12 with injuries
c. 53 falls/ 17 with injuries
d. 51 falls/ 15 with injuries
C. 53 falls with 17 with injuries