Aging Clients (Cues & Fall Prevention)
What is the first action a nurse should take when recognizing a patient at high risk of falls?
Perform a fall risk assessment using the ABCs and implement fall precautions.
What score is used to assess pressure ulcer risk?
The Braden Score.
What is the difference between osteopenia and osteoporosis?
Osteopenia is low bone density, a precursor to osteoporosis, which involves more severe bone loss.
What is the normal range for fasting blood glucose?
70-100 mg/dL.
What is the first sign of delirium in older adults?
Sudden confusion or changes in mental status.
Name two age-related changes that affect hearing.
Presbycusis (age-related hearing loss) and increased cerumen (earwax) buildup.
What is the primary function of a negative pressure wound vacuum (Wound Vac)?
It promotes healing by reducing swelling, removing excess fluid, and increasing blood flow to the area.
What is the first-line drug treatment for osteoarthritis?
Acetaminophen or NSAIDs.
What are two hallmark symptoms of hypoglycemia?
Shakiness and confusion.
What is the difference between dementia and delirium?
Dementia is a chronic, progressive decline in cognitive function, while delirium is an acute, temporary state of confusion.
What Braden Score range indicates a high risk for pressure ulcers?
Answer: A score of 12 or less indicates high risk.
What type of dressing would you use for a moist wound with light drainage?
A hydrocolloid or foam dressing.
What ergonomic principle is essential to safe patient handling?
Use your legs, not your back, to lift, and keep objects close to your body to reduce strain.
What is the priority nursing action for a patient with a blood glucose level of 45 mg/dL?
Administer 15 grams of fast-acting carbohydrates (e.g., juice or glucose tabs).
What CJM component should be used when identifying Alzheimer’s disease progression?
Recognize cues like memory loss, confusion, and changes in behavior.
Describe the normal changes in muscle strength with aging.
Muscle mass decreases, leading to reduced strength and increased risk for weakness and falls.
Which cues indicate a wound infection?
Increased redness, warmth, swelling, purulent drainage, and fever.
When should a nurse reassess pain after administering an opioid?
Reassess pain 30 minutes after administration.
What lab test gives a long-term picture of blood glucose control?
Hemoglobin A1C
What is the primary goal for a patient with Parkinson's disease?
Maintain mobility and function as long as possible through medications and physical therapy
Which CJM step is used when prioritizing care for an older adult with multiple health problems?
Analyze cues and prioritize care based on the most life-threatening or pressing health concern.
What is the best way to prevent cross-contamination when changing a wound dressing?
Use sterile technique and ensure proper hand hygiene and disposal of contaminated materials.
What is the key component in prioritizing care for a patient with chronic low back pain?
Assess the impact on quality of life, mobility, and daily activities to create an individualized pain management plan.
What is the difference between type 1 and type 2 diabetes?
Type 1 is an autoimmune disorder where the pancreas produces no insulin. Type 2 involves insulin resistance and often insufficient insulin production.
What is the priority intervention for a patient with multiple sclerosis during an exacerbation?
Prevent complications like immobility and infections, and administer corticosteroids to reduce inflammation.