Tools, Risks, Questions, Oh my
Which tool predicts ulcer risk?
What is Braden Scale?
Which of the following is correct in documenting every day?
A. Q.D.
B. q1d
C. Daily
D. qd
What is C?
Patient weighs 286 lbs, how many kgs?
What is 130 kgs?
What is included in the S for SBAR?
The nurse is setting up an education session with an 85 year-old patient who will be going home on anticoagulant therapy. Which strategy would reflect consideration of aging changes that may exist with this patient?
A. Show colorful video about anticoagulation therapy
B. Present all the information in one session just before discharge
C. Give the patient pamphlets about the medications to read at home
D. Develop large-print handouts that reflect verbal information presented
What is D?
Rationale: Option D addresses altered perception in two ways. First, by using visual aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear high-frequency sounds. By developing the handouts in large print, one addresses the possibility of decreased visual acuity. Option A does not allow discussion of the information; furthermore, the text and print may be small and difficult to read and understand.
What are the two biggest risks that a nurse has to assess for in an older adult?
What are fall and dysphagia risk?
What does SBAR stand for?
What is Situation, Background, Assessment, Recommendation?
Calculate intake:
1 8 oz glass of water
250 mL IV fluid
What is 490 mL?
What is included in the B in SBAR?
What is patient history, medications, vital signs, lab results, code status, signs and symptoms?
When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should:
A. use a standardized geriatric nursing care plan
B. plan for likely long term care transfer to allow for additional time to recover
C. consider preadmission functional abilities when setting patient goals
D. minimize activity level during hospitalization
What is C?
Rationale: The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan is unlikely to address individual patient needs and strengths. A patients need for discharge to a long-term-care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.
When assessing an older adult, what assessment tool should the nurse use for quick cognitive evaluation?
What is mental status examination (MSE)?
Which of the following would cause the charge nurse to intervene?
A. Graduate nurse is documenting skin assessment with another nurse
B. Graduate nurse gives login information to another graduate nurse to document the skin assessment
C. The graduate nurse logs out of patient's chart before leaving a patient's room
What is B?
Calculate output:
Voided: 120 mL
Voided: 200 mL
Voided: 400 mL
1 large BM
What is 720 mL and 1 BM?
What is included in the R in SBAR?
What is what you want, how to proceed, readback of orders received?
Which information obtained by the home health nurse when making a visit to an 88 year old with mild forgetfulness is of the most concern?
A. The patient's son uses a marked pillbox to set up the patient's medications weekly.
B. The patient has lost 10 pounds during the last month
C. The patient is cared for by a daughter during the day and stays with a son at night
D. The patient tells the nurse that a close friend recently died
What is B?
Rationale: A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse.
When assessing an older adult, what two components are added to the health history questionnaire for the patient's ability?
What are ADLs and IADLs?
How should the nurse conduct a patient interview?
What is be prepared prior to entering room, speak clearly with proper pronunciation, ensure privacy and environment free of distractions (if you can), use open-ended questions to obtain adequate medical information?
Calculate intake:
2 8 oz glasses of water
1 20 oz coke
2 4 oz cups of chicken broth
4 4 oz jellos
What is 1800 mL?
What is included in the A in SBAR?
What is what you think the key underlying problem/concern is, key changes in assessments such as vitals, neurologic, respiratory, cardiac, GI, GU, musculoskeletal, skin, nutrition, mentation, ADL, transfer, safety, environmental changes?
In performing a physical assessment for an older adult, the nurse anticipates finding which of the following normal physiological changes of aging?
A. Increased perspiration
B. Increased airway resistance
C. Increased salivary secretions
D. Increased pitch discrimination
B. Increased airway resistance
Rational: Normal physiological changes of aging include increased airway resistance in the older adult. The older adult would be expected to have decreased perspiration and drier skin as they experience glandular atrophy (oil, moisture, sweat glands) in the integumentary system. The older adult would be expected to have a decrease in saliva. A normal physiological change of the older adult related to hearing is a loss of acuity for high-frequency tones (presbycusis).
What is the correct medical abbreviation/documentation for the following?
twice a day, body mass index, three times a day, as needed, before meals and at bedtime
What is BID, BMI, TID, PRN, and ACHS?
Calculate Intake and Output, report findings.
250 mL IV antibiotic, 300 mL urine, 975 mL IV fluid, 4- 4 oz soups, 4- 12 oz water, 500 mL urine, 75 mL JP drain, vomit 400 mL, 1- 4 oz jello
What is intake 3265 mL; output 1275 mL?
Patient has fluid balance excess.
Tell me an SBAR--Patient: John Doe, DOB 1/1/1958, Room 212 on surgical unit. Patient is pale and sweaty, feels confused and weak with chest pain, has history of HTN, admitted for GI bleed, hemoglobin at 0600 was 9.0, he has had two small bloody BM in the last hour. Vitals 90/50, pulse 110, T 97.1F orally, R 24, O2 sat 95% on room air.
What is: Situation: Dr. Jones, this is Jane Smith calling from the surgical unit. I have Mr. Doe in room 212, DOB 1/1/1958. He is pale, sweaty, reports that he feels confused and weak, complains of chest pain.
Background: Patient has history of HTN, was admitted for GI bleed. His last hemoglobin at 0600 was 9.0. He has had two small bloody BMs in the last hour. Vitals 90/50, pulse 110, T 97.1, R 24, O2 sat 95% on room air.
Assessment: I think he has an active GI bleed, but we can't rule out an MI. We do not have recent cardiac enzymes or an updated H&H.
Recommendation: I would like you to evaluate him right away and get an EKG and updated labs stat.
There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age:
A. Men have the greatest incidence of osteoporosis
B. Muscle fibers increase in size and become tighter
C. Weight-bearing exercise reduces the loss of bone mass
D. Muscle strength does not diminish as much as muscle mass
C. Weight-bearing exercise reduces the loss of bone mass