Basic Geriatric Nursing Chps. 8,10,11,12

CHAPTER 8 NOTES - correct answer Which assessment tool is most highly regarded and often used to determine the mental status of the older adult? - correct answer The Mini-Cog When assessing the respiratory system of an older adult, the nurse hears continuous, coarse, low-pitched sounds. How would these sounds be reported? - correct answer Gurgles (low-pitched wheezes) When taking a racial pulse of an older adult, the nurse finds it difficult to count a weak and thready pulse. What should the nurse do? - correct answer Take an apical pulse instead. When performing an assessment of the gastrointestinal system of an older adult, the nurse would proceed in what order? Place the parts of a gastrointestinal system assessment in sequence from first to last. - correct answer 1.) Obtain a health history 2.) Inspect the oral cavity 3.) Observe abdomen for scars 4.) Auscultate bowel sounds 5.) Palpate abdomen When performing an interview with an older adult, the nurse should consider physical environment factors by: - correct answer *Explaining what will take place during the assessment *Ensuring privacy and minimum noise levels *Selecting a room with a comfortable temperature *Seeking a location in close proximity to a restroom The nurse is preparing to assess the blood pressure of a patient and measures the patient s arm to determine the proper sized cuff. The diameter of the patient s arm is 50 cm. How wide should the blood pressure cuff be? - correct answer 60 Older adults developing various disease processes may present with different symptoms from younger adults. The nurse would be concerned about which disease if the patient were to demonstrate a decreased appetite, constipation, and changes to his sleep pattern in which he is awake at night and sleeps during the day? - correct answer Depression The nurse is assessing a patient and counts a respiratory rate of 8 breaths per minute. The nurse should be concerned about which condition? - correct answer Impending infection The 71-year-old patient presents to the clinic for her routine exam. While reviewing the patient's chart, the nurse notes the patient's most recent blood pressure screening, mammogram, and clinical breast exam were performed at age 70. She last had her cholesterol levels checked at age 68. Her last guaiac test and colonoscopy were performed at age 69. The nurse knows this patient should have which screening test(s) performed? - correct answer * Guaiac test * Blood pressure * Screening for obesity The patient presents to the clinic complaining of abdominal pain. Which information should be charted as objective data? - correct answer Patient is hunched in her chair, clutching her abdomen The nurse is recording subjective data of a patient recently admitted following a myocardial infarction. The patient states, "I have never been so scared in my life. On Tuesday, it felt like an elephant was sitting on my chest and I couldn't catch my breath." How should the nurse chart this information? - correct answer "The patient stated, 'I have never been so scared in my life. On Tuesday, it felt like an elephant was sitting on my chest and I couldn't catch my breath'" The nurse is interviewing the patient who has recently been admitted to the long term care facility with the patient's son present. Although the nurse directly addresses the patient with each question, the patient's son interrupts and answers the question for the patient. How should the nurse best handle this situation? - correct answer Request the patient's son allow the patient to answer the questions The nurse in the long term care facility knows each resident will be assessed using which comprehensive tool to determine care needs and appropriate interventions? - correct answer Minimum Data Set 3.0 The nurse palpates for the 78-year-old patient's radial pulse and counts 82 beats in one minute. Then, the nurse auscultates the patient's apical pulse and counts 94 beats per minute. The nurse knows which term describes this discrepancy? - correct answer Pulse deficit The nurse is assessing the older adult patient using the SPICES screening tool. Which questions would be helpful to complete the screening tool? - correct answer * "Have you fallen in the past 3 months?" * "Do you have difficulty getting to the bathroom on time?" * "Have you noticed your sleep patterns have changed in the past year?" Health screenings are done to - correct answer identify older adults who need further assessment. Which of the following statements is an example of objective data? - correct answer Blood pressure is 150/65 mm Hg. Why is it essential to collect accurate and complete data? - correct answer Nursing diagnoses and plan of care are formulated based on data It is more precise to - correct answer take a temperature reading. Which environment would be best for conducting an interview with an older adult? - correct answer A warm, diffusely lit patient room with access to a bathroom At first contact, the proper way to address the older adult women is - correct answer Ms., Mrs. Which method is the most commonly used during physical assessment? - correct answer Inspection Which method uses the sense of touch to obtain data? - correct answer Palpation Which method is used to evaluate heart sounds? - correct answer Auscultation The method used least by nurses is - correct answer percussion. Acronym for 6 common "marker conditions" in older adults that can identify potential health-related problems: - correct answer SPICES ******** S-sleep disorders P-problems w/ eating or feeding I-incontinence C-confusion E-evidence of falls S-skin breakdown Mnemonic used for when a serious problem is present or might be developing; a deep, focused assessment: - correct answer FANCAPES ************ F-fluid A-aeration (oxygenation) N-nutrition C-cognition, communication A-activity/abilities P-pain E-elimination S-skin/socialization What is the tool that allows the evaluation of core function in a resident in a long-term care facility? -