Nursing 240 Exam Questions with 100% Correct Answers

Trigger vent setting Correct Answer initiates the change between exhalation and inspiration. High acuity care of elderly Correct Answer Older adults are a vulnerable population needing skilled care. Physiological changes occur as a normal part of aging-don't cause illness or disability but put older adults at risk for complications and negative outcomes while hospitalized. Nurses need to be aware of these changes to properly assess these patients. Appropriate application of interventions and protocols improves care, promotes optimal function, prevents complications and provides for the best possible outcomes. Neuro system changes for the elderly Correct Answer Prone to falls. Slower cognition. Senses (hearing, vision) may be affected. Memory loss not a normal part of aging. Memory processes are slower Learning takes longer. Blood brain barrier more permeable. Meds cross easier into brain; SE/toxicity. Decrease in brain volume. Nursing implications (neuro) for the elderly Correct Answer Changes affect safety. Increased vulnerability to confusion, depression, falls and traumatic injury. Pain sensation is reduced. Sight and hearing changes increase vulnerability to sensory perceptual alterations. Cardiovascular and pulmonary changes Correct Answer 82% of people who die of CAD are 65 or older. Changes in heart rhythm, cardiac output, contractility, hypertrophy, increased afterload and impaired endothelial function. Changes in the peripheral vascular system can cause Systolic blood pressure to rise until 80 years of age; Diastolic BP is less affected. Changes in lung volumes, chest expansion (compliance). Reduced mucus clearance. Nursing implications CV system for elderly. Correct Answer ACS/MI in elderly may present with atypical chest pain, syncope, failure to thrive, confusion or falls. ECG changes may not be specific for ACS/MI. Biomarkers not elevate as expected. Elderly more sensitive to hypovolemia (orthostatic hypotension) and pulmonary edema. Nursing implications of pulmonary system Correct Answer Assess for aspiration, atelectasis, pneumonia or any hospital acquired infection. Encourage coughing and deep breathing. At higher risk for VAP, follow care bundles. Assess gas exchange, ventilation and perfusion. Typical pao2 for healthy adult 65 years = 89mm Hg compared to 100 mm Hg when younger. Integumentary and musculoskeletal system for the elderly. Correct Answer Skin more friable and vulnerable to injury. Muscular system loses mass and strength - to stiffness and increased risk of falls and fracture. Changes in integumentary function predisposes to hypo/hyperthermia and F/E imbalances. Perform passive or active ROM. Encourage early mobility. Nursing implications for integumentary and musculoskeletal system elderly. Correct Answer Assess for rashes and cellulitis. Assess and prevent skin breakdown; wound healing often impaired. Threat to mobility is the most important challenge—ambulate quickly or perform ROM. Functional ability is a key factor in D/C planning. Chnages in GI/GU system in elderly. Correct Answer GI changes can alter nutritional status. Swallowing ability needs assessed. Diminished liver function decreases capacity to metabolize medications. Kidney function decreases with age. Changes in bladder muscles lead to changes in urination. Incontinence can be problematic: is not a normal part of aging. Nursing implications for GI/GU system elderly Correct Answer Ensure hydration. Advocate for early enteral/parenteral nutrition. Constipation is of significant concern in elderly. UTI's are responsible for most Correct Answer cases of bacteremia. UTI symptoms atypical of infection. Shows signs of Correct Answer mental status changes, confusion, N&V, abdominal pain. Endocrine and immune system changes Correct Answer Decrease hormone production. Decrease insulin production. Increased insulin resistance. Thyroid dysfunction. Develop autoantibodies (autoimmune disorders). Decreased temperature (lack of fever in response to infection). Decrease T & B cell function. Nursing implications for endocrine and immune system elderly. Correct Answer Monitor blood sugar. Watch for hypoglycemia with "tight glucose control". Pneumonia and influenza remain in top 10 causes of death for older adults. Infections in elderly hard to treat...best to prevent. Sepsis develops easily and has high mortality rate. S&S of infection are not as normally expected, be vigilant in assessment; changes in mental status, anorexia, incontinence, generalized weakness or falls. Cognitive changes in the elderly Correct Answer Dementia. Depression. Delirium. Assess mental status Correct Answer Mini-Cog mental status test. Delirium assessment scales Correct Answer Richmond Agitation & Sedation Scale (RASS). Confusion Assessment Method(CAM, CAM-ICU). Geriatric depression scale Correct Answer elderly can be suicidal