HONDROS NUR 163 EXAM 1 2025

6 rights - -Right patient, right drug, right dose, right route, right time, right documentation Assess for before pt fall risk discharge - -stairs, rugs, meds, furniture Benefits of exercise - -keep joints flexible, maintain muscle, decrease blood sugar level, heart health, decrease wt, increase sense of well being Calories needed per day - -1200 calories Decreased fluid volume - -inadequate intake or excessive loss of fluid, progress into dehydration Dry mucous membranes, thirst, decrease skin turgor, rapid wt loss, sunken eyes, weakness, decrease or increased concentration of urine Increase HR Decrease pulse pressure Hypotension and orthostatic hypotension Increase body temp Hypovolemic shock Delerium - -what disorder usually has an rapic onset and is reversible if treated Ex. Confusion, nausea, dark urine, foul odor-UTI Dementia - -slow onset, impaired memory, judgment, language, motor skills, recognizing familiar people or objects Not reversible Direct questioning - -yes or no answer short answer Drug excretion for elderly - -kidneys are less effective in the excretion of drugs bc of reduced renal perfusion more drugs remain in the circulation, leading to elevated drug levels and sx of drug toxicity Electrolyte important to elderly - -pottasium Electrolytes are excreted through - - Stool Ememsis Urine Sweat Epworth sleepiness scale - -Determines how likely PT will Fall asleep in a given scenario, 0-3 scale. Score of 9or is high index for sleep. AIR Executive function - -higher-order, complex cognitive processes, including thinking, planning, and problem solving Exercise legnth - -30 minutes to be beneficial Expressive aphasia - -person is unable to express themselves using language(speech) Eye exam - -every 12mo Food high in pottasium - -apple juice Global aphasia - -person loses the ability to understand language and to express themselves using language Cant understand speech or speak Hard of hearing - -eliminate background noise Speak in low even tone Face pt when speak to them Eye contact Healthy diet interventions - -portion control Reduce fat, sugar, unhealthy cholesterol, salts Exercise How long is a pulse taken - -1 min Hypothermia sx - -core body temp 95 or lower Mental confusion pulse and respitory rate slow, skin cool cold to touch, pallor or cyanosis, poor balance gait changes If pt says I am fine - -comfort And inquire more info Indians and s diet - -rice and fish Intervention for leg swelling - -ted hose Ambulation Scds Lasix Elevate legs Intimate space - -0-18" Joint commision - -fall prevention a priority, national pt safety goal Requires organizations to implement and evaluate a falls reduction program AIR AIR AIR Katz Index - -Measures adls based on 1 point or0 points in relation to bathing, toiling, transferring, continence, feeding and dressing. Used to measure performance, evaluate treatment, outcomes, and predict the need for continuing supervised care Memory - -retention and recall of past experiences Metabolism in elderly - -since there is decrease in liver function then the drugs stay in system longer increasing half life so that drug builds up in system causing drug toxicity Mini-Cog Test - -■ Quick method for assessing dementia. If abnormal, screen further with MMSE. ■ Use these two methods: the clock drawing test with word recall test (three unrelated words). ■ Instruct patient to draw a clock and mark it with the hands showing a certain time. ■ Example: Instruct patient to "Draw a clock that shows 20 minutes past 4." - Scoring clock test: Hands point to the correct time and numbers on clock are in correct Sequence. Total score of 3,4,5 low likelihood of dementia but doesn't rule out cognitive impairment Montreal cognitive assesment - -used for detecting cognitive impairment, assists in identifying dementia Takes 10-12 min Scores range 0-30 26 higher norm 16 and below alzeimers Tests for executive function Morse fall risk assess for - -history of falls Secondary diagnosis Ambulatory aid(holding furniture highest score) IV therapy Mental status Morse fall risk scale - -0-24 good, basic nursing care, no risk 25-50 Implement standard fall prevention interventions, Low risk fall risk band, yellow sign 51 implement high fall risk prevention interventions, fall risk band, yellow sign New med is started and pt c/o dizziness - -go back and check the med Objective data - -info that can be gathe