Final Exam Review
Neurosensory
Confusion: What are the causes of acute confusion in the elderly?
Some common causes are infection, new prescriptions of medication, not enough sleep, and stress,
dehydration
Differentiate between dementia, delirium and depression in the elderly
Delirium is an acute brief state of disorientation that makes people have a difficult time with attention and
concentration but is reversible. Dementia is a gradual decline where the patient is alert but will be able to
comprehend and have loss of ability and a have gradual loss of knowledge, memory, and judgement; is
not reversable. Depression can be both gradual or sudden from an accident or built-up stress. They will
be self-absorbed and feel worthless. they are able to do things but doesn’t want to and choose to forget
things; this is reversible
What is important in the nursing care of dementia patients to control their S&S?
For a dementia patient keep their environment calm, structured and familiar; don’t move stuff. Remove
any dangerous item and speak calmly. Take frequent walks because they will wander around, secure any
car keys, and lock the front door. When they are in the early stage reorient them. In the later stage don’t
reorient just distract, deneprizil
What are the S&S of depression and what is the nurses responsibility if you recognize these S&S
in a patient?
S/S for depression are feelings of sadness, anxiety, self-blame, and worthlessness. They could be angry
even over small matters. They will lose interest in the things they love. They will have reduced sleep,
appetite or can have increased cravings. They will have slow and troubled thinking, concentrating,
speaking, decision making. They will have suicidal thoughts and unexplained physical problems.
nursing responsibility is to keep patient safe and allow patient to go over their feelings and problem
What teaching would you provide regarding SSRI’s
SSRI’s is the first line defense for depression. Some teaching is to administer in the morning, report any
S/S or suicidal thoughts avoid hazardous activities because of dizziness and fatigue, assess mental
status and mood changes, changes in appetite and nutrition intake. Can lead to serotonin levels
Restraints: What orders are required when applying restraints?
Restraints are last resort, use least restrictive device. The order must be placed and renewed every
24hrs
What nursing care is required when restraints are applied?
Nursing care when restraint is applied are to check neurovascular assessment every 2 hours like color,
cap refills, sensation, and movement. Assess for breakdown, redness, and irritation. Every 2 hour offer
toileting, food, and the need to continue restraints. Always DOCUMENT
Seizure: What are the signs and symptoms of generalized seizures?
Generalized seizure include absence seizures which are blank starring that starts and ends abruptly and
last 10 seconds, awareness is usually impaired. Tonic-clonic seizures have 2 phases: tonic phase that
involves crying or groaning, loss of awareness, falling and stiffening. They will also be incontinent and
have blue lips. Clonic phase is convulsion and jerking + twitching of all limbs; they can have foamy
mouth and blinking. Myoclonic seizures are sudden jerking and falls. Atonic seizures are sudden loss of
muscle tone
, What is the priority nursing care of patients having a seizure?
Nursing priority care for seizures is to provide airway and decrease risk of aspiration by turning them to
the side. Protect client from injury, start timing and loosen clothes. Do not restrain
Vision: What is the nursing care of patients newly diagnosed with glaucoma?
Provide patient safety, assess vision (PERRLA), educate patient about eyedrop compliance, educate
patient about glaucoma and the importance of follow up exam and manage anxiety. Limit strenuous
activity, no bending over, lifting heavy objects, no coughing or sneezing. Lit environments to reduce glare
and proper eye care like clean and use eyeglasses, magnifying glass, big letter in meds, good lighting,
no rugs.
What patient teaching should you provide to patients with glaucoma regarding ALL
medications?
Teach patient about how to administer eye drops: give tissue, tilt head back, pull down conjunctal sac
and drop, close eye gently, don’t touch eye drop medication to any parts of body. Take eyedrops for rest
of your life.
Hearing: How can the nurse best communicate with a patient with a hearing impairment?
Sit front and face directly. Have adequate lighting and use short simple language. Make sure patient
understand by either writing down, repeating yourself or make them repeat you. Make sure they are
wearing their hearing aid. talk near better side. Talk in lower voice. Look for nonverbal communications if
necessary.
Pain: How do you assess pain?
you can assess if there in pain by using a pain scale (0-10)or ask question like how the pain feels like,
the onset & duration and what makes it worse/better. If they are unable to verbalize check for nonverbal
pain indicators like facial expression, vocalization, body movement and activity patterns. Pain is what the
patient tells you and what they are experiencing
What is the difference between addiction and physical dependence?
An addiction is influence by genetics, environment, and psychosocial factors. It is an impaired control
over drug use despite harm and cravings.
A physical dependence is a normal response after repeated administration of opioids over several days.
If they don’t receive dose (withdrawals), they will become agitated and have high HR and BP. Built up
intolerance of it.
What can we teach patients to prevent withdrawal after long term use of opiates for pain?
Ween off opioid by cut dose in half, use lower dose. Switch to less potent pain med.
Elimination
Urinary:
What patient teaching would you provide to a patient scheduled for extracorporeal shock
wave lithotripsy?
Before lithotripsy do not take NSAIDs or blood thinners; need to do a bowel prep the day before. NPO
after midnight. After lithotripsy strain their urine, they may have bruising on their flank, may need to stent
to keep urethra open for stone to pass, flush with 3L of water and will have strict I&Os. Ambulate to help
pass stones. Look for bleeding
What patient teaching would you provide to a patient with recurrent UTI’s?
Change birth control, take cranberry juice, drink more fluids, urinate after and before intercourse, wipe
front to back. Avoid potentially irritating feminine products. take antibiotics, cotton underwear, don’t wear
restrictive clothing. Shower before and after sex
What post-op assessments are important for a patient after a TURP & why?
Patient will have 3-way foley; this allows irrigation to prevent clots. They will be pulled tight so there is
traction on catheters. Keep patient leg straight, there will be continuous bladder irrigation; keep pushing
fluid 1st 24hrs to flush clots. Measure I&Os (30ml/hr). Skin protection. Kegel exercise to strengthen
muscles.
Bowel:
Neurosensory
Confusion: What are the causes of acute confusion in the elderly?
Some common causes are infection, new prescriptions of medication, not enough sleep, and stress,
dehydration
Differentiate between dementia, delirium and depression in the elderly
Delirium is an acute brief state of disorientation that makes people have a difficult time with attention and
concentration but is reversible. Dementia is a gradual decline where the patient is alert but will be able to
comprehend and have loss of ability and a have gradual loss of knowledge, memory, and judgement; is
not reversable. Depression can be both gradual or sudden from an accident or built-up stress. They will
be self-absorbed and feel worthless. they are able to do things but doesn’t want to and choose to forget
things; this is reversible
What is important in the nursing care of dementia patients to control their S&S?
For a dementia patient keep their environment calm, structured and familiar; don’t move stuff. Remove
any dangerous item and speak calmly. Take frequent walks because they will wander around, secure any
car keys, and lock the front door. When they are in the early stage reorient them. In the later stage don’t
reorient just distract, deneprizil
What are the S&S of depression and what is the nurses responsibility if you recognize these S&S
in a patient?
S/S for depression are feelings of sadness, anxiety, self-blame, and worthlessness. They could be angry
even over small matters. They will lose interest in the things they love. They will have reduced sleep,
appetite or can have increased cravings. They will have slow and troubled thinking, concentrating,
speaking, decision making. They will have suicidal thoughts and unexplained physical problems.
nursing responsibility is to keep patient safe and allow patient to go over their feelings and problem
What teaching would you provide regarding SSRI’s
SSRI’s is the first line defense for depression. Some teaching is to administer in the morning, report any
S/S or suicidal thoughts avoid hazardous activities because of dizziness and fatigue, assess mental
status and mood changes, changes in appetite and nutrition intake. Can lead to serotonin levels
Restraints: What orders are required when applying restraints?
Restraints are last resort, use least restrictive device. The order must be placed and renewed every
24hrs
What nursing care is required when restraints are applied?
Nursing care when restraint is applied are to check neurovascular assessment every 2 hours like color,
cap refills, sensation, and movement. Assess for breakdown, redness, and irritation. Every 2 hour offer
toileting, food, and the need to continue restraints. Always DOCUMENT
Seizure: What are the signs and symptoms of generalized seizures?
Generalized seizure include absence seizures which are blank starring that starts and ends abruptly and
last 10 seconds, awareness is usually impaired. Tonic-clonic seizures have 2 phases: tonic phase that
involves crying or groaning, loss of awareness, falling and stiffening. They will also be incontinent and
have blue lips. Clonic phase is convulsion and jerking + twitching of all limbs; they can have foamy
mouth and blinking. Myoclonic seizures are sudden jerking and falls. Atonic seizures are sudden loss of
muscle tone
, What is the priority nursing care of patients having a seizure?
Nursing priority care for seizures is to provide airway and decrease risk of aspiration by turning them to
the side. Protect client from injury, start timing and loosen clothes. Do not restrain
Vision: What is the nursing care of patients newly diagnosed with glaucoma?
Provide patient safety, assess vision (PERRLA), educate patient about eyedrop compliance, educate
patient about glaucoma and the importance of follow up exam and manage anxiety. Limit strenuous
activity, no bending over, lifting heavy objects, no coughing or sneezing. Lit environments to reduce glare
and proper eye care like clean and use eyeglasses, magnifying glass, big letter in meds, good lighting,
no rugs.
What patient teaching should you provide to patients with glaucoma regarding ALL
medications?
Teach patient about how to administer eye drops: give tissue, tilt head back, pull down conjunctal sac
and drop, close eye gently, don’t touch eye drop medication to any parts of body. Take eyedrops for rest
of your life.
Hearing: How can the nurse best communicate with a patient with a hearing impairment?
Sit front and face directly. Have adequate lighting and use short simple language. Make sure patient
understand by either writing down, repeating yourself or make them repeat you. Make sure they are
wearing their hearing aid. talk near better side. Talk in lower voice. Look for nonverbal communications if
necessary.
Pain: How do you assess pain?
you can assess if there in pain by using a pain scale (0-10)or ask question like how the pain feels like,
the onset & duration and what makes it worse/better. If they are unable to verbalize check for nonverbal
pain indicators like facial expression, vocalization, body movement and activity patterns. Pain is what the
patient tells you and what they are experiencing
What is the difference between addiction and physical dependence?
An addiction is influence by genetics, environment, and psychosocial factors. It is an impaired control
over drug use despite harm and cravings.
A physical dependence is a normal response after repeated administration of opioids over several days.
If they don’t receive dose (withdrawals), they will become agitated and have high HR and BP. Built up
intolerance of it.
What can we teach patients to prevent withdrawal after long term use of opiates for pain?
Ween off opioid by cut dose in half, use lower dose. Switch to less potent pain med.
Elimination
Urinary:
What patient teaching would you provide to a patient scheduled for extracorporeal shock
wave lithotripsy?
Before lithotripsy do not take NSAIDs or blood thinners; need to do a bowel prep the day before. NPO
after midnight. After lithotripsy strain their urine, they may have bruising on their flank, may need to stent
to keep urethra open for stone to pass, flush with 3L of water and will have strict I&Os. Ambulate to help
pass stones. Look for bleeding
What patient teaching would you provide to a patient with recurrent UTI’s?
Change birth control, take cranberry juice, drink more fluids, urinate after and before intercourse, wipe
front to back. Avoid potentially irritating feminine products. take antibiotics, cotton underwear, don’t wear
restrictive clothing. Shower before and after sex
What post-op assessments are important for a patient after a TURP & why?
Patient will have 3-way foley; this allows irrigation to prevent clots. They will be pulled tight so there is
traction on catheters. Keep patient leg straight, there will be continuous bladder irrigation; keep pushing
fluid 1st 24hrs to flush clots. Measure I&Os (30ml/hr). Skin protection. Kegel exercise to strengthen
muscles.
Bowel:
