NUR 2214 / NUR2214 Module 2 Quiz – Nursing Care of the Older Adult (Latest 2026/2027 Update) | Rasmussen University | Verified Questions & Answers | 100% Correct Solutions | Grade A

NUR 2214 / NUR2214 Module 2 Quiz – Nursing Care of the Older Adult (Latest 2026/2027 Update) | Rasmussen University | Verified Questions & Answers | 100% Correct Solutions | Grade A Two nursing students are shadowing a neurology nurse and together they observe a patient who is lying in the supine position with their arms and legs extended forming an “E-shape.” What does this patient’s position indicate? A. Damage to the pons or brain stem B. Damage to the spinal tract C. Damage to the cerebral hemisphere D. Damage to the lumbar spine A. Damage to the pons or brain stem Rationale: The patient appears to be in a decerebrate position, which involves damage to the pons or brain stem. A patient with osteoporosis is prescribed Risedronic (Actonel). What teaching should go along with this medication? Select all that apply: A. Take medication 30 minutes before breakfast B. Take medication 2 hours after breakfast C. Take medication with an 8 oz glass of water D. Take medication right before going to bed E. Take medication during lunch F. Take medication while sitting up G. Take medication in the supine position A. Take medication 30 minutes before breakfast C. Take medication with an 8 oz glass of water F. Take medication while sitting up A patient with multiple sclerosis (MS) has an acute exacerbation. What medication does the nurse anticipate the HCP ordering? A. Diphenhydramine (Benadryl) B. Metoprolol (Lopressor) C. Amoxicillin (Moxatag) D. Methylprednisolone (Solu-Medrol) D. Methylprednisolone (Solu-Medrol) What are some likely medications for a patient with osteoarthritis? A. Antibiotics B. Anticholinergics C. NSAIDs D. Antihypertensive C. NSAIDs Rationale: NSAIDs are the most effective treatment for patients with osteoarthritis. Cox-2 Inhibitors are a very common NSAID used for osteoarthritis A nursing student observes a PA working in a cardiology clinic. The PA and the student assess an infant patient with a "machine-like heart murmur." The student notices the patient has a bounding heart pulse. The PA knows the teaching has been successful when the student is able to identify the condition as: A. Pulmonary embolism B. Patent Ductus Arteriosus C. Coarctation of Aorta D. Tetralogy of Fallot B. Patent Ductus Arteriosus Rationale: A "machine-like heart murmur" should be associated with Patent Ductus Arteriosus (PDA) A nurse overhears an HCP encouraging a patient to add Vitamin D to their diet as well as calcium. Later that day, the patient states, "I thought I just needed to increase my calcium intake. Why is Vitamin D necessary, too?" How should the nurse respond? A. Vitamin D potentiates the effect of calcium B. Vitamin D helps absorb calcium C. Vitamin D helps reduce stomach secretions D. Vitamin D has the same effect as calcium B. Vitamin D helps absorb calcium A nurse is working with a neurology patient who has increased intracranial pressure (ICP). During the assessment, the nurse notates abnormal posturing because they are lying the in the supine position with their arms flexed inward, forming a "C-shape." How should the nurse recognize this position? A. Decerebrate position B. Spasmodic Torticollis C. Dystonia D. Decorticate position D. Decorticate position The nurse should understand the normal range of intracranial pressure (ICP) is: A. 5 - 15 B. 10 - 21 C. 15 - 30 D. 20 - 30 A. 5 - 15 Rationale: millimeters of mercury is how this is measured What are some nursing interventions for a child suffering from Tetralogy of Fallot (TOF)? Select all that apply: A. Decrease stimuli B. Place child in high fowler's position C. Weigh child at various times throughout the day D. Check peripheral pulses, including capillary refill E. Check for edema F. Prevent child from playing A. Decrease stimuli D. Check peripheral pulses, including capillary refill Rationale: Children should still be allowed to play, just not in a way that will cause over exertion. These patients should be placed in the semi-fowler's position. In addition, these patients should be weighed every day, at the same time, and ideally before breakfast. A student nurse receives education on how changes in mobility will occur throughout a person's lifespan. What are these expected changes considered to be part of? A. Family Systems Theory B. Sedentary lifestyle C. Growth and development D. Rare physiological changes C. Growth and development A nursing instructor describes this heart defect as one the easiest ones to diagnose. It can often be identified on a chest-X-Ray because of its "boot-like" appearance. A. Coarctation of the aorta B. Right Ventricular Hypertrophy C. Pulmonary Stenosis D. Overriding Aorta B. Right Ventricular Hypertrophy Rationale: This is one of the four heart defects associated with Tetralogy of Fallot (TOF). A nurse and a cardiology nurse practitioner discuss nursing interventions for a patient with an aorta that is positioned directly above a ventricular septal defect (VSD). This condition allows blood from both ventricles to enter the aorta. What is this specific phenomenon known as? A. Ventricular Septal Defect (VSD) B. Right Ventricular Hypertrophy C. Pulmonary Stenosis D. Overriding Aorta D. Overriding Aorta Rationale: This is one of the four heart defects associated with Tetralogy of Fallot (TOF). A graduate nurse hears the term "palliative interprofessional core team." The nurse should know this includes the specific disciplines of: Select all that apply: A. Nursing B. Child protective services C. Medicine D. Respiratory Therapy E. Social Work F. Physical/Occupational therapy G. Clergy A. Nursing C. Medicine E. Social Work G. Clergy Rationale: The palliative interprofessional core team includes Nursing, Medicine, Social Work, and Clergy Which medication is the nurse most likely to administer to a patient with atrial septal defect (ASD)? A. Amoxicillin B. Atropine C. Clindamycin D. Digoxin D. Digoxin A nursing student studies different heart conditions. She asks her instructor if she can write a paper on a rare condition that includes "four congenital heart defects." What is this condition called? A. Pulmonary embolism B. Patent Ductus Arteriosus C. Coarctation of Aorta D. Tetralogy of Fallot D. Tetralogy of Fallot A 62-year-old female Caucasian patient has been diagnosed with osteoporosis. Which medication(s) is the HCP likely to prescribe? Select all that apply: A. Alendronate B. Atropine C. Risedronate (Actonel) D. Ibandronate E. Prednisolone F. Zoledronic A 62-year-old female Caucasian patient has been diagnosed with osteoporosis. Which medication(s) is the HCP likely to prescribe? Select all that apply: A. Alendronate C. Risedronate (Actonel) D. Ibandronate F. Zoledronic Rationale: Risedronate (Actonel) is commonly used to treat patients with osteoporosis. Prednisolone is a corticosteroid and should be withheld from patients with osteoporosis. Corticosteroids have a major impact on how the body uses calcium and can actually cause bone loss. While auscultating a newborn's chest, the nurse appreciates a heart murmur. An electrocardiogram (EKG) confirms the murmur occurs as blood passes through the left and right ventricles. What condition does the newborn most likely have? A. Coarctation of the aorta (COA) B. Ventricle Septal Defect (VSD) C. Patent Ductus Arteriosus (PDA) D. Atrial Septal Defect (ASD) B. Ventricle Septal Defect (VSD) An HCP decides surgery is the best option for a patient with a patent ductus arteriosus (PDA). The parents ask what the purpose of this surgical procedure is. How should the nurse respond? A. The purpose is to prevent your child from developing diabetes later in life B. The purpose is to prevent your child's aorta from narrowing C. The purpose is to ensure oxygenated blood continues to go back to the lungs D. The purpose is to stop oxygenated blood from going back to the lungs D. The purpose is to stop oxygenated blood from going back to the lungs Which Glasgow Coma scale is most concerning to the nurse? A. 6 B. 8 C. 10 D. 13 A. 6 Rationale: Lowest possible score on Glasgow coma is 3 and the highest possible score is 15. The Glasgow Coma scale includes three categories: eye opening, verbal response, and motor function. A score of 8 or less is considered a severe neurological injury. A student nurse receives education on pain management and why it is important to prevent patients from having "long-term exposure to pain." The nursing educator deems the teaching to be successful after the student is able to verbalize: A. Exposure to prolonged stress (from pain) impacts the entire body B. Pain always hinders a person's ability to follow commands C. Long-term exposure to stress (from pain) leads to depression D. Pain hinders a person's ability to communicate A. Exposure to prolonged stress (from pain) impacts the entire body A labor and delivery nurse notified the HCP after suspecting her newborn patient has coarctation of the aorta (COA). What symptoms likely alerted the nurse that the patient was suffering from this condition? Select all that apply: A. Bounding pulses in the upper extremities B. Epistaxis C. Weak, thready pulses in the lower extremities D. Bounding pulses in the lower extremities E. Legs are warm to touch F. Weak, thready pulses in the upper extremities G. Difference in blood pressure findings A. Bounding pulses in the upper extremities B. Epistaxis C. Weak, thready pulses in the lower extremities G. Difference in blood pressure findings Rationale: Patients with COA will show a disparity in blood pressure readings; legs are usually cool to touch, and epistaxis (nosebleeds) may be present A 70-year-old male patient is recovering from an automobile accident in which he sustained traumatic injuries throughout his body. He explains to the HCP that controlling his pain is the biggest challenge. Which type of pain management is the most likely to be successful for this patient? A. Around the clock Demerol B. PRN ibuprofen C. Morphine IV 2hrs PRN D. Morphine PCA D. Morphine PCA Rationale: EBP says PCA control is the best way to control severe pain. The PCA reduces the patient's risk of overdose, too. Demerol is contraindicated in patients that are considered elderly and therefore should not be prescribed. A nurse cares for a patient who has ventricular septal defect (VSD). Which genetic anomaly is most commonly associated with this cardiac condition? A. Cystic Fibrosis B. Down Syndrome C. Fragile X Syndrome D. Marfan Syndrome B. Down Syndrome Rationale: Down syndrome (Trisomy 21) poses the greatest risk for heart defects in newborns. A nurse observes a 2-year-old patient with Tetralogy of Fallot (TOF) squatting. Why is the child most likely in this position? A. It relaxes the patients back muscles B. It improves the child's posturing C. It prevents the child from having a bowel movement D. It returns blood blow to the lungs D. It returns blood blow to the lungs A graduate nurse is consulting with their nurse preceptor on how to care for patients with increased intracranial pressure (ICP). Which statement by the graduate indicates a need for further teaching? A. "My patient may require a stool softener in addition to their antiemetic." B. "I will try to cluster as many episodes of care as possible for this patient." C. "I will educate my patient on why the act of straining should be avoided." D. "My patient will remain in the semi-fowler's position." B. "I will try to cluster as many episodes of care as possible for this patient." Rationale: when caring for patients with increased intracranial pressure (ICP), nurses should space the care out as much as possible so they can reduce the number of stimuli the patient is exposed to. The goal is to not get patients with ICP overly worked up. Which patient population will NSAIDs most likely be used to treat patent ductus arteriosus (PDA)? A. Macrosomia infants B. Late full-term infants C. Premature infants D. Full-term infants C. Premature infants Rationale: NSAIDs can be used to care for premature infants. Surgical/ligation is significantly more likely to be used for late and full-term infants A student nurse receives education from a NP about osteoporosis. Which statement by the student nurse indicates the teaching has been successful? A. "Calcium helps with vitamin D absorption." B. "There is no way to treat osteoporosis after menopause." C. "For five years after menopause women will lose about 2% of bone mass each year." D. "Osteoporosis is the progressive deterioration and loss of cartilage and bone in one or more joints." C. "For five years after menopause women will lose about 2% of bone mass each year." Rationale: Vitamin D helps with Calcium absorption. Osteoporosis can be treated five years after menopause. Osteoarthritis is the progressive deterioration and loss of cartilage and bone in one or more joints." A nurse at shift change determines the patient with the highest priority is a 1-month old infant who has a patent ductus arteriosus (PDA). What signs and symptoms should the nurse suspect to see in this patient? Select all that apply: A. Abnormal sweating B. Tachycardia C. Poor eating and growth D. Macrosomia E. Bradycardia F. Weak/thready femoral pulse A. Abnormal sweating B. Tachycardia C. Poor eating and growth A nurse provides care for a patient with increased intracranial pressure (ICP). The HCP orders and an antiemetic. What other medication should the nurse anticipate the HCP ordering? A. Antibiotic B. Stool softener C. Anti-mucosal agents D. Vasodilators B. Stool softener Rationale: The goal is to prevent straining for patients with ICP. The HCP does not want the patient bearing down so an antiemetic will prevent the patient from vomiting. However, a side effect of antiemetic is constipation, which could also encourage the patient to start bearing down. Therefore, a stool softener might be necessary. A nurse plans on discharging a 74-year-old female patient with osteoporosis who lives alone. What should be the nurse's first priority? A. Conduct a home risk assessment B. Encourage the patient to follow up with their HCP C. Instruct the patient to be careful walking around the house D. Tell the patient to call the HCP's office if she thinks she is a fall risk A. Conduct a home risk assessment An HCP instructs a nurse to provide education on using a transdermal patch. What should be included in the teaching? A. Always apply the new patch to same exact location B. Always remove the previous patch before applying a new one C. Do not keep on longer than 24 hours D. Always remove the patch by after 4 days Rationale: the patch should be changed every 72 hours (3 days) B. Always remove the previous patch before applying a new one Rationale: the patch should be changed every 72 hours (3 days) What is the lowest and highest possible score a patient can receive on the Glasgow Coma scale? A. 3 and 15 B. 5 and 20 C. 8 and 17 D. 10 and 21 A. 3 and 15 What is responsible for pushing oxygenated blood to the rest of the body? A. The left bronchus B. Right ventricle C. Left ventricle D. Both the right ventricle and the left ventricle C. Left ventricle A 5-year-old child with an atrial septal defect (ASD) has symptoms that appear to be getting worse. The child's cardiologist recommends cardiac catherization. What is the purpose of this procedure? A. To flatten against the septum on both sides and permanently seal the ASD B. To conduct a biopsy on the cardiac tissue C. Widen the opening of the ASD to promote blood flow D. To determine if the child is a candidate for a heart transplant A. To flatten against the septum on both sides and permanently seal the ASD A nursing instructor asks a student to provide an example of a "biologically based therapy." Select all that apply: A. Herbs B. Opioids C. Weightlifting D. SSRIs E. Vitamins F. Tai Chi A. Herbs E. Vitamins F. Tai Chi This medication is an anticonvulsant that is also used to treat nerve pain: A. Amoxicillin B. Nadolol C. Aricept D. Gabapentin D. Gabapentin A nurse interviews a 55-year-old female patient who suspects she might have osteoporosis. The patient inquiries about estrogen therapy. What in the patient's medical history makes estrogen therapy contraindicated? A. The woman is a breast cancer survivor B. The woman is post-menopausal C. The woman does not have the proper BMI for this therapy D. The woman has had a cholecystectomy A. The woman is a breast cancer survivor Rationale: Cancer cells like estrogen and therefore estrogen therapy runs the risk of causing the woman's cancer to reoccur A nurse is instructed to administer prostaglandin E-1 to a 2-year-old male patient with patent ductus arteriosus (PDA). What is the purpose of administering this medication? A. Acts as a calcium channel blocker B. Improve oxygenation and increase pulmonary blood flow C. To surgically remove the patency of the ductus (PDA) D. Improve oxygenation and decrease pulmonary blood flow B. Improve oxygenation and increase pulmonary blood flow A nurse performs an assessment on a pulmonary patient who describes his condition as having an "excess of muscle mass" around the right side of his heart. Before checking his chart, what condition should the nurse assume the patient is referring to? A. Coarctation of the aorta (COA) B. Right Ventricular Hypertrophy C. Pulmonary Stenosis D. Overriding Aorta B. Right Ventricular Hypertrophy Rationale: This is one of the four heart defects associated with Tetralogy of Fallot (TOF). How should a patient with increased intracranial pressure (ICP) be positioned? A. Semi-Fowler's position B. Prone position C. High-Fowler's position D. Supine position A. Semi-Fowler's position Rationale: positioned upward at 30 degrees A 4-year-old patient has a heart defect. The defect involves an obstruction of blood flow from his right ventricle of the heart to the pulmonary artery. What condition does the child most likely have? A. Coarctation of the aorta B. Right Ventricular Hypertrophy C. Pulmonary Stenosis D. Overriding Aorta C. Pulmonary Stenosis Rationale: This is one of the four heart defects associated with Tetralogy of Fallot (TOF). Thirty minutes after administering morphine to a 1-year-old patient, the nurse suspects the patient is having an overdose. Which action should the nurse perform first? A. Notify the HCP B. Call the rapid response team C. Administer IV fluids D. Administer Narcan D. Administer Narcan A nursing professor provides teaching on patent ductus arteriosus (PDA) in a newborn baby. What is the time frame for when the "shunt" should close? A. 24 hours B. 48 hours C. 72 hours D. 96 hours C. 72 hours A nursing professor conducts a lecture on assessment findings for patients with multiple sclerosis (MS). The professor asks the students to list the assessment findings associated with late onset of MS. Select all that apply: A. Excessive somnolence B. Heat intolerance C. Blurred vision D. Fatigue E. Nystagmus F. Hyper reflexes A. Excessive somnolence B. Heat intolerance F. Hyper reflexes A nurse meets with a female patient who was admitted to the ED for a possible fractured ankle. She states the pain will not go away. After completing an entire interview on the patient's injury, the nurse asks the patient to rate her pain on a scale from 0 - 10. The patient describes her pain as a "5." How should the nurse respond? A. "What level of pain do you consider to be acceptable?" B. "Have you ever had this type of pain before?" C. "Do you know anyone who has also experienced this type of pain?" D. "Please point to where it hurts again—one more time." A. "What level of pain do you consider to be acceptable?" Rationale: Pain is subjective and therefore nurses should try to determine what the pain level is acceptable to the patient. While reviewing a cardiology patient's chart, the nurse learns the patient suffers from an opening in their atria. As the nurse begins her assessment, the patient states, "I have a hole in my heart." Which condition should the nurse suspect the patient has? A. Coarctation of the aorta (COA) B. Ventricle Septal Defect (VSD) C. Patent Ductus Arteriosus (PDA) D. Atrial Septal Defect (ASD) D. Atrial Septal Defect (ASD) A neurology nurse observes a patient with their arms and legs flexed toward the body. What does this indicate to the nurse about the patient's condition? A. Damage to the spinal tract or cerebral hemisphere B. Damage to the brain stem C. Damage to the midbrain D. Damage to the pons A. Damage to the spinal tract or cerebral hemisphere Rationale: the patient appears to be in the decorticate position A graduate nurse and her preceptor provide care for an infant patient who has a history of Tetralogy of Fallot (TOF). The infant's skin appears blueish. The preceptor pushes the baby's knees to his chest. What is the baby experiencing? A. An infection B. A Tet-spell C. Hypoglycemic episode D. Ascites B. A Tet-spell The elderly population's thermoregulation begins to dimmish. What age does this start happening at? A. 60 B. 70 C. 80 D. 90 B. 70 Rationale: Thermoregulation starts diminishing at age 70 and it gets worse each decade after that. In elderly patients, it takes twice the amount of time for their temperature to return to its normal range (because of changes in metabolism). This means drastic temperature changes are more life threatening for elderly patients. A patient who has been taking opioids complains of constipation. What dietary recommendations should the nurse make to the patient? Select all that apply: A. Bran foods B. Green leafy vegetables C. Cheese D. Steak E. Apples F. Prunes G. Peanuts A. Bran foods B. Green leafy vegetables E. Apples F. Prunes G. Peanuts A nurse interviews a 75-year-old male patient who says he has a condition where his body "cannot keep up with making enough cartilage and bone." Which disorder should the nurse assume the patient has? A. Osteoporosis B. Osteomyelitis C. Osteoarthritis D. Rheumatoid arthritis C. Osteoarthritis What are some likely assessment findings in a patient with osteoarthritis? Select all that apply: A. Shortness of breath B. Fluid buildup in the knees C. Presence of Heberden's nodes D. Joints are soft on palpation E. Limp or restricted walking pattern F. Kyphosis B. Fluid buildup in the knees C. Presence of Heberden's nodes E. Limp or restricted walking pattern Rationale: Joints are "hard" on palpation. Kyphosis is associated with osteoporosis. Shortness of breath is not associated with this condition. A nurse suspects a patient is suffering form Cushing's triad. What assessment findings led the nurse to believe this? Select all that apply: A. Elevated temperature B. Hypertension C. Bradycardia D. Tachycardia E. Hypotension F. Irregular breathing B. Hypertension C. Bradycardia F. Irregular breathing An 80-year-old female patient is post-op from a total hip replacement because of a fracture she sustained. The nurse observes the patient appearing as confused, restless and nervous. What nursing intervention should the nurse perform first? A. Notify the physician B. Administer IV fluids C. Abduct legs with a pillow D. Notify the Rapid Response Team C. Abduct legs with a pillow Rationale: positioning is very important, and the patient is not likely to remember which position they are supposed to be in if they are confused. This task can be delegated to a UAP. An HCP describes a patient's rare heart defect as causing "decreased pulmonary blood flow." Which condition does the nurse suspect the patient has? A. Atrial Septal Defect (ASD) B. Patent Ductus Arteriosus (PDA) C. Tetralogy of Fallot (TOF) D. Coarctation of the Aorta (COA) C. Tetralogy of Fallot (TOF) A labor & delivery nurses provides care for a newborn baby, who was delivered within the last hour. The baby has a "machine-like heart murmur" and the nurse suspects the newborn has patent ductus arteriosus (PDA). What other assessment findings support the nurse's suspicion? A. Hyperventilation B. The baby has lots of energy C. The baby appears very tired D. Signs of poor feeding E. The baby appears to have acrocyanosis F. Respiratory distress C. The baby appears very tired D. Signs of poor feeding F. Respiratory distress A nurse practitioner assesses a patient with increased intracranial pressure (ICP) and notates the patient is lying in the supine position, with their extremities extended making an "E-shape." How should the NP document this finding? A. Decerebrate position B. Spasmodic Torticollis C. Dystonia D. Decorticate position A. Decerebrate position Upon performing an assessment on a male patient with a tibial fracture, the nurse notes an absence of pulses while the patient simultaneously complains of a "numbness and tingling" feeling. The nurse also records an increase in pallor and pressure in the patient's wound. What does the nurse fear the patient may be suffering from? A. Petechiae B. Release of endogenous endorphins C. Phantom pain D. Compartment syndrome D. Compartment syndrome Rationale: Compartment syndrome is a serious complication that must be dealt with immediately. It can be assessed with the 6 P's: Pain, pulselessness, pallor, paresthesia, paralysis, and pressure. In short, it results from the compression of nerve, blood vessels, and muscle inside a closed space. If patients are experiencing these symptoms, they could be at risk for severe infection. Look for signs such as "numbness and tingling." A nurse works with a cardiologist and together they assess a patient suffering from a ventricular septal defect (VSD). What causes this pathologic condition? A. Oxygenated blood flows into the right ventricle and into the lungs B. Oxygenated blood flow into the left ventricle and into the lungs C. Oxygenated blood flows in the rest of the body, putting the patient at risk for sepsis D. Oxygenated blood spills into the left atrium A. Oxygenated blood flows into the right ventricle and into the lungs An HCP determines a 1-year-old patient will require balloon angioplasty in order to correct coarctation of the aorta (COA). The nurse understands the purpose of this procedure is to: A. Narrow the aorta B. Create anastomosis between the aorta and ductus arteriosus C. Conduct a biopsy D. Widen the aorta D. Widen the aorta A nurse provides care to a patient who was recently diagnosed with fibromyalgia. Which medication does the nurse anticipate the HCP ordering? A. Oxycodone (Oxycontin) B. Duloxetine (Cymbalta) C. Valtrex (Valacylovir) D. Furosemide (Lasix) B. Duloxetine (Cymbalta) Rationale: Duloxetine (Cymbalta) is an anti-depressant but it is also used to treat nerve pain in patients with fibromyalgia. A nurse assesses a 42-year-old male patient who recently had heart surgery and is 36 hours post op. The nurse notices the patient's temperature has increased to 100 F. How should the nurse respond? A. Notify the HCP B. Administer IV fluids C. Perform the Glasgow Coma Scale D. Document the finding D. Document the finding Rationale: Patients whose temperature increases within 24 - 48 hours is considered a normal finding that should be documented. However, if the temperature reaches above 100 F or goes on longer than 48 hours, the HCP must be notified. A nurse studies heart defects in newborn babies. The nurse learns diabetes is a significant risk factor for babies having a heart defect. What is the reason behind this? A. Poor control of blood sugar B. Poor circulation C. Poor wound healing D. Poor tissue perfusion A. Poor control of blood sugar Rationale: hyperglycemia in early pregnancy An Electrocardiogram (EKG) confirms a newborn patient displays a heart murmur at the pulmonic valve. What condition does the patient most likely have? A. Coarctation of the aorta (COA) B. Pulmonary Stenosis C. Patent Ductus Arteriosus (PDA) D. Atrial Septal Defect (ASD) D. Atrial Septal Defect (ASD) What is the ultimate goal of using non-pharm methods to help with pain management in pediatric patients? A. To eradicate all of the child's pain B. To reduce the child's pain temporarily C. To change the child's perception of pain D. To trick the child into thinking their pain has permanently gone away C. To change the child's perception of pain What are some signs and symptoms an infant is suffering from increased intracranial pressure (ICP)? Select all that apply: A. Negative Babinski Reflex B. Cheyene Stokes C. Bulging Fontanelle D. Positive Babinski Reflex E. Changes in LOC F. Cranial Suture Separation A. Negative Babinski Reflex B. Cheyene Stokes C. Bulging Fontanelle E. Changes in LOC F. Cranial Suture Separation Why does thermoregulation go down in the older patient population? A. Increased intracranial pressure causes thermoregulation to go down B. Older patients have decreased subcutaneous fat composition C. Older patients are more likely to have diabetes D. Osteoporosis decreases thermoregulation in older patients B. Older patients have decreased subcutaneous fat composition A nurse receives education from a NP on dietary factors that lead to osteoporosis. The NP knows the teaching has been successful when the nurse is able to verbalize which dietary factors increase the risk for osteoporosis (Select all that apply): A. Green leafy vegetables B. Carbonated beverages C. Soybeans D. Alcohol E. Fish F. Caffeine B. Carbonated beverages D. Alcohol F. Caffeine What are some medications that are not recommended for patients with osteoporosis? Select all that apply: A. Corticosteroids B. Calcium supplements C. Loop Diuretics D. Barbiturates E. Vitamin D supplements A. Corticosteroids C. Loop Diuretics D. Barbiturates What are some signs that a child might be experiencing a Tet-spell? Select all that apply: A. Cyanosis B. Hyperventilation C. Squatting D. Hypoxia E. Acrocyanosis F. Shortness of breath A. Cyanosis C. Squatting D. Hypoxia F. Shortness of breath A nurse provides additional education to a male patient with Parkinson's disease while his wife accompanies him. This reeducation was prompted by the wife's revelation that her husband has difficulty swallowing his food. Which statement by the spouse indicates the education was successful? A. "My husband can only eat food that is completely liquified." B. "My husband should only eat tiny, bite-size pieces of food and chew them as quickly as possible." C. "My husband should only eat tiny, bite-size pieces of food." D. "My husband cannot eat any vegetables because of the chewing involved." C. "My husband should only eat tiny, bite-size pieces of food." A nursing instructor provides teaching on why nurses should incorporate both the "Faces Pain Scale" in addition to observing physiological signs of pediatric patients. What takeaway does the nursing instructor want the students to have from this teaching? A. The Faces Pain Scale is the only way to confirm pain in children B. The Faces Pain Scale is not as reliable as the Stanford Pain Scale (0-10) in children. C. Physiological signs are not the only way measure pain in children. D. Physiological signs are often very misleading when it comes to assessing pain in children. C. Physiological signs are not the only way measure pain in children. A patient diagnosed with fibromyalgia states she wants to stop using her Cymbalta medication to control her pain. What other types of treatment should the nurse educate the patient on? A. Imagery B. Meditation C. Meperidine (Demerol) D. Yoga E. Tai Chi F. Swimming G. Acupuncture A. Imagery B. Meditation D. Yoga E. Tai Chi F. Swimming G. Acupuncture Rationale: No heavy weightlifting or vigorous exercise A nursing instructor provides teaching on Tetralogy of Fallot (TOF). The instructor knows the teaching has been successful when the student is able to name the different types of heart defects. Select all that apply: A. Ventricular Septal Defect (VSD) B. Patent Ductus Arteriosus (PDA) C. Coarctation of the Aorta (COA) D. Right Ventricular Hypertrophy E. Overriding Aorta F. Atrial Septal Defect (ASD) G. Pulmonary Stenosis A. Ventricular Septal Defect (VSD) D. Right Ventricular Hypertrophy E. Overriding Aorta G. Pulmonary Stenosis Rationale: Tetralogy of Fallot includes four different heart defects: Overriding Aorta, Right Ventricular Hypertrophy, Pulmonary Stenosis, and Ventricular Septal Defect A nurse receives a page from a patient who was admitted for a fractured tibia in her left leg. The nurse enters the room and hears the patient complains of "numbness and tingling" her left lower leg where the fracture occurred. What does the nurse fear the patient is at risk for? A. Generalized edema B. Compartment Syndrome C. Osteomyelitis D. Referred Pain B. Compartment Syndrome Rationale: Compartment syndrome is serious complication that must be dealt with immediately. It can be assessed with the 6 P's: Pain, pulselessness, pallor, paresthesia, paralysis, and pressure. In short, it results from the compression of nerve, blood vessels, and muscle inside a closed space. If patients are experiencing these symptoms, they could be at risk for severe infection. Look for signs such as "numbness and tingling." A nurse provides education on palliative care to a patient. The nurse knows the teaching has been successful when the patient verbalizes: A. "Palliative care is only used for patients with cancer." B. "Palliative care is the exact same thing as hospice." C. "Palliative care does not provide a cure for my illness." D. "Palliative care involves symptom management but no pain relief." C. "Palliative care does not provide a cure for my illness." A nurse working in general surgery is caring for four patients. Which patient should the nurse assess first? A. A male patient who had abdominal surgery complains of pain around their abdomen 15 minutes after pain medication has been administered. B. The wife of a male patient, who recently had neurosurgery, says her husband complained of a minor headache before his pain medication was administered C. A male patient who had abdominal surgery complains of sudden and abrupt pain in his right lower calf 30 minutes after his pain medication has been administered. D. A female patient who fell of her bicycle and fractured her knee complains of knee pain 10 minutes after the pain medication has been administered. C. A male patient who had abdominal surgery complains of sudden and abrupt pain in his right lower calf 30 minutes after his pain medication has been administered. Rationale: New (acute) pain is the most concerning. Pain in the calf could indicate a thromboembolism. What is the best test to measure the pressure of the cerebrospinal fluid? A. Nervous system exam B. Spinal tap C. CT scan D. MRI scan B. Spinal tap A 75-year-old male patient is post-op from a total hip replacement because of a fracture he sustained. The nurse delegates repositioning of this patient to a UAP. The nurse is responsible for ensuring the UAP will avoid which potential complication? A. Aspiration B. Changes in LOC C. Compartment syndrome D. Friction and shearing D. Friction and shearing A student nurse does a presentation on how to assess patients with increased intracranial pressure (ICP). What behavior categories make up the Glasgow Coma Scale? Select all that apply: A. Eye opening response B. Skin breakdown C. Auditory response D. Verbal response E. Motor Response F. Crying response A. Eye opening response D. Verbal response E. Motor Response Which heart defect involves an increase in blood that is flowing to the lungs. What is this condition called? A. Atrial Septal Defect (ASD) B. Patent Ductus Arteriosus (PDA) C. Tetralogy of Fallot (TOF) D. Coarctation of the Aorta (COA) A. Atrial Septal Defect (ASD) A nurse assesses several patients with osteoporosis. Which patient is exhibiting kyphosis (image on the other side)? A. Patient 1 B. Patient 2 C. Patient 3 D. None of the three patients B. Patient 2 What is one of the first signs a patient is experiencing increased in intracranial pressure (ICP)? A. Jaundice B. Shearing C. Decerebrate position D. Changes in LOC D. Changes in LOC What are some nursing interventions that can help a patient with fibromyalgia who is having trouble sleeping at night? Select all that apply: A. Cluster care B. Encourage the patient to take a cold shower before bed C. Keep a calm environment D. Make sure the lights are turned off E. Encourage the patient to take a warm shower before bed F. Try to determine the patient's normal sleeping routine A. Cluster care C. Keep a calm environment D. Make sure the lights are turned off E. Encourage the patient to take a warm shower before bed F. Try to determine the patient's normal sleeping routine A 29-year-old female patient is diagnosed with Multiple Sclerosis (MS). What early signs did she likely exhibit before having a confirmed diagnosis? A. Excessive somnolence B. Heat intolerance C. Blurred vision D. Fatigue E. Nystagmus F. Hyper reflexes C. Blurred vision D. Fatigue E. Nystagmus Rationale: Blurred vision, fatigue, and nystagmus (repetitive, uncontrolled eye movement) are all early signs of MS. Excessive somnolence, heat intolerance, and hyper reflexes would be considered late signs of MS. An HCP indicates they want to start a patient on Percocet. What information should the nurse obtain from the patient? A. Ask if the patient has taken Percocet before B. List of OTC medications the patient is taking C. List of the medications the patient's spouse is taking D. Ask if the patient's spouse takes Percocet B. List of OTC medications the patient is taking Which pain takes priority? Acute pain (vis a vis chronic) Areas of pain that take priority? Chest pain Leg/calf pain What determines priorities with surgical pain? 1. How long after surgery? 2. Were they given meds? What are life threating pains? (New) Chest (MI) (New) Calf (Thrombus) What should you ask from a patient who is in pain? - PQRST - Is this level of pain alright for you? Bio Based therapy - it is a CAM - non pharm, but it is something coming from the earth or directly from the body Bio Based Therapy Examples - tai chi - acupuncture - herbs - vitamins - stretching Assessing child pain Wong Baker and Physiological signs What is the thing to be careful of when assessing physiological s/s of pain? Dont go only on physiological signs, make sure nothing is missing Assessing pain in the elderly - one question at a time - go slowly - take your time Types of pain - dull - sharp PCA patient controlled analgesia Importance of PCA - EBP says that PCA improves PT outcomes over round-the-clock analgesic dosing - provides autonomy for the PT ` Combination analgesics ex: Percocet (Oxycodone + Acetaminophen) Percocet precautions make sure PT is not taking another OTC acetaminophen (hepatoxic risk) PT is constipated from opioids add fiber How do we add fiber? - green leafies - bran - prunes/apples - peanuts/peanut butter Why is it important to relieve pain? Pain hinders healing by causing stress on the body. It interferes with the body's ability to restore equilibrium Pediatric pain Focus on Non-pharm Non-pharm Pediatric pain relief Doesnt take the pain away but changes perception of pain Transdermal patch teaching - rotate sites - take the old one off before putting on the new one adjuvent analgesics non-analgesic drugs administered for an analgesic effect Some adjuvant analgesics cymbalta and gabapentin Mind-body therapies - music therapy - pet therapy - meditation - guided imagery Changes in mobility changes in mobility throughout the lifespan is part of growth and development compartment syndrome involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles Compartment syndrome s/s - numbness - tingling immediate intervention is needed Potential risk factor for congenital heart defect Down Syndrome Priority for children with congenital heart defects That the children can still run and play (even if rests are encouraged) CAM therapies for fibromyalgia - Stress reduction (acupuncture, yoga, tai-chi, meditation) - low stress exercise (stretching) - Cymbalta adjuvant - Trouble sleeping with fibromyalgia? - low light - quiet environment - replicate home sleep routine as much as possible - warm shower before bed - cluster care Osteoporosis A condition in which the body's bones become weak and break easily. Which gender sees osteoporosis more? Women How do you slow down Osteoporosis? - estrogen hormones - calcium - vitamin D How much bone mass does a womn lose after menopause? 5 years after menopause, women will lose 2% of bone mass per year Which meds can cause osteoporosis? - loop diuretics (get rid of Ca) - barbiturates - corticosteroids Taking actonel for OP - take on an empty stomach - in the morning, 30min before breakfast - drink with 8 oz water - stay upright for 30 min after administration Home life/discharge for OP PTs fall risk precautions Dietary factors that cause OP - insufficient Ca - insufficient Vit D - carbonated drinks, alcohol, caffeine Early MS findings - change sin motor skills, vision, sensation + - nygastamus (rapid invountary eye movement) - change in sensation - fatigue Later MS findings - hyperreflexia - excessive somulance (fatigue) Early and Late MS findings - lack of coordination - diminished and extra reflexes Acute exacerbation methylpredselone hip replacement/repair, first thing you do abduction pillow between legs Palliative care landmarks - doesnt cure - relieves symptoms - symptomatic care Palliative Interprofessional Team (Select all that apply) - nursing - medicine - social work - clergy What to watch out for when you're moving patients in bed shearing and friction ICP treatment - HOB 30-35 degrees - head midline - no flexion of neck or hips - no straining - high fiber diet - stool softeners - antiemetics - no cluster care (space it all out, let them rest) First thing to notice that something is wrong with ICP LOC Biggest concern with a head injury hypertension and bradycardia (cushing's triad) Atrial Septal Defect flaw in the septum that divides the two atria of the heart ASD S/s Increased pulmonary blood flow coarctation of the aorta narrowing of the aorta coarctation of the aorta s/s Upper extremities: High BP Lower extremities: Low BP Patent Ductus Arteriosus right to left shunt of aorta and pulmonary arteries PDA treatment pharm prostaglandin E1 to increase pulmonary blood flow/oxygenation PDA surgical treatment surgical closure to prevent blood from going back into the lungs PDA s/s Machine-like murmur components of tetralogy of fallot - pulmonary stenosis - Overriding aorta - ventricular septal defect - right ventricular hypertrophy tetralogy of fallout s/s for child child with low pulmonary blood flow. Will squat to increase it How much longer does it take the elderly to thermoregulate 2x When does thermoreg get worse? Age 70, and worsens with each decade Temp signs for kids in cardiac surgery may spike up to 100F for 24-48 hours When is a high child temp after cardiac surgery a problem? - higher than 100 - longer than 48 hours What are we looking at in the Glasgow Coma Scale? Eye response Motor response Verbal response Using the GCS to gauge a brain injury 13-15 = minor brain injury 12-9 = moderate brain injury 8-3 = severe brain injury Osteoarthritis degenerative joint disease Body cannot keep up Parkinson's disease Give small bites of food so they can chew it properly Give enough independence as possible Why do we raise a sprained/broken limb above the heart level? To prevent edema Where should a PT bear weight for a four point gait? both crutches and both legs What will you see in a PT with Guillain-Barre syndrome? Increased muscle weakness What should the nurse assess for a Pt with Myesthenia Gravis? Respiratory exchange and the ability to swallow Is pain a characteristic symptom of MS? no Right hip replacement/fracture, which hand holds the cane? The left hand A patient is confused after a hip replacement, what does the nurse do? Abduction pillow between the legs Femoral nerve block Client should still be able to dorsiflex/plantar flex their foot TJC requires what to be given when discharging a client to another provider? A hand-off report Common Biological Theories of Aging - Free Radical Theory - Cross Linkage Theory - Biological Clock Theory - Wear and Tear Theory The Free Radical Theory states that "free radicals" are formed from incomplete molecule formation or overexposure to harmful substances. This leads to the destruction of healthy DNA, cells, and connective tissues reducing function and viability. As an individual ages, "free radicals" destroy healthy cells and tissues more readily, this predisposes the individual to various diseases. The Cross-Linking Theory Also referred to as the glycosylation theory of aging, states that accumulation of cross-linked proteins damages cells and tissues, slowing down bodily processes resulting in aging. Free Radical Molecules that are harmful and unstable that are produced by process of metabolism or exposure to harmful substances Free radical spread can be limited by -smoking cessation -limiting sun exposure -limiting UV light exposure -Diet management Antioxidants - neutralizes free radicals - can be found in food elements such as in vitamins and various fruits and vegetables Diseases often seen in older adults that can be caused by free radicals - cancers - diabetes - arthritis - atherosclerosis Biological Clock Theory The theory that cell-reproduction and death of cells is genetically preprogrammed. This helps determine a person's life span. *Note that this varies from person to person* Name some manifestations of cell division loss associated with aging - Menopause - skin changes ( dryness, wrinkles, loss of elasticity - graying of the hair - atrophy of organs Wear and Tear Theory a view of aging as a process by which the human body wears out because of the passage of time and exposure to environmental stressors; much like a machine would. Factors that may speed up the process of "aging" or the wear and tear effect on the human body that causes damage to internal organs, hormones, DNA, tissues and cells, skeletal structures like bones, ligaments, muscles, spinal structure, and cartilage. - stressors - exposure - diet - weight - lifestyle - environment immunologic theory of aging Developmental theory of aging associated with reduced resistance to disease secondary to reduced T-cell function and enhanced autoimmune responses. Proposes that as one ages so does that of the function of the immune system. Factors that lend to the decline of immune system functions - free radicals - natural decline in cell division - wear and tear on body tissues, cells, and organs - other external damages to the body processes Consequence of a weakened immune system in relation to the older adult client client has increased susceptibility to certain infections, illness and diseases. This includes autoimmune diseases where the immune system attacks itself or certain body processes or that related to allergies in which the immune system becomes hypersensitive to certain allergens such as pollen, dust, mold, etc. Social Theories of Aging -Activity theory -Continuity theory -Age stratification theory -Person-environment fit theory activity theory of aging The psychosocial theory that life satisfaction in late adulthood is highest when people maintain the level of activity they displayed earlier in life. *One maintains "activity" through physical means or social interactions.* Nursing interventions related to the Activity Theory of Aging - Encourages and assists the older adult with planning realistic activities and promote interaction with their family, friends, and loved ones within physical, social, and intellectual means Benefits of physical and social activity in older adults Lowers risk for: -arthritis -cancers -osteoporosis -cardiovascular disease -mental health illness -Alzheimer's Continuity Theory of Aging Proposes that individuals for the most part maintain their same values, beliefs, and behavior throughout life. Older adults prefer to maintain an order or independence, control and routine of their activities of living. Nursing interventions in relation to the continuity theory - Encourage the older adult client to maintain their normal routines, habits, & hobbies as they are accustomed to with considerations to safety. - Provides means for the older adult client to have access activities that they are accustomed to mentally, physically, and spiritually. For example, cultural rituals may be continued while the patient is hospitalized such as prayer and meditation. Age Stratification Theory of Aging Proposes that older adults are key elements of society and interacts therefore within it and with others It is the hierarchical ranking of adults based on age. Associated with systems of inequalities linked to one's age group perceiving the younger age group as more desirable. May lead to "Ageism" Areas of society where Age stratification has relevant implications - workforce - social norms - family structures - government policies health outcomes Riley's proposal in 1985 1) each individual age cohort collectively progresses socially, biologically and psychologically. 2) new cohorts are born and experience their own sense of history. 3) society is divided according to age and roles or generations. 4) each generation or cohort is changing as society changes. 5) the interaction between the aging cohorts and society is a dynamic process. Nursing intervention related to Age stratification - The nurse should advocate for the older adult clients in the case of discrimination, elder abuse or negative perceptions. Person-Environment Fit Theory of Aging Proposes that the older adults characteristics or levels of competencies are inter-related with that of the society. In other words there is a certain degree to where individual and environmental characteristics line up, or match accordingly. Nursing interventions related to Person-Environment Fit Theory Nurses should encourage older adults to remain as active as positive in both intellectual and social contexts even perhaps when one is institutionalized in long term care, assisted living or within community groups. What are the Psychological Theories of Aging? - Maslow's Hierarchy of Needs - Erickson's Eight Stages of Development' - Jung's Psychological Development Theory Maslow's Hierarchy of Needs Theorizes that people are motivated by 5 basic categories of needs and that each level should be completed prior to advancing through to the next level. Order of priority: (level 1) Physiological Needs (level 2) Safety and Security (level 3) Relationships, Love and Affection, (level 4) Self Esteem (level 5) Self Actualization Nursing interventions related to Maslow's theory - Assist the older adult to adapt and provide appropriate resources - Engage the older adult in life reflection - Apply essential needs to plan of care Erickson's eight stages of psychosocial development Proposed eight stages psychosocial tasks that an individual processes throughout their life span. 1) Trust vs Mistrust 2) Autonomy vs Shame and doubt 3) Initiative vs guilt 4) Industry vs inferiority 5) Identity vs role confusion 6) Intimacy vs isolation 7) Generativity vs stagnation 8) Integrity vs despair The last stage in Erickson's theory, Integrity vs despair, as it related to the older adult This stage is commonly a struggle with the older adult client. This stage is where the older adult client reflects on their own lives, their families, how much they enjoyed or disliked their achievements in life. They could either perceive all of this as positive or negative. If in previous stages the were successful then this stage is where the older adult will feel a sense of understanding, acceptance, and wisdom. If not, then the last stage can be full of regret and despair. Nursing interventions in relation to Erickson's theory It is important for the nurse to encourage older adults to use reflection and reminisce about his or her life and to discuss feelings about his or her life's accomplishments. Carl Jung's Psychological Development Theory Proposes that the older adult goes through a development process in which one reaches a point of individuation, self-realization and spirituality. The theory is closely related to the self-actualization process, however, there is a distinct difference and that is the development of personality. Personality Factors that promote accepting and valuing of self during the process of adjustment to aging regardless of the perception of others. - Ego - Personal unconsciousness - Collective unconsciousness Nursing Theories of Aging - Roy's Adaption Model - Pender's Health Promotion Model - Kolcabas's Comfort Theory Calista Roy's Adaptation Model The older adult client's perception of adapting to cumulative psychological and physiological stressors. Psychological stressors: -loss of independance -loss of function -depression -anxiety -loss of loved one Pysiological Stressors -illness -disease -infection Coping mechanisms in Roy's Adaptation Model -Adaptation of functional performance mechanisms -Intrapsychic factors or resilience or self-concept -Spirituality Nursing Implication as it relates to Roy's Adaptation Model When caring for older adults nurses should examine their own ability to cope with stressors and educate on the proper coping mechanisms. Examples of proper coping mechanisms: -meditation -yoga -music Nurses should also consider implementation of interventions that are aimed at achieving successful aging regarding mental, physical, and spiritual health. Nola Pender's Health Promotion Model - Geared towards disease prevention and health maintenance of the older adult client -Proposes that health is a dynamic state of improving one's overall health and well-being. Includes: proper rest, nutrition, exercise, smoking cessation, promoting mental health free of anxiety and depression, maintaining social and intimate relationships, and remaining engaged in the community Health as defined in Pender's Model -multidimensional -based on unique experiences and one's own behavior modifications, motivation, and cognition Nursing intervention in relation to Pender's Model Nurses should encourage older adult clients to engage in healthy behaviors to promote the best health and disease prevention as discussed through education and guidance. Katherine Kolcaba's Comfort Theory Proposes that comfort is the experience of relief, ease and transcendence as one ages and experiences various functional, emotional, and physical ailments. Highly attributable to medical-surgical nursing. Highly associated with hospice and palliative care associated with the end-of-life care in which the idea is to keep the patient as comfortable as possible by providing comfort care measures only. Nursing Intervention relating to Kolcabas's Theory Nurses should allow the patient to be an active participant in their plan of care as comfort is a subject term and is treated or assumed based on the client explanation or manifestation of this level of comfort. Morals and Spiritual Development in relation to the older adult client - The process of one seeking an explanation or validation for one's existence - This is especially important as the older adult client nears end-of-life - Spirituality does not equate religion - Nurses should acknowledge and support the spiritual growth and development of the older adult client -Utilize holistic approach when assess and providing spiritual needs -Encourage the older adult at all stages of moral development