NUR303 Midterm Exam With
Complete Solution
SPICES- ANSWER-to obtain pertinent information that will assist in
preventing health inequities within the older adult population
-sleep disorders, problems with eating or feeding, incontinence, confusion,
evidence of falls, skin breakdown
MNA- ANSWER-to detect risk for malnutrition in older adults; identify older
adult who either are at risk or are malnourished
-Nutrition loss/different, weight loss in the last 3 months, mobility, psych
stress or acute illness in the previous 3 months, neuropsychological issues,
BMI or calf circumference
Braden Scale - ANSWER-a pressure ulcer risk predictor
-Sensory perception, moisture, activity, mobility, nutrition, friction and shear
Hendrich II scale - ANSWER-measures fall risk in older adults
-2 sections; risk factors and get up and go test
confusion/disorientation/impulsivity, symptoms of depression (symptomatic
depression), altered elimination, dizziness/vertigo, gender (male),
administration of epileptics or benzodiazepines
timed up and go test - ANSWER -how a patient gets up
, -single movement with no loss of balance, pushes up once successfully,
multiple attempts but successful, unable to rise without assistance
KATZ scale - ANSWER -evaluate ADL tasks to indicate either decline or
improvement
-bathing, dressing, toileting, transferring, continence, feeding
normal vital signs - ANSWER resp: 16-20
bp: 120/80
hr: 60-100
temp:
sp02: 90-100%, 95-100% preferred
abnormal vital signs interventions - ANSWER notify provider, calm patient
down before taking again, administer medications if indicated, non
pharmacologic interventions to decrease pain and discomfort
How do we measure/apply TED hose? - ANSWER -measure calf or thigh
circumference and length from ankle to knee or hip
-apply folded over itself and slowly pull/wiggle up the leg
-stop 1-2 inches below knee or 1-3 inches below gluteal fold
-NEVER fold down
Complete Solution
SPICES- ANSWER-to obtain pertinent information that will assist in
preventing health inequities within the older adult population
-sleep disorders, problems with eating or feeding, incontinence, confusion,
evidence of falls, skin breakdown
MNA- ANSWER-to detect risk for malnutrition in older adults; identify older
adult who either are at risk or are malnourished
-Nutrition loss/different, weight loss in the last 3 months, mobility, psych
stress or acute illness in the previous 3 months, neuropsychological issues,
BMI or calf circumference
Braden Scale - ANSWER-a pressure ulcer risk predictor
-Sensory perception, moisture, activity, mobility, nutrition, friction and shear
Hendrich II scale - ANSWER-measures fall risk in older adults
-2 sections; risk factors and get up and go test
confusion/disorientation/impulsivity, symptoms of depression (symptomatic
depression), altered elimination, dizziness/vertigo, gender (male),
administration of epileptics or benzodiazepines
timed up and go test - ANSWER -how a patient gets up
, -single movement with no loss of balance, pushes up once successfully,
multiple attempts but successful, unable to rise without assistance
KATZ scale - ANSWER -evaluate ADL tasks to indicate either decline or
improvement
-bathing, dressing, toileting, transferring, continence, feeding
normal vital signs - ANSWER resp: 16-20
bp: 120/80
hr: 60-100
temp:
sp02: 90-100%, 95-100% preferred
abnormal vital signs interventions - ANSWER notify provider, calm patient
down before taking again, administer medications if indicated, non
pharmacologic interventions to decrease pain and discomfort
How do we measure/apply TED hose? - ANSWER -measure calf or thigh
circumference and length from ankle to knee or hip
-apply folded over itself and slowly pull/wiggle up the leg
-stop 1-2 inches below knee or 1-3 inches below gluteal fold
-NEVER fold down
