FINALLLL Flashcards
(182 cards)
1
Q
vulnerability of the old-old; mid eighties and nineties
More chronic disabilities and function less independently
A
frail elderly
2
Q
skeletal muscle mass decrease
A
sarcopenia
3
Q
why does sarcopenia occur
A
due to Decreases physical activity and decreased protein intake
4
Q
muscle mass decrease with excessive body fat
A
sarcopenia obesity
5
Q
why are older people are usually cold, gain weight, and decreased glucose
A
decreased in metabolism
6
Q
most common in older adults
A
pressure ulcers, incontinence, falls, functional decline, and delirium
7
Q
what are signs of infection
A
incontinence and confusion
8
Q
Activities necessary for well- being as an individual in society
A
katz ADLs
9
Q
how is katz scoring ranked
A
6 points= independent
0 points= complete dependence
10
Q
Scoring ranges 8-28, 8 being the best/independent and 28 being the worst
A
lawton scale for IADLs
11
Q
common symptom of acute illness
A
sudden deterioration of cognition.
12
Q
how to assess mental status
A
use SLUMS and CAM
13
Q
t or f depression is more common in older adults
A
false
14
Q
referred to as depression
A
pseudodementia
15
Q
circulatory disorder affecting the peripheral blood vessels of the leg; symptoms are bilateral and progressive
A
Intermittent claudication
16
Q
most common cause of infection-related deaths in older adults
A
pneumonia
17
Q
weak or hoarse voice, pocketing of food, coughing after food or fluids to drooling
A
dysphagia
18
Q
Disturbances in mental abilities resulting in confused thinking and is usually rapid progression
A
delirium
19
Q
s/s of delirium
A
Hallucinations, restlessness, depression, mood swings
20
Q
Interferes with daily life ; decline in mentality over a period of time
A
dementia
21
Q
geriatric depression scale
A
Scoring 0-10 is within normal range ; 11 or higher indicates possible depression
22
Q
short blessed test is used for what
A
rules out dementia disorder
23
Q
how to score the short blessed test
A
0-4 normal cognition; 5-9 questionable impairment; 10 or more is impairment consistent with dementia
24
Q
Involuntary loss of urine associated with an abrupt and strong desire to void. Impairs the ability of the bladder or urinary sphincter to contract and relax
A
urge incontinence
25
Involuntary loss of urine during coughing, sneezing, laughing, or other physical activities that increase abdominal pressure
stress incontinence
26
Involuntary loss of urine associated with overdistension of the bladder. BPH
overflow incontinence
27
Inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition
functional incontinence
28
round or irregularly shaped tan, scaly lesions that may bleed or be inflamed.
Actinic keratoses
29
sun exposed areas (basal cell carcinoma)
waxy or raised
30
squamous cell carcinoma, melanoma
Irregularly shaped lesions or scaly, elevated lesions
31
draining clear fluid or pustules atop an erythematous base following a clear, linear pattern and accompanied by pain
herpes zoster vesicles (shingles)
32
red-purple, nonblanchable petechiae (platelet deficiency)
pinpoint size
33
anticoagulant therapy, a fall, renal or liver failure, or elder abuse
larger bruises
34
extremely thin, fragile skin
friable skin
35
Sudden heat or cold intolerance could be signs of
thyroid dysfunction
36
foul smelling breath
periodontal disease
37
turning in of the lower eyelids
entropion
38
yellowish / brownish discoloration of the lens
cataracts
39
how to test for glaucoma
tonometry
40
difficulty seeing with one eye which turns into both
macular degeneration
41
speaking to someone slower and in lower frequency is better
prebycusis
42
aka the silent killer
pneumonia
43
male breast enlargement ; results from a decrease in testosterone
GYNECOMASTIA
44
get up and go test
```
People who take more than 30 seconds are dependent for their ADLs
o 1=normal
o 2=very slightly abnormal
o 3= mildly abnormal
o 4= moderately abnormal
o 5=severely abnormal
```
45
when retinal detachment occurs
blindness will occur if not fixed in time
46
how long should you be outside to get vitamin d
at least 30 mins
47
pain unrelated to activity
venous insufficiency
48
correct technique to assess urinary incontinence
obtain a voiding diary
49
normal finding on the skin of an elderly client
senile purpura
50
The nurse utilizes the SLUMS mental status examination on a client who has recently shown some memory deficits. The total score is 12. What would this signify?
D. Dementia
51
In the _____________ belief system, the entire universe is seen to have supernatural forces at work.
Magicoreligious
52
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
Note-taking may make the client think the interview is unimportant
53
In which situation would it be best for the nurse to use open-ended questioning?
When taking the initial health history of a home care client
54
A client tells a nurse they want to try turmeric to lower their blood pressure. The nurse should take which action?
Encourage the client to discuss the use of turmeric with the provider
55
A patient tells the nurse that she has had a fever every day for the past two weeks. What would be the nurse’s best response?
“This pattern of elevated temperature may indicate a chronic infection.”
56
When documenting data, it is important to use sentences instead of phrases to record data?
False
57
A 80-year old man is at the outpatient clinic for an initial patient interview. The nurse is aware that the interview may take longer than an interview with a younger person. What is the reason for this?
he has a longer story to tell
58
The client scores a 4 on their PHQ-2. What would the nurse do next?
use the phq 9
59
The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows the physiologic changes can directly affect the nutritional status of the older adult and include:
Slow Gastrointestinal motility
60
During a nutritional assessment, why is it important for the nurse to ask the patient what medications he or she is taking?
Certain drugs can affect the metabolism of nutrients
61
A client with hypertension asks a nurse why a diet low in fat is recommended. The nurse explains to the client:
Diets high in fat increase the risk of cardiovascular disease
62
Waist to hip ratio is used as a marker of risk assessment for:
obesity related disease
63
During an assessment, the nurse uses the CAGE test. The patient's answer is “yes” space to two of the questions. What could this be indicating?
The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment
64
A nurse works in a facility that uses charting by exception. What would the nurse expect to document?
Skin turgor greater than 7 seconds
65
It is important to document what the client tells you, what you observe, and what you interpret or infer from the presented data?
FALSE
66
A nurse knows when collecting and analyzing data that the first and most critical step of the nursing process is?
assessment
67
Pain from an abdominal surgery would be classified as:
visceral
68
A client has a body mass index (BMI) of 37, but has no other risk factors. The nurse should:
refer client to a dietician
69
Which of the following is true about axillary temperature?
The axillary route is 1 degree lower than oral temperature
70
The Confusion Assessment Method (CAM) test mood, feelings, expressions, and perceptions.
false
71
When performing a physical assessment, the first technique the nurse will always use is:
inspection
72
There are many sites in which arterial pressure can be taken, but there is one pulse in particular that gives a good overall picture of a client’s health status. This pulse is known as the?
radial pulse
73
In response to a question regarding the use of alcohol a patient asked the nurse why the nurse needs to know. What is the reason for needing this information?
Alcohol can interact with medications and can make some diseases worse
74
The nurse is assessing a client’s pain. The nurse knows that the most reliable indicator of pain would be the:
subjective
75
A client is brought in to the emergency department after being involved in a serious motor vehicle accident. The client is not alert and his injuries are severe. How would the nurse proceed with data collection?
Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit
76
Each step in the nursing process depends on the accuracy of the proceeding step.
true
77
Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
Patient in an outpatient clinic has cold-like symptoms
78
A client is brought in to the emergency department after being found unresponsive. The client’s Glascow Coma Scale is 6, this score would be considered?
Considered to be in a coma
79
In addition to validation, what is another crucial part of the first step in the nursing process?
documentation
80
In addition to validation, what is another crucial part of the first step in the nursing process?
documentation
81
A patient has been in the intensive care unit for 15 days. The patient has just been moved to the medical surgical unit and the admitting nurse is planning to perform a mental status examination. During the test of cognitive function, the nurse would expect that the client:
Will be oriented to place and person, but the patient may not be certain of the date
82
Which situation is most appropriate during which the nurse performs a frequent or ongoing assessment?
patient has hypertension
83
A client being seen in the emergency room in acute pain, has not been feeling well lately. The client has had increased heart rate, increased blood pressure, and an increased respiratory rate. Which complaint should the nurse address first?
respiratory rate
84
The client asks the nurse what blood pressure means. Which statement correctly reflects the nurses understanding of blood pressure?
“Blood pressure is the measurement of the pressure of blood in the arteries when the ventricles are contracted and when the ventricles are relaxed.”
85
A client mentions that they are not as tall as they once were. Which would be the nurse’s appropriate response to the client’s statement?
“You are right, as you age the intervertebral discs become thinner.”
86
The nurse is using the Visual Analog Scale to assess a client's pain. What data will the nurse prioritize?
The client's rating on a 0 to 10 visual analog scale
87
The nurse teaches a client newly diagnosed with tachycardia about measuring their radial pulse. Which statement indicates to the nurse that the client understood the discharge teaching?
Palpate with pads of first and second fingers on lateral aspect of wrist
88
A nurse measures a client’s radial pulse and finds the pulse to be irregular. The nurse knows the best next step would be to?
count for a full minute
89
When assessing the quality of a client’s pain, the nurse should ask which question?`
what do your pain feel like
90
collecting subjective and objective data
assessment
91
ongoing and continuous throughout all phases of the nursing process
assessment
92
analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, referral)
diagnosis
93
determine outcome criteria and developing a plan
planning
94
carrying out the plan
implementation
95
assessing whether outcome criteria have been met and revising the plan as necessary
evaluation
96
collection of subjective data about the clients perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practice, as well as objective data gathered during a step be step physical examination
initial comprehensive assessment
97
client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared
initial
98
any problems that were initially detected in the clients body system or holistic health patterns are erased to determine any changes
ongoing or partial assessment
99
comprehensive database exists for a client who comes to the health care agency
center assessment
100
what does COLDSPA stand for
character; onset; location; duration; severity; pattern; associated factors
101
skin cancer that is the worst
melanoma
102
common problems in older adults warranting further investigation is SPICES
```
Skin impairment
Poor nutrition
Incontinence
Cognitive impairment
Evidence of falls or functional decline
Sleep disturbances
```
103
examples of ADLs katz
bathing, dressing, toileting, transferring, continence, feeding
104
examples of IADLs lawton
```
ability to telephone
shopping
food prep
housekeeping
laundry
transportation
medication
ability to handle finances
```
105
```
night sweats
chronic fatigue
weight loss
dementia
swollen lymph nodes
```
aids
106
symptoms of depression in older adults manifest as changes in
cognitive and physical symptoms
107
early signs of alz
irritability
aggression
suspiciousness
withdrawal
108
when an older adult complains of weakness and fatigue what must be ruled out
anemia
109
what are common causes of anemia
gi bleeding, low B12, folate, iron
110
```
cough
fatigue
weight loss
SOB
productive cough (sometimes bloody)
```
lung cancer
111
weight loss
night sweats
changes in respiratory status
TB
112
```
digoxin
theophylline
quinidine
antibiotics
accompanied with nausea and vomiting
```
drug toxicity
113
corticosteroid use can
thin the skin
114
shortening of neck from vertebral degeneration
buffalo hump
115
any drug with anticholinergic side effect may
promote dental caries and pneumonia
116
floaters are a symptom of
diabetic retinopathy
117
respiratory rates above 20-25
infections or CHF
118
resp rate when living independently
12-18
119
resp rate when living in long term care
16-25
120
old lady nips
are pendulus and retraction of the nips are normal but if only one retracts it could be cancer
121
tender and soft prostate
prostatitis
122
hard asymmetrical enlarged nodular prostate
cancer
123
tenderness
stiffness and pain in the shoulders and elbows and hips
aggravated by movement
polymyalgia rheumatica
124
```
poor judgment and decision making
inability to manage a budget
losing track of the date or season
difficulty having conversation
misplacing things and being unable to retrace steps to find them
```
alz disease
125
whats the AUDIT test used for
alc use. total score of 8 or more is an indicator of harmful alc use
126
what is SAD PERSONS used for
people are risk for suicide
127
glasgow coma scale
3-15 scoring. 3 is the worst; 15 is the best
| 10 or lower needs emergency attention ; 7 or lower is considered to be in a coma
128
what is SLUMS used for
mental status; made in st louis
129
tests LOC, memory, speech, and cognitive functions but not mood, feelings, expressions, thought processes or perceptions
SLUMS and CAM
130
PHQ-2 and PHQ-9
used to detect depression. score 3 or higher on phq-2 then you use phq-9. score of 10 or higher indicates major depression
131
use of SBAR
situation- what you need to communicated the clients data- why patient is here
background- events that led up to the current situation
assessment- subjective and objective data
recommendation- suggest what you believe needs to be done for the client
132
96.6-99.9
oral
133
95.6-98.5
axillary
134
97.4-100.3
rectal
135
98-100.9
tympanic
136
vital signs including the 5th one
```
temp
respirations
blood pressure
heart rate
pain
```
137
cultural expressions
p.148
138
circumstance when a person gives up the traits of his or her culture of origin as a result of context with another culture to variable degrees
acculturation
139
gradual adoption and incorporation of characteristics of the prevailing culture
assimilation
140
natural conscious and unconscious conditioning process of learning accepted culture norms, values, and roles in society and achieving competence in ones culture through socialization
enculturation
141
humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways
ethnocentrism
142
group of people with a culture that differentiates them from the larger culture of which they are a part of
subculture
143
bmi
bmi less than 18.5 is underweight. bmi between 25-29.9 is considered overweight. bmi at 30 is considered obese
144
type of body is better
pear shaped
145
The skin plays a vital role in?
Vitamin D synthesis and Excretion
146
The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. What would the nurse expect to find?
Red and scaling on the areola
147
If heard, this extra heart sound is heard early in diastole?
s3
148
The nurse uses which of the following techniques to assess dehydration?
elevation of skin turgor
149
The nurse is performing a respiratory assessment of a client who has congestive heart failure. What type of respiratory pattern should the nurse anticipate?
Cheyne-Stokes
150
A COPD client asks the nurse what is the difference between asthma and COPD. The nurse replies correctly.
"COPD is treatable and not fully reversible"
151
A client has large, pendulous breasts. What would be most appropriate to ensure better access while examining the client's breasts for retraction and dimpling?
have the client sit then lead forward
152
A nurse is palpating the skin on the neck of a newly referred client. What would the nurse suspect if assessment reveals that the client has velvety darkening of the skin in the folds and creases?
Acanthosis nigricans
153
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
When part of the lung is obstructed or collapsed
154
ask the client to repeat the phrase ninety nine while you auscultate the chest wall
bronchophony
155
ask the client to repeat the letter E while you listen over the chest wall
egophony
156
ask the client to whisper the phrase 1-2-3 while you auscultate
whispered pectoriloquy
157
what is abnormal in bronchophony
words easily understood and louder over increased density
158
what is abnormal in egophony
sounds like A
159
what is abnormal in whispered pectoriloquy
sound is transmitted clearly and distinctly ; sounds as if the client is whispering directly into the stethoscope.
160
The nurse should use the bell of the regular stethoscope to listen for:
Soft, low pitched sounds such as some heart murmurs
161
Most common skin cancer in Caucasians
basal cell
162
Most common skin cancer in African Americans
squamous
163
Most common on areas with very heavy sun exposure
squamous
164
Indoor tanning raises the risk of
melanoma
165
signs of skin cancer
```
ABCDE
asymmetry
irregular border
color
diameter
evolving
```
166
present when fluid or solid tissue replaces air in the lung or occupies the pleural space
dullness
167
elicited in cases of trapped air such as emphysema or pneumothorax
hyperresonnace
168
percussion tone elicited over normal lung tissue
resonnance
169
What finding would a nurse expect to find in a client who has right-sided heart failure?
increased jugular venous pressure
170
While inspecting the skin of an older adult client, the nurse notes a localized collection of blood. The nurse should recognize the presence of which of the following?
cherry angioma
171
what does the allen test test
Document the lack of patency in the ulnar and/or radial arteries
172
slight pitting
1+
173
deeper than 1+
2+
174
noticeable deep pit; extremity looks larger
3+
175
very deep pit; gross edema in extremity
4+
176
usually unilateral
venous insuffiency
177
dry and shiny skin
arterial
178
toes and heels
arterial
179
very painful
arterial
180
pain is aching and cramping
venous
181
medial malleolus or anterior tibial area
venous
182
superficial ucler
venous
