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Flashcards in FINALLLL Deck (182)
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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
Q

Involuntary loss of urine during coughing, sneezing, laughing, or other physical activities that increase abdominal pressure

A

stress incontinence

26
Q

Involuntary loss of urine associated with overdistension of the bladder. BPH

A

overflow incontinence

27
Q

Inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition

A

functional incontinence

28
Q

round or irregularly shaped tan, scaly lesions that may bleed or be inflamed.

A

Actinic keratoses

29
Q

sun exposed areas (basal cell carcinoma)

A

waxy or raised

30
Q

squamous cell carcinoma, melanoma

A

Irregularly shaped lesions or scaly, elevated lesions

31
Q

draining clear fluid or pustules atop an erythematous base following a clear, linear pattern and accompanied by pain

A

herpes zoster vesicles (shingles)

32
Q

red-purple, nonblanchable petechiae (platelet deficiency)

A

pinpoint size

33
Q

anticoagulant therapy, a fall, renal or liver failure, or elder abuse

A

larger bruises

34
Q

extremely thin, fragile skin

A

friable skin

35
Q

Sudden heat or cold intolerance could be signs of

A

thyroid dysfunction

36
Q

foul smelling breath

A

periodontal disease

37
Q

turning in of the lower eyelids

A

entropion

38
Q

yellowish / brownish discoloration of the lens

A

cataracts

39
Q

how to test for glaucoma

A

tonometry

40
Q

difficulty seeing with one eye which turns into both

A

macular degeneration

41
Q

speaking to someone slower and in lower frequency is better

A

prebycusis

42
Q

aka the silent killer

A

pneumonia

43
Q

male breast enlargement ; results from a decrease in testosterone

A

GYNECOMASTIA

44
Q

get up and go test

A
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
Q

when retinal detachment occurs

A

blindness will occur if not fixed in time

46
Q

how long should you be outside to get vitamin d

A

at least 30 mins

47
Q

pain unrelated to activity

A

venous insufficiency

48
Q

correct technique to assess urinary incontinence

A

obtain a voiding diary

49
Q

normal finding on the skin of an elderly client

A

senile purpura

50
Q

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?

A

D. Dementia

51
Q

In the _____________ belief system, the entire universe is seen to have supernatural forces at work.

A

Magicoreligious

52
Q

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?

A

Note-taking may make the client think the interview is unimportant

53
Q

In which situation would it be best for the nurse to use open-ended questioning?

A

When taking the initial health history of a home care client

54
Q

A client tells a nurse they want to try turmeric to lower their blood pressure. The nurse should take which action?

A

Encourage the client to discuss the use of turmeric with the provider

55
Q

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?

A

“This pattern of elevated temperature may indicate a chronic infection.”

56
Q

When documenting data, it is important to use sentences instead of phrases to record data?

A

False

57
Q

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?

A

he has a longer story to tell

58
Q

The client scores a 4 on their PHQ-2. What would the nurse do next?

A

use the phq 9

59
Q

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:

A

Slow Gastrointestinal motility

60
Q

During a nutritional assessment, why is it important for the nurse to ask the patient what medications he or she is taking?

A

Certain drugs can affect the metabolism of nutrients

61
Q

A client with hypertension asks a nurse why a diet low in fat is recommended. The nurse explains to the client:

A

Diets high in fat increase the risk of cardiovascular disease

62
Q

Waist to hip ratio is used as a marker of risk assessment for:

A

obesity related disease

63
Q

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?

A

The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment

64
Q

A nurse works in a facility that uses charting by exception. What would the nurse expect to document?

A

Skin turgor greater than 7 seconds

65
Q

It is important to document what the client tells you, what you observe, and what you interpret or infer from the presented data?

A

FALSE

66
Q

A nurse knows when collecting and analyzing data that the first and most critical step of the nursing process is?

A

assessment

67
Q

Pain from an abdominal surgery would be classified as:

A

visceral

68
Q

A client has a body mass index (BMI) of 37, but has no other risk factors. The nurse should:

A

refer client to a dietician

69
Q

Which of the following is true about axillary temperature?

A

The axillary route is 1 degree lower than oral temperature

70
Q

The Confusion Assessment Method (CAM) test mood, feelings, expressions, and perceptions.

A

false

71
Q

When performing a physical assessment, the first technique the nurse will always use is:

A

inspection

72
Q

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?

A

radial pulse

73
Q

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?

A

Alcohol can interact with medications and can make some diseases worse

74
Q

The nurse is assessing a client’s pain. The nurse knows that the most reliable indicator of pain would be the:

A

subjective

75
Q

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?

A

Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit

76
Q

Each step in the nursing process depends on the accuracy of the proceeding step.

A

true

77
Q

Which situation is most appropriate during which the nurse performs a focused or problem-centered history?

A

Patient in an outpatient clinic has cold-like symptoms

78
Q

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?

A

Considered to be in a coma

79
Q

In addition to validation, what is another crucial part of the first step in the nursing process?

A

documentation

80
Q

In addition to validation, what is another crucial part of the first step in the nursing process?

A

documentation

81
Q

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:

A

Will be oriented to place and person, but the patient may not be certain of the date

82
Q

Which situation is most appropriate during which the nurse performs a frequent or ongoing assessment?

A

patient has hypertension

83
Q

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?

A

respiratory rate

84
Q

The client asks the nurse what blood pressure means. Which statement correctly reflects the nurses understanding of blood pressure?

A

“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
Q

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?

A

“You are right, as you age the intervertebral discs become thinner.”

86
Q

The nurse is using the Visual Analog Scale to assess a client’s pain. What data will the nurse prioritize?

A

The client’s rating on a 0 to 10 visual analog scale

87
Q

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?

A

Palpate with pads of first and second fingers on lateral aspect of wrist

88
Q

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?

A

count for a full minute

89
Q

When assessing the quality of a client’s pain, the nurse should ask which question?`

A

what do your pain feel like

90
Q

collecting subjective and objective data

A

assessment

91
Q

ongoing and continuous throughout all phases of the nursing process

A

assessment

92
Q

analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, referral)

A

diagnosis

93
Q

determine outcome criteria and developing a plan

A

planning

94
Q

carrying out the plan

A

implementation

95
Q

assessing whether outcome criteria have been met and revising the plan as necessary

A

evaluation

96
Q

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

A

initial comprehensive assessment

97
Q

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

A

initial

98
Q

any problems that were initially detected in the clients body system or holistic health patterns are erased to determine any changes

A

ongoing or partial assessment

99
Q

comprehensive database exists for a client who comes to the health care agency

A

center assessment

100
Q

what does COLDSPA stand for

A

character; onset; location; duration; severity; pattern; associated factors

101
Q

skin cancer that is the worst

A

melanoma

102
Q

common problems in older adults warranting further investigation is SPICES

A
Skin impairment 
Poor nutrition 
Incontinence
Cognitive impairment 
Evidence of falls or functional decline 
Sleep disturbances
103
Q

examples of ADLs katz

A

bathing, dressing, toileting, transferring, continence, feeding

104
Q

examples of IADLs lawton

A
ability to telephone 
shopping 
food prep
housekeeping 
laundry
transportation 
medication 
ability to handle finances
105
Q
night sweats
chronic fatigue
weight loss
dementia
swollen lymph nodes
A

aids

106
Q

symptoms of depression in older adults manifest as changes in

A

cognitive and physical symptoms

107
Q

early signs of alz

A

irritability
aggression
suspiciousness
withdrawal

108
Q

when an older adult complains of weakness and fatigue what must be ruled out

A

anemia

109
Q

what are common causes of anemia

A

gi bleeding, low B12, folate, iron

110
Q
cough
fatigue
weight loss
SOB
productive cough (sometimes bloody)
A

lung cancer

111
Q

weight loss
night sweats
changes in respiratory status

A

TB

112
Q
digoxin
theophylline
quinidine
antibiotics
accompanied with nausea and vomiting
A

drug toxicity

113
Q

corticosteroid use can

A

thin the skin

114
Q

shortening of neck from vertebral degeneration

A

buffalo hump

115
Q

any drug with anticholinergic side effect may

A

promote dental caries and pneumonia

116
Q

floaters are a symptom of

A

diabetic retinopathy

117
Q

respiratory rates above 20-25

A

infections or CHF

118
Q

resp rate when living independently

A

12-18

119
Q

resp rate when living in long term care

A

16-25

120
Q

old lady nips

A

are pendulus and retraction of the nips are normal but if only one retracts it could be cancer

121
Q

tender and soft prostate

A

prostatitis

122
Q

hard asymmetrical enlarged nodular prostate

A

cancer

123
Q

tenderness
stiffness and pain in the shoulders and elbows and hips
aggravated by movement

A

polymyalgia rheumatica

124
Q
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
A

alz disease

125
Q

whats the AUDIT test used for

A

alc use. total score of 8 or more is an indicator of harmful alc use

126
Q

what is SAD PERSONS used for

A

people are risk for suicide

127
Q

glasgow coma scale

A

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
Q

what is SLUMS used for

A

mental status; made in st louis

129
Q

tests LOC, memory, speech, and cognitive functions but not mood, feelings, expressions, thought processes or perceptions

A

SLUMS and CAM

130
Q

PHQ-2 and PHQ-9

A

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
Q

use of SBAR

A

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
Q

96.6-99.9

A

oral

133
Q

95.6-98.5

A

axillary

134
Q

97.4-100.3

A

rectal

135
Q

98-100.9

A

tympanic

136
Q

vital signs including the 5th one

A
temp
respirations
blood pressure
heart rate
pain
137
Q

cultural expressions

A

p.148

138
Q

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

A

acculturation

139
Q

gradual adoption and incorporation of characteristics of the prevailing culture

A

assimilation

140
Q

natural conscious and unconscious conditioning process of learning accepted culture norms, values, and roles in society and achieving competence in ones culture through socialization

A

enculturation

141
Q

humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways

A

ethnocentrism

142
Q

group of people with a culture that differentiates them from the larger culture of which they are a part of

A

subculture

143
Q

bmi

A

bmi less than 18.5 is underweight. bmi between 25-29.9 is considered overweight. bmi at 30 is considered obese

144
Q

type of body is better

A

pear shaped

145
Q

The skin plays a vital role in?

A

Vitamin D synthesis and Excretion

146
Q

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?

A

Red and scaling on the areola

147
Q

If heard, this extra heart sound is heard early in diastole?

A

s3

148
Q

The nurse uses which of the following techniques to assess dehydration?

A

elevation of skin turgor

149
Q

The nurse is performing a respiratory assessment of a client who has congestive heart failure. What type of respiratory pattern should the nurse anticipate?

A

Cheyne-Stokes

150
Q

A COPD client asks the nurse what is the difference between asthma and COPD. The nurse replies correctly.

A

“COPD is treatable and not fully reversible”

151
Q

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?

A

have the client sit then lead forward

152
Q

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?

A

Acanthosis nigricans

153
Q

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

A

When part of the lung is obstructed or collapsed

154
Q

ask the client to repeat the phrase ninety nine while you auscultate the chest wall

A

bronchophony

155
Q

ask the client to repeat the letter E while you listen over the chest wall

A

egophony

156
Q

ask the client to whisper the phrase 1-2-3 while you auscultate

A

whispered pectoriloquy

157
Q

what is abnormal in bronchophony

A

words easily understood and louder over increased density

158
Q

what is abnormal in egophony

A

sounds like A

159
Q

what is abnormal in whispered pectoriloquy

A

sound is transmitted clearly and distinctly ; sounds as if the client is whispering directly into the stethoscope.

160
Q

The nurse should use the bell of the regular stethoscope to listen for:

A

Soft, low pitched sounds such as some heart murmurs

161
Q

Most common skin cancer in Caucasians

A

basal cell

162
Q

Most common skin cancer in African Americans

A

squamous

163
Q

Most common on areas with very heavy sun exposure

A

squamous

164
Q

Indoor tanning raises the risk of

A

melanoma

165
Q

signs of skin cancer

A
ABCDE 
asymmetry 
irregular border
color 
diameter 
evolving
166
Q

present when fluid or solid tissue replaces air in the lung or occupies the pleural space

A

dullness

167
Q

elicited in cases of trapped air such as emphysema or pneumothorax

A

hyperresonnace

168
Q

percussion tone elicited over normal lung tissue

A

resonnance

169
Q

What finding would a nurse expect to find in a client who has right-sided heart failure?

A

increased jugular venous pressure

170
Q

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?

A

cherry angioma

171
Q

what does the allen test test

A

Document the lack of patency in the ulnar and/or radial arteries

172
Q

slight pitting

A

1+

173
Q

deeper than 1+

A

2+

174
Q

noticeable deep pit; extremity looks larger

A

3+

175
Q

very deep pit; gross edema in extremity

A

4+

176
Q

usually unilateral

A

venous insuffiency

177
Q

dry and shiny skin

A

arterial

178
Q

toes and heels

A

arterial

179
Q

very painful

A

arterial

180
Q

pain is aching and cramping

A

venous

181
Q

medial malleolus or anterior tibial area

A

venous

182
Q

superficial ucler

A

venous