The nurse is caring for a patient in a long-term care facility. What action does the nurse take to reduce the risk of fall and injury?
Place the bed in the lowest position.
The nurse should place the bed in the lowest position to reduce the risk of fall and injury. Split or full bedside rails are considered to be restraints. However, if the patient tries to climb over it to get out of bed, it can prove dangerous. The health care provider assesses the patient's physical movement to determine fall-risk possibilities. The nurse ensures that the patient's eyeglasses are within reach, so that the patient does not have to get out of bed to look for them.
What should the nurse include in the assessment when looking for signs of skin breakdown including pressure ulcers?
Tissue integrity
Skin breakdown, especially pressure ulcers, is a major tissue integrity problem among older adults in hospitals and nursing homes. Delusions and acute psychosis are psychiatric disorders. Thiothixene is a drug appropriate only for the control of certain behavioral problems.
An older adult patient who is admitted to the medical-surgical unit with a diagnosis of heart failure states to the nurse, "I am of no use to anyone. I just want to die." What does the nurse do to ensure this patient's safety?
Report the patient's statement to the health care provider
Older adults have the highest suicide rate of any age group. Any suicidal tendencies should be reported to the health care provider to assess the need for selective serotonin reuptake inhibitors (SSRIs) and risk to the patient. Asking the patient about spiritual guidance, encouraging the patient to rest, and reporting to the family do not address the safety issue at hand.
Which statement about delirium in older adults is correct?
Surgery and infection can cause delirium.
Delirium is an acute state of confusion that can be caused by multiple factors such as surgery, infection, and drugs. The onset of delirium is usually quick. Reorienting the patient to reality is often a helpful nursing intervention. Delirium is managed by removing or treating the cause rather than focusing solely on a symptomatic treatment.
Which group of medications is appropriate for the control of certain behavioral problems, such as delusions, acute psychosis, and schizophrenia?
Anti-psychotic drugs
The most potent group of psychoactive drugs is anti-psychotics. These drugs are appropriate only for the control of certain behavioral problems, such as delusions, acute psychosis, and schizophrenia. Chemical restraints are often overused in hospital settings and include antianxiety drugs, anti-psychotic drugs, antidepressant drugs, and sedative-hypnotic drugs.
Why should a patient who is in a restraint be checked every 30 to 60 minutes and have that restraint released at least every 2 hours? Select all that apply.
Turning
Toileting
Repositioning
Check the patient in a restraint every 30 to 60 minutes, and release the restraint at least every 2 hours for turning, toileting, and repositioning. Pet visiting and watching TV are alternatives to restraints.
What is also referred to as chronic confusion?
Dementia
Dementia is the correct answer as it is considered chronic confusion and is not reversible. Delirium is related to acute confusion and is often reversible. Hendrich and STRATIFY are the tools that are used to help a nurse focus on factors that increase an older person's risk for falling.
Which assessment tool is used for older adults when predicting pressure sore risk?
Braden Scale
The Braden scale is the assessment tool used for older adults to predict pressure sore risk. STRATIFY has been developed to help nurses focus on factors that increase an older person's risk for falling. The Glasgow Coma Scale is used to determine a patient's level of consciousness. The Morse Fall Scale has been developed to help the nurse focus on factors that increase an older person's risk for falling.
An 80-year-old patient is being relocated from a home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome?
Reorienting the patient frequently to his or her new location
Reorienting the patient to the new location helps minimize relocation stress syndrome effects. All procedures and routines should be explained to the patient as well as the family. Familiar and special personal belongings are helpful to keep at the patient's bedside to minimize the effects of relocation stress syndrome. The patient should be provided opportunities to assist in decision making, which helps the patient feel more in control.
The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants. Which of these nursing actions does the RN delegate to a nursing assistant?
Assisting a patient with chronic joint stiffness to ambulate
Nursing assistant education and scope of practice include ambulation of stable patients. The other nursing actions require broader education and scope of practice and should be done by licensed nurses. Admission of a new patient who has clinical manifestations that may have been caused by abuse is the responsibility of the RN. The RN should assess the patient with acute problems such as delirium and dementia. LPN/LVN education and scope of practice include monitoring, repositioning, and toileting of patients who require restraints.
What term is used for waking up at night to urinate?
Nocturia
Nocturia is a condition in which people wake up during the night to urinate. A restraint is a device or a drug that prevents a patient from moving freely and must be prescribed by a health care provider. Dementia is chronic, progressive confusion, whereas delirium is acute confusion.
The nurse at a long-term care facility is attending a patient suffering from urinary incontinence. What intervention does the nurse perform for this patient?
Initiate a bladder training program.
The nurse should engage the patient in a bladder-training program. The nurse should not ask the patient to reduce fluid intake, as it will lead to dehydration. Coordinating a plan of care with the dietitian and promoting sleep are an essential part of nursing care for the patient in the long-term care facility.
What should the nurse incorporate in the plan of care for a patient who has fragile skin?
Reduce friction and sheering when moving the patient.
Friction and shearing happens when moving patients up in the bed and turning them from side to side. The nurse should be careful when transferring the patient. Placing the patient in an area where he or she can be supervised would be beneficial for patients who are confused. Administering antipsychotics will help decrease signs and symptoms of agitation in the psychotic patient. A shuffling gait or tremors are signs of parkinsonism.
At a follow-up visit after repair of a fractured radial bone, an older adult patient states, "I am not sleeping at all during the night." The patient's partner reports that the patient is sleeping all day. Which intervention does the nurse suggest?
Increasing the patient's daytime activities
Older adult patients should try to stay awake during the day to prevent insomnia at night. Increasing activities will facilitate this goal. The patient did not report interruptions, but insomnia; placing a "Do not disturb" sign on the door, although it may be effective in increasing "sleep time," does not address the patient's symptom. Pain medication is best taken at night because it causes drowsiness. Encouraging herbal sleep remedies to try to enhance the effects of other medications is not an appropriate suggestion for the nurse to make.
Which nursing interventions should the nurse implement for a patient who is at a higher risk for falls?
Use technological devices to alert staff about the patient getting out of bed.
Using technological devices to alert staff that the patient is getting out of bed such as mattress sensor pads and chair alarms will help prevent patient falls. Administering a sedative or hypnotic prior to bedtime will make the patient groggy and at a higher risk for falls. Changing the bed linens when the patient is incontinent will help prevent skin breakdown, but it has no impact on the fall risk. The nurse should leave a light on somewhere so the patient does not fall.
The nurse is creating a plan of care for a patient with insomnia. Which interventions should the nurse include in the plan? Select all that apply.
Turn off the lights in the room.
Put a "Do not disturb" sign on the
door.
Do not let the patient sleep during the daytime
Keeping the room dark at night will help the patient sleep more soundly. Placing a "Do not disturb" sign on the door prevents frequent visits by caregivers and promotes sleep. If the patient sleeps for long periods during the daytime, he or she is more likely to have trouble falling asleep at night. Placing the patient near the nursing station may cause sleep disturbance because of noise. Waking the patient for nonessential treatments, such as changing the pillowcase or bed sheet, is inappropriate for a patient with insomnia. The nurse should not give the patient large amounts of fluid before sleep because it may cause frequent urination and sleep disturbance.
What serious "marker conditions" are listed under the Fulmer SPICES framework that can lead to longer hospital stays, higher medical costs, and even death in older adults? Select all that apply.
Sleep disorders
Incontinence
Confusion
Skin breakdown
The Fulmer SPICES framework is a part of the Nurses Improving Care for Health System Elders (NICHE) project. It identifies six serious conditions in older adults that require longer hospital stays, increase medical costs, and may even lead to death. These conditions include sleep disorders, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin breakdown. Polymedicine (the use of many drugs to treat multiple health problems) and elder neglect and abuse are causes of concern in older adults but are not a part of the Fulmer SPICES framework.
Skin tears are common in older adults, especially the old-old group and those who are receiving long-term steroid therapy. What precautions should be taken when caring for these patients?
Use gentle touch and report any open areas.
Skin tears are common in older adults, especially the old-old group and those who are on chronic steroid therapy. When caring for these patients, gentle touch should be used and open areas should be reported. It is important to avoid bruising because older adults have increased capillary fragility. It is important to check the patient's condition every hour, turn off the television if the patient is agitated, or ask a family member or friend to stay with the patient at night.
What should the nurse include in the plan of care for a patient suffering from a sleep disorder? Select all that apply.
Refrain from making loud noises such as slamming the doors.
Manage the pain by giving the pain medication before bedtime
Keep staff conversations as quiet as possible and away from patient's rooms.
Sleep disorders are common in hospitalized patients, especially older adults. Adequate rest is important for healing, and for physical and mental functioning. Refraining from making loud noises such as slamming doors near a patient suffering from sleep disorders should be included in the patient's plan of care. The nurse should manage the patient's pain by giving pain medication before bedtime. The nurse should also facilitate keeping staff conversations as quiet as possible and away from patients' rooms. The nurse should keep the patient awake during the day to prevent insomnia. Assessing the patient to identify causes for incontinence or retention would be included in a care plan for a patient suffering from urinary and bowel elimination issues.
Which assessment tools would help a nurse focus on factors that increase an older person's risk for falling? Select all that apply.
STRATIFY
Morse Fall Scale
Hendrich II Fall Risk Model (HIIFRM)
Many evidence-based assessment tools, such as the STRATIFY, Morse Fall Scale, and the Hendrich II Fall Risk Model (HIIFRM) have been developed to help nurses focus on factors that increase an older person's risk for falling. The Braden scale is used for predicting pressure sore risk. The Geriatric Depression Scale-Short Form (GDS-SF) is a screening tool used to help determine if a patient has clinical depression.
The Fulmer SPICES framework, which was developed as part of the NICHE project, identified many serious "marker conditions" that can lead to longer hospital stays, higher medical costs, and even deaths. How many marker conditions were identified?
6
The Fulmer SPICES framework was developed as part of the NICHE project and identifies six serious "marker conditions" that can lead to longer hospital stays, higher medical costs, and even deaths. These conditions are sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown.
Which statement about older adults and incontinence is correct?
A bladder training program is often helpful in its management.
A bladder or bowel training program is often helpful for patients with incontinence. Incontinence is not a physiologic change of aging, it occurs due to acute and chronic ailments, and may be influenced by the patient's ability to perform activities of daily living or the availability of staff. It is also very common in long-term care settings.
A patient with end-stage lung cancer and metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this patient?
Releasing the restraints at least every 2 hours
The Joint Commission recommends releasing restraints every 2 hours for patient care such as turning, repositioning, and toileting. The restraints must be checked every 30 to 60 minutes. Chemical sedation is also considered a restraint. The least restrictive devices should be used.
The RN has delegated nursing actions to experienced unlicensed assistive personnel (UAP) working in a long-term care facility. Which actions require direct supervision by the RN? Select all that apply.
Assisting a 70-year-old patient who has new-onset leg pain when ambulating
Repositioning a 69-year-old patient who has recently become unconscious
The RN should supervise all care delegated to UAP when there is a change in the patient's condition, such as a change in the patient's level of consciousness. Routine hygiene care and helping a patient eat is within the UAP's scope of practice without ongoing direct supervision from the RN.
What medication side effect causes constipation, dry mouth, and urinary retention?
Anticholinergic
Anticholinergic effects are the most common side effects that occur when taking antipsychotic medications. They cause constipation, dry mouth, and urinary retention. Orthostatic hypotension increases the patient's risk for falls and fractures due to a drop in blood pressure with change in position. Parkinsonism is a clinical syndrome characterized by tremors, bradykinesia, rigidity, and postural instability. Hyperglycemia occurs when there is very little to no insulin in the blood.
A 72-year-old patient admitted to the hospital for congestive heart failure has a history of a fractured hip due to a previous fall. The patient is taking oxycodone-acetaminophen as needed for pain secondary to a recent dental procedure. Which risk factor puts this patient at greatest risk for a fall?
History of a fall
The patient's recent history of falling is the single most important predictor for falls. Older adults aged 80 years and older and those with multiple diagnoses are at higher risk for falls. Oxycodone-acetaminophen may cause mental changes, but this isn't the best answer.
Anticholinergic effects, orthostatic hypotension, and Parkinsonism are some of the consequences of the group of medications that are considered antipsychotics. Under which category would this be labeled?
Adverse effects
Adults receiving antipsychotics should be monitored for adverse drug events. Side effects are normal expected events that happen when a medication is taken. Therapeutic effects are the desired outcomes of the medication. Unexpected effects are idiosyncratic events that happen without warning due to a medication.
The nurse is conducting a medication assessment on an older adult patient who is being admitted to a long-term care facility for rehabilitation following a hip replacement. With Beers Criteria used as a resource, which drug poses a potential risk for this patient?
Digoxin
Digoxin is listed in the Beers Criteria as a drug that leads to toxicity and drug interaction problems. Patients receiving this medication are at greater risk for serious side effects and interactions. Acetaminophen, celecoxib, and mesalamine are not listed in the Beers Criteria as drugs that lead to toxicity and drug interaction problems.
The nurse should include what food substances in the diet plan of an older adult to promote better health? Select all that apply.
Milk
Yogurt
Carrots
Oranges
Milk and yogurt are good sources of calcium. Older patients have a decreased ability to store calcium; therefore, increasing the intake of milk and yogurt will strengthen bones and reduce the risk of fractures. Carrots are rich in vitamin A and oranges are rich in vitamin C. As older adults lose the ability to absorb, use, and store vitamins and minerals, increasing the intake of carrots and oranges will help them prevent vitamin A and C deficiencies. Older patients with poor dentition may over rely on soft, high-calorie foods such as mashed potatoes at the expense of more nutritious high-fiber foods. Fried foods are often high in saturated or trans-fat and should be avoided.
What nursing interventions should be implemented for all patients, regardless of a high risk for falls? Select all that apply.
Place objects that the patient needs within his or her reach.
Place the patient's bed in
the lowest position with the brakes locked.
Observe the patient for side effects and toxic effects of drug therapy.
Remind the patient to call for help before getting out of bed or a chair.
Placing objects that the patient needs within reach, putting the bed in the lowest position with the brakes locked, observing for side effects and toxic effects of drug therapy, and reminding the patient to call for help before getting out of bed or a chair are the nursing interventions that are to be implemented for all patients regardless of risk. Encouraging family members or significant other to stay with the patient and using low beds or futon-type beds to prevent injury if the patient falls out of bed are the nursing interventions that are to be implemented specifically for patients at a high risk for falls.
The nurse works at an elder-care center. Which interventions does the nurse implement for all older adult patients, regardless of their risk for falls? Select all that apply.
Monitor the patient's activities as often as possible.
Teach the patient to use grab bars when walking.
Educate the patient on how to use a walker or cane.
Arrange furniture in the patient's room to eliminate clutter.
Some nursing interventions are implemented for all patients, regardless of their risk for falls. Patient activities and behaviors should be monitored as often as possible, preferably every half hour to one hour. Patients should be taught to use grab bars when walking around without any assistive devices. They should also be educated on how to use a walker or cane in case the need arises. Arranging furniture in the patients' rooms to eliminate clutter removes obstacles that might contribute to a fall. Relocating the patient to an area of best visibility and supervision and encouraging a family member to stay with the patient is not needed for all patients; these are specific nursing interventions for those who are at high risk for falls.
According to a study by Volkert et al. in 2010, what percentage of patients received enteral nutritional supplements?
8.3%
Problems with eating and feeding prevent the older patient from receiving adequate nutrition. Malnutrition is common among older adults and is associated with poor clinical outcomes including death. In a study by Volkert et al. (2010), nutrition-related problems were present in half of 205 older patients admitted to a community hospital, but only 8.3% of them received enteral nutrition supplements. Researchers concluded that nutritional screenings and standard protocols should be implemented for older patients in all hospitals. Therefore 2.9%, 14.1%, and 15.5% are not correct.
What factors are responsible for the lag in the health of Hispanic older adults? Select all that apply.
Language barrier
Lack of health care access
Inadequate health insurance
The health of Hispanic older adults continues to lag behind that of non-Hispanic whites due to a number of factors, such as language barriers, lack of health care access, and inadequate health insurance. To add to this health disparity, most nurses and other health care professionals are not trained in Hispanic language or culture. Discrimination and fear of rejection are some of the factors why LGBTQ (lesbian, gay, bisexual, transgender, and questioning) older adults hide their gender identity and sexual orientation from nurses and other health care providers when admitted to the hospital or nursing home.
What would the nurse use to prevent a patient from falling out of a wheelchair?
Restraint
A restraint is the correct answer because it is a device that prevents a patient from falling out of a wheelchair and must be prescribed by a health care provider. STRATIFY, the Morse Fall Scale, and the Hendrich II Fall Risk Model are evidence-based assessment tools which have been developed to help nurses assess for factors that increase an older person's risk for falling.
An older adult patient who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure ulcers, and limb contractures. What does the nurse do first?
Contacts the hospital social worker
The social worker will assess the patient's situation and will contact the appropriate authorities if needed. Asking the daughter sets up a potential confrontation that need not be handled by the nurse. The patient should be given a bath, but this is not the first action to be taken. Notifying the health care provider will be appropriate at a later time, but is not the best action to take at this point.
What was developed to limit the use of physical restraints in hospitals and nursing homes?
The National Patient Safety Goals (NPSGs)
The Joint Commission developed the National Patient Safety Goals (NPSGs), which has specific standards that limit the use of physical restraints in hospitals and nursing homes. STRATIFY is a fall risk assessment tool nurses use in the hospital setting to determine a patient's risk for sustaining a fall. The Braden scale is used for predicting pressure sore risk. The Nurses Improving Care for Healthsystem Elders (NICHE) project generates evidence-based practice guidelines for older adult care.
The nurse is assessing residents of a senior care center for possible signs of abuse and neglect. What are the common manifestations of neglect the nurse looks for? Select all that apply.
Pressure ulcers on the back
Excessive body odor
Listlessness in the patient
Pressure ulcers, excessive body odor, and listlessness are signs of elder neglect which occurs when the caregiver does not provide for the patient's basic needs of food, clothing, medications, or assistance with activities of daily living. Burns and unusual loss of hair may be signs of abuse where physical force is used to cause bodily harm to the patient.
An older adult with severely decreased mobility is cared for in the hospital. What precautions and interventions should the nurse use to prevent pressure ulcers in the patient? Select all that apply.
Using a gentle touch when caring for the patient.
Using moisture barriers to keep the skin dry.
Avoiding absorbent pads that cause skin irritation.
Blood capillaries are fragile in older adults, so using a gentle touch when caring for older patients with severely decreased mobility prevents bruising. Using moisture barriers keeps the skin dry and prevents infection and skin breakdown. Absorbent pads that cause skin irritation can lead to skin breakdown and infection as well. Frequent turning and repositioning do help to minimize pressure on bony prominences and prevent pressure ulcers. The skin should be checked every 8 hours for reddened areas that do not blanch.
The nurse is teaching a class of unlicensed assistive personnel (UAP) about turning and repositioning patients in a long-term care setting. Which patient requires extreme caution and is at greatest risk for a skin tear?
85-year-old patient with breathing problems receiving daily doses of prednisone
UAP need to use extreme caution when handling members of the old old age group and patients who are on long-term steroid therapy. These groups are most prone to skin tears. This patient has both of these high risk indicators. Although the patient with paraplegia has limited mobility, no other factors place the patient at high risk for a skin tear. Most total hip repairs have short periods of immobility, with minimal skin breakdown potential; no specific risk factors are evident in this patient's history. Although the patient with a recent stroke is at risk for skin breakdown because of age and immobility, fewer risk factors are present than in the older patient on steroid therapy.
What should the nurse include in the plan of care for a patient with restraints? Select all that apply.
Check the patient often, at least every hour.
Turn off the television if the patient is agitated.
Keep the patient busy with an activity, puzzle, or art project.
Make sure that the patient's needs for food,
fluids, and comfort are met.
What is another term for the SPICES framework?
Geriatric vital signs
The Fulmer SPICES framework was developed as part of the NICHE project and identified six serious "marker conditions" that can lead to longer hospital stays, higher medical costs, and even deaths. Rather than being fully comprehensive, the SPICES framework is intended to be an easy tool that has been called "geriatric vital signs." Geriatricians are the ones who specialize in the care of older adults. Geriatric syndromes include the major health issues that are associated with late adulthood in community and inpatient settings. The Acute Care of the Elderly (ACE) unit has geriatric resource nurses and geriatric clinical nurse specialists.
What tasks can be assigned to unlicensed assistive personnel (UAP)? Select all that apply.
Apply moisture barriers to the patient's skin.
Place pressure-relieving mattresses on the bed.
Certain tasks can be assigned to unlicensed assistive personnel (UAP). These include applying moisture barriers to the patient's skin and placing pressure-relieving mattresses on the patient's bed. Only a registered nurse can assess; therefore, assessing the skin every 8 hours does not fall within the scope of UAP. Providing soft, calming music is a restraining alternative, not something performed by UAP. The nurse should not instruct the UAP to place briefs or absorbent pads on the patient. These actually trap moisture and lead to skin breakdown.
Which nursing intervention is most important for an older adult patient who is at high risk for falls?
Use low beds or futon-type beds for the patient.
Using low beds or futon-type beds prevents injury in case the patient falls out of bed. This is a specific nursing intervention needed for patients who are at high risk for falls. Reminding the patient to call for help before getting out of bed, cleaning up spills immediately, and placing objects the patient needs within reach are nursing interventions for all patients, irrespective of their fall risk.
Which factors contribute to insomnia in the acute and long-term care setting? Select all that apply.
Lighting
Excessive pain
Chronic disease
Staff conversations
Environmental noise
Sleep disorders are common in hospitalized patients, especially older adults. Adequate rest is important for healing, and for physical and mental functioning. Lighting, pain, chronic disease, staff conversations, and environmental noise are a few of the many contributing factors to insomnia in the acute and long-term care setting. Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury and is marked by memory disorders, personality changes, and impaired reasoning. Urinary tract infections usually occur when bacteria enter the urinary tract through the urethra and multiply in the bladder. Infection-fighting assets are found in the urinary system and help inhibit the growth of bacteria.
Which chemical restraints are often overused in hospital settings? Select all that apply.
Antianxiety drugs
Anti-psychotic drugs
Antidepressant drugs
Sedative-hypnotic drugs
The chemical restraints that are often overused in hospital settings include antianxiety drugs, anti-psychotic drugs, antidepressant drugs, and sedative-hypnotic drugs. The most potent group of psychoactive drugs is the anti-psychotics. These drugs are appropriate only for the control of certain behavioral problems, such as delusions, acute psychosis, and schizophrenia. Anti-Parkinson drugs may be used to treat conditions that contribute to sleep disruption such as restless leg syndrome and periodic limb movement disorder (nocturnal myoclonus syndrome).