The nurse is completing her assessment of an older adult and notices some cognitive impairment not normally associated with aging. Which of these alterations would prompt further follow-up? (Select all that apply.)
a. The patient does not remember where her son lives.
b. The patient is unable to balance her checkbook.
c. The patient got lost in a city she never traveled to before.
d. The patient often has difficulty remembering words.
e. The patient got lost going to her usual grocery store.
ANS: A, B, D, E
Symptoms of cognitive impairment include disorientation, loss of language skills, loss of the ability to calculate, poor judgment, and memory loss. If a patient exhibits these symptoms, further investigation is needed. Some decline in cognitive function occurs with aging, such as the ability to navigate easily in new areas.
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In the emergency department, a patient's vital signs are: BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow
The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic overdose. Select the priority outcome. a. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. b. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. c. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields. d. The patient will demonstrate effective coping skills within 1 week of hospitalization. e. The patient will identify community resources for treatment of substance abuse.
The informatics nurse attends a presentation about a smart home. In which way should this type of home support independence for older adults? Select all that apply.
A) Monitor for falls B) Monitor vital signs C) Examine sleep habits D) Monitor for poor eating E) Provide medication reminders
The nurse should base a response to a parent's question about the prognosis of acute lymphoblastic leukemia (ALL) on which information?
a. Leukemia is a fatal disease although chemotherapy provides increasingly longer periods of remission. b. Research to find a cure for childhood cancers is very active. c. The majority of children go into remission and remain symptom free when treatment is completed. d. It usually takes several months of chemotherapy to achieve a remission.
The nurse is explaining to student nurses the different heart sounds that are assessed during the cardiac assessment. Which statement made by a student indicates understanding of the expected normal heart sounds?
1. "If I hear the S1 as lub and S2 as dub, then that is normal and means that the valves are working." 2. " If I hear a ‘lub-dub-ee' it means the client has a ventricular gallop." 3. "If I hear ‘dee-lub-dub' then the client may have an atrial gallop. This occurs near the very end of diastole just before S1 and creates the sound." 4. "If I hear the ‘dee-lub-dub' sound in an older adult, then I should know that is considered normal for the older client."