This topic contains a solution. Click here to go to the answer

Author Question: A 75-year-old woman walks into the emergency department with complaints of not feeling well. Her ... (Read 77 times)

washai

  • Hero Member
  • *****
  • Posts: 523
A 75-year-old woman walks into the emergency department with complaints of not feeling well. Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300.
 
  Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings?
  a. Normal in the older adult
  b. A need for the patient to be evaluated for cognitive impairment
  c. A side effect of anti-hypertensive medication
  d. Pathologic impairment of sensory responses

Question 2

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching?
 
  a. Bathing and drying the skin vigorously to stimulate circulation
  b. Keeping the head of the bed elevated 30 degrees
  c. Limiting intake of fluid and offer frequent snacks
  d. Turning the patient at least every 2 hours



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

jxjsniuniu

  • Sr. Member
  • ****
  • Posts: 343
Answer to Question 1

ANS: D
This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.

Answer to Question 2

ANS: D
The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.




washai

  • Member
  • Posts: 523
Reply 2 on: Jul 22, 2018
YES! Correct, THANKS for helping me on my review


rachel

  • Member
  • Posts: 323
Reply 3 on: Yesterday
Gracias!

 

Did you know?

Your skin wrinkles if you stay in the bathtub a long time because the outermost layer of skin (which consists of dead keratin) swells when it absorbs water. It is tightly attached to the skin below it, so it compensates for the increased area by wrinkling. This happens to the hands and feet because they have the thickest layer of dead keratin cells.

Did you know?

Each year in the United States, there are approximately six million pregnancies. This means that at any one time, about 4% of women in the United States are pregnant.

Did you know?

According to the American College of Allergy, Asthma & Immunology, more than 50 million Americans have some kind of food allergy. Food allergies affect between 4 and 6% of children, and 4% of adults, according to the CDC. The most common food allergies include shellfish, peanuts, walnuts, fish, eggs, milk, and soy.

Did you know?

Approximately 15–25% of recognized pregnancies end in miscarriage. However, many miscarriages often occur before a woman even knows she is pregnant.

Did you know?

According to the National Institute of Environmental Health Sciences, lung disease is the third leading killer in the United States, responsible for one in seven deaths. It is the leading cause of death among infants under the age of one year.

For a complete list of videos, visit our video library