The nurse caring for an older cognitively impaired patient with ...

[tingc95]

The nurse caring for an older cognitively impaired patient with osteoarthritis in both hands assesses the patient for hand pain by
 
  a. observing for facial grimacing when the patient uses a fork to eat.
  b. being alert for signs of agitation when washing the patient's hands.
  c. listening to detect moaning when patient makes a fist.
  d. watching for signs that the patient is re-luctant to shake hands.

Question 2

A patient is brought to the emergency department after an unexplained fall. What actions by the nurse are most appropriate? (Select all that apply.)
 
  a. Placing the patient on a cardiac monitor
  b. Obtaining a urine sample for cultures
  c. Checking a quick bedside blood glucose
  d. Assessing the patient for asthma
  e. Performing tests for orthostatic vital signs

[Heffejeff]

Answer to Question 1

B
Cognitively impaired patients in pain may not portray any visible signs of pain or distress or may be unable to communicate their pain. Pain may result in agitation, as well as increased pulse, respiration, blood pressure, and confusion. The other options are not as indicative of pain in the cognitively impaired older adult.

Answer to Question 2

A, B, C, D
Common causes of falls include cardiac dysrhythmias, urinary tract infection, hypoglycemia, and dehydration, so the nurse assesses for these conditions. Asthma most likely is not an issue.