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NUR 111 QUIZ #4 Questions With Complete Solutions
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NUR 111 QUIZ #4 Questions With Complete Solutions
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NUR 111 QUIZ #4 Questions With Complete SolutionsAging hearing Correct Answer - progressive in older adults is
sensorineural
- presbycusis
- happens slowly (pt may not notice but family does)
Alteration in attention Correct Answer - demonstrates
difficulty in ability to focus, shift, and sustain attention
consistently
- short term difficulties can occur with acute stress, anxiety or
illness
Alteration in cognition Correct Answer disruption of any
physiological system may cause cognitive impairment
Alteration in memory Correct Answer `- initial manifestation
of cognitive disorder
- related to underlying disease caused by treatment or
medication
- short term: Alzhemier's, Lewey body dementia
Alteration in motor coordination Correct Answer - tics,
tremors, balance, and coordination
*pathways used for cognitive processing and motor
coordination/function are SHARED
Atelectasis Correct Answer partial/complete collapse of the
lung
Attention Correct Answer brains ability to remain alert/aware
,Auscultation assessment oxygenation Correct Answer - listen
to anterior, posterior, lateral
- quality of sound (on skin)
Blood pressure Correct Answer - know baseline
- sites (brachial artery)
Carotid artery assessment Correct Answer - Carotid arteries
supply O2 and blood to the head and neck
- pt sit/lie supine with head elevated 30 degrees
- ausculate and palpate
- diminished/unequal pulse rates indicate a blockage
*never press both carotids at the same time
Chambers of the heart Correct Answer -right atrium
- right ventricle
- left atrium
- left ventricle
Cognition clinical manifestations Correct Answer - reduced
awareness
- impaired thinking skills
- changes in behavior/activity level
Cognition nursing process Correct Answer Primary duty in
caring for an individual with acute confusion (delirium) is to
promote resolution of whatever the condition is, causing the pts
cognitive impairment
- Safety
- Comfort
, - Nutrition
- Antibiotics
Cognition pt preparedness Correct Answer - Nurses must
always be aware of pt's reactions when assessing mental status
- anxiety
- increase confusion
Cognitive assessment Correct Answer - essential component
for all pts
- on-going assessment for those who are at risk
- best info comes from the pt
- use judgement in direct questions with established
cognitive/perceptual problems
- open ended questions
Cognitive assessment parts Correct Answer - health history
(chronic illness, hx drugs/alcohol, meds, family hx)
- physical exam
- mental status exam (CAM)
- MME (mini mental state exam)
Cognitive interview focus Correct Answer - orientation
- cognitive function
- judgment
- memory
- thought processes
- perception
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