NURS 130 Final Exam Study Guide Solutions

NURS 130 Final Exam Study Guide Solutions nursing process - Ans:-ADPIE = Assessment, Diagnosis, Planning, Implementation, Evaluation subjective data - Ans:-symptoms - what the client says about himself or herself objective data - Ans:-signs - what the health professional observes during the exam cultural competency - Ans:-caregivers understand and attend to the total context of the individuals situation - immigration status - stress and social factor - cultural similarities and differences exam technique on older adults - Ans:-- do everything slower - don't overwhelm with questions - assist them as needed - don't talk in elder voice ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/16 interviewing interventions for diverse cultures - Ans:-- use interpreters if necessary - don't make assumptions - make sure you understand their beliefs and restrictions regarding healthcare purpose of health history - Ans:-- collect subjective data - provides picture of person's past and present health - describes person as a whole and how the person interacts with their environment - records health strengths and coping skills - recognize and affirm what patient is doing right and point out improvements needed collecting data on allergies - Ans:-note the allergen and the reaction mental status - Ans:-level of consciousness - alert and oriented to person, time, and place A&O X3, lethargic, stuporous, comatose older adult expected findings (related to mental status) - Ans:-*delirium* - acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (pneumonia, alcohol or drug intoxication), usually resolved when underlying cause is treated ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/16 *dementia* - gradual progressive process causing decreased cognitive function even though person is fully conscious and awake, not reversible, 2/3 is alzheimer's, not part of normal aging, non-caucasions, older adults, women, singles living alone, lower education and income are more at risk *depression* - sad gloomy and dejected, symptoms may occur with rainy weather, after a holiday, or with illness; if situation is temporary, symptoms fade quickly abstract reasoning - Ans:-math problems, picking what word doesn't fit, anything that involves deeper thinking assessing techniques and sequence - Ans:-inspect, percuss, palpate, auscultate normal changes with the older adult (general overview) - Ans:-*physical appearance* - sharper body contour, angular features, redistributed body proportions *posture* - general flexion *gait* - wider base to compensate for diminished balance, arms out, steps shorter or uneven *weight* - body weight decreases, subcutaneous fat lost from face and periphery, more fat accumulates at hips and abdomen *height* - vertebral discs thinning, vertebrae shortening, kyphosis posture, flexion in knees and hips vital signs and normal ranges - Ans:-*temperature* - normal is 98.6 F or 37 C (oral, rectal, tympanic, temporal, axillary) ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 4/16 *pulse* - normal is 60-100 bpm, graded 0-3+ *respirations* - normal is 12-20 bpm *blood pressure* - normal is 120/80 mmHg *oxygen saturation* - normal is 95-100% age related changes to vital signs - Ans:-*temperature* - sweat gland activity diminished, increased risk of hypothermia, decreased risk for fever *pulse* - radial artery may feel stiff, rigid, or tortuos, more rigid vessels (easier to palpate) *respirations* - decreased vital capacity and inspiratory reserve volume, shallower and faster breathing *blood pressure* - systolic pressure increases due to rigid aorta an