Page 1 of 62
MED SURG NUR 242 EXAM 1 STUDY GUIDE
ACTUAL EXAM WITH RATIONALE GRADED A+
NEW MODIFIED EXAM WITH DETAILED
SOLUTIONS
Changes in Dark skin - cyanosis ---- ANSWER----- examine lips and tongue for gray color
- examine nail beds, palms, and soles for blue tinge
- Examine conjunctiva for pallor
Changes in Dark skin - Inflammation ---- ANSWER----- Compare effective area with non
affected area for increased warmth
-examine skin of affected area to determine whether it is shiny or taut or pits with pressure
- Compare the skin color of affected area with the same area on the opposite side of the body
- palpate the affected area and compare it with unaffected area to determine whether texture
is different (affected area may feel hard or "woody"
Changes in Dark skin - Jaundice ---- ANSWER----- Check for yellow tinge to oral mucous
membranes, especially the hard palate
- examine the sclera nearest to the iris rather than the corners of the eye
Changes in Dark skin - Bleeding ---- ANSWER----- Compare the affected area with the same
area on the unaffected body side for swelling or skin darkening
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- if the patient has thrombocytopenia, petechiae may be present on the oral mucosa or
conjunctiva
Dementia older adults ---- ANSWER----slowly progresses
generally chronic intellectual impairment
Most common Alzheimer's
Multi-infarct dementia, the second most common resulting from a vascular disorder
Delirium older adults ---- ANSWER----Acute and fluctuating onset results
from an unfamiliar place
Symptoms - inattentiveness, disorganized thinking, and altered level of consciousness
Nurse's role in Rehab ---- ANSWER----Advocate for the patient and family
Create therapeutic rehab milieu provide whole person patient-centered care
Collaborate with healthcare team for patient outcome and develop care plan
Communicate with effectively with all members of the health care team, patient and family
Evaluate effectiveness of plan of care for the patient and family
Use Braden scale - skin break down risk
Safe Patient Handing and Mobility (SPHM) ---- ANSWER-----Maintain a wide, stable base
with your feet
-Put the bed at the correct height - waist level while providing direct care and hip level when
moving patients
- Keep the patient or work directly in front of you to prevent your spine from rotating
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- Keep the patient as close to your body as possible to prevent reaching
walker - assisted and cane - assisted procedure ---- ANSWER----- Apply a transfer belt
around patients waist
- guide patient to a standing position
- remind patient to place both hands on the walker
- ensure that the patient's body is well balanced
walker teaching ---- ANSWER----- lift the walker
- move the walker about 2 feet forward and set it down on all legs
-while resting on the walker, take small steps
- check balance
- repeat sequence
cane teaching ---- ANSWER----- be sure cane is at the height of the patients wrist when the
arm is placed at his or her side
- remind patient to place his or her strong hand on cane
- ensure that the patient's body is well balanced
- move the cane and weaker leg forward at the same time
- move the stronger leg one step forward
- check balance and repeat the sequence
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Four Major subgroups of Late Adulthood ---- ANSWER----65 - 74 young old
75 - 84 middle old
85 - 99 old old
100 and older elite old
Lifestyle and Practice to Promote Wellness older adults ---- ANSWER----Yearly flu vaccine
pneumococcal vaccine Shingles vaccine tetanus and booster every 10 years wear seat belts
alcohol in moderation avoid smoking smoke detectors prevent falls - waxed floors and
scattered rugs medications as prescribed avoid OTC medications unless primary care
phyisican directs Yearly physicial regular exercise socialization reminisce
Common health Issues and Concerns older adults ---- ANSWER----Decreased nutrition and
hydration
Decreased mobility
Stress and loss
Accidents - falls most common/MVA
Drug use and misuse
Mental health/cognition problems (including substance abuse)
Elder neglect and abuse
GFTT ( Geriatric Failure To Thrive) Complex Syndrome ---- ANSWER----Under nutrition
Impaired mobility
MED SURG NUR 242 EXAM 1 STUDY GUIDE
ACTUAL EXAM WITH RATIONALE GRADED A+
NEW MODIFIED EXAM WITH DETAILED
SOLUTIONS
Changes in Dark skin - cyanosis ---- ANSWER----- examine lips and tongue for gray color
- examine nail beds, palms, and soles for blue tinge
- Examine conjunctiva for pallor
Changes in Dark skin - Inflammation ---- ANSWER----- Compare effective area with non
affected area for increased warmth
-examine skin of affected area to determine whether it is shiny or taut or pits with pressure
- Compare the skin color of affected area with the same area on the opposite side of the body
- palpate the affected area and compare it with unaffected area to determine whether texture
is different (affected area may feel hard or "woody"
Changes in Dark skin - Jaundice ---- ANSWER----- Check for yellow tinge to oral mucous
membranes, especially the hard palate
- examine the sclera nearest to the iris rather than the corners of the eye
Changes in Dark skin - Bleeding ---- ANSWER----- Compare the affected area with the same
area on the unaffected body side for swelling or skin darkening
, Page 2 of 62
- if the patient has thrombocytopenia, petechiae may be present on the oral mucosa or
conjunctiva
Dementia older adults ---- ANSWER----slowly progresses
generally chronic intellectual impairment
Most common Alzheimer's
Multi-infarct dementia, the second most common resulting from a vascular disorder
Delirium older adults ---- ANSWER----Acute and fluctuating onset results
from an unfamiliar place
Symptoms - inattentiveness, disorganized thinking, and altered level of consciousness
Nurse's role in Rehab ---- ANSWER----Advocate for the patient and family
Create therapeutic rehab milieu provide whole person patient-centered care
Collaborate with healthcare team for patient outcome and develop care plan
Communicate with effectively with all members of the health care team, patient and family
Evaluate effectiveness of plan of care for the patient and family
Use Braden scale - skin break down risk
Safe Patient Handing and Mobility (SPHM) ---- ANSWER-----Maintain a wide, stable base
with your feet
-Put the bed at the correct height - waist level while providing direct care and hip level when
moving patients
- Keep the patient or work directly in front of you to prevent your spine from rotating
, Page 3 of 62
- Keep the patient as close to your body as possible to prevent reaching
walker - assisted and cane - assisted procedure ---- ANSWER----- Apply a transfer belt
around patients waist
- guide patient to a standing position
- remind patient to place both hands on the walker
- ensure that the patient's body is well balanced
walker teaching ---- ANSWER----- lift the walker
- move the walker about 2 feet forward and set it down on all legs
-while resting on the walker, take small steps
- check balance
- repeat sequence
cane teaching ---- ANSWER----- be sure cane is at the height of the patients wrist when the
arm is placed at his or her side
- remind patient to place his or her strong hand on cane
- ensure that the patient's body is well balanced
- move the cane and weaker leg forward at the same time
- move the stronger leg one step forward
- check balance and repeat the sequence
, Page 4 of 62
Four Major subgroups of Late Adulthood ---- ANSWER----65 - 74 young old
75 - 84 middle old
85 - 99 old old
100 and older elite old
Lifestyle and Practice to Promote Wellness older adults ---- ANSWER----Yearly flu vaccine
pneumococcal vaccine Shingles vaccine tetanus and booster every 10 years wear seat belts
alcohol in moderation avoid smoking smoke detectors prevent falls - waxed floors and
scattered rugs medications as prescribed avoid OTC medications unless primary care
phyisican directs Yearly physicial regular exercise socialization reminisce
Common health Issues and Concerns older adults ---- ANSWER----Decreased nutrition and
hydration
Decreased mobility
Stress and loss
Accidents - falls most common/MVA
Drug use and misuse
Mental health/cognition problems (including substance abuse)
Elder neglect and abuse
GFTT ( Geriatric Failure To Thrive) Complex Syndrome ---- ANSWER----Under nutrition
Impaired mobility
