Based on an understanding of the cognitive changes that normally occur with aging. what would the nurse expect a newly hospitalized older adult to do?
Interrupt with frequent questions
Answer slowly and be confused
Withdraw from strangers
Take longer to respond and react
The Correct Answer is D
A) Interrupt with frequent questions: While older adults may have questions, they typically do not interrupt frequently. This behavior is more indicative of anxiety or agitation rather than a cognitive change associated with aging.
B) Answer slowly and be confused: While some older adults may exhibit slower responses, confusion is not a normal cognitive change associated with aging. Confusion may suggest underlying issues such as delirium or dementia, rather than typical age-related cognitive changes.
C) Withdraw from strangers: Social withdrawal can occur in some older adults, but it is not a universal expectation. Many older adults remain engaged and sociable, and withdrawal is more commonly associated with mental health issues rather than cognitive changes.
D) Take longer to respond and react: It is common for older adults to take longer to process information and respond due to normal cognitive slowing. This may reflect changes in processing speed rather than a decline in cognitive function, and it is an expected part of aging.
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Correct Answer is C
Explanation
A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.
B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."
C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.
D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.
Correct Answer is D
Explanation
A) Splint and immobilize the extremity: While immobilizing the injured extremity is important to prevent further injury, it should follow an initial assessment of blood flow and nerve function to ensure there are no vascular or neurological compromises.
B) Apply an ice pack to the ankle: Applying ice can help reduce swelling and alleviate pain. However, it is essential first to assess the circulation to the limb to ensure that applying ice will not worsen any underlying issues.
C) Encourage weight bearing and ambulation: Encouraging weight bearing on a potentially injured ankle can lead to further damage and is not appropriate. The priority is to assess the injury and understand its severity.
D) Assess pulse, color, temperature, and capillary refill: This step is crucial as it evaluates the vascular status of the limb. Assessing these factors helps identify any potential complications, such as compartment syndrome or inadequate blood flow, and guides further management of the injury.