Deck 9: Evaluation

Question 1

Eloise fell on her patio and sustained a left fractured femur. She was 1 day postoperative following fixation of the hip with three pins. The incision site is clean and dry with no sign of infection. She still describes her pain at 4 on a scale of 10 and has been requesting her medication every 4 hours. Hydrocodone 5 mg/500 mg is ordered every 4 to 6 hours, as needed. However, she does not want to ambulate even to the bathroom. She describes her fear of falling and is having difficulty with using her walker. She is due to be discharged home tomorrow, and you need to now consult with a home health agency for the family because she lives alone and has requested in-home care. Consider the following diagnostic labels:
?Impaired physical mobility
?Acute pain

-Evaluate which of the following is a first priority NANDA diagnosis statement?

A) Risk for falls
B) Activity intolerance
C) Risk for constipation
D) Compromised family coping
E) Deficient diversional activity

Answer 1

Risk for falls

Question 2

Eloise fell on her patio and sustained a left fractured femur. She was 1 day postoperative following fixation of the hip with three pins. The incision site is clean and dry with no sign of infection. She still describes her pain at 4 on a scale of 10 and has been requesting her medication every 4 hours. Hydrocodone 5 mg/500 mg is ordered every 4 to 6 hours, as needed. However, she does not want to ambulate even to the bathroom. She describes her fear of falling and is having difficulty with using her walker. She is due to be discharged home tomorrow, and you need to now consult with a home health agency for the family because she lives alone and has requested in-home care. Consider the following diagnostic labels:
?Impaired physical mobility
?Acute pain

-Identify an area to address with Eloise for a nursing diagnosis of deficient knowledge?

A) Wound care
B) Use of assistive devices
C) Nutritional supplements
D) Nursing home placement

Answer 2

Use of assistive devices

Question 3

Eloise fell on her patio and sustained a left fractured femur. She was 1 day postoperative following fixation of the hip with three pins. The incision site is clean and dry with no sign of infection. She still describes her pain at 4 on a scale of 10 and has been requesting her medication every 4 hours. Hydrocodone 5 mg/500 mg is ordered every 4 to 6 hours, as needed. However, she does not want to ambulate even to the bathroom. She describes her fear of falling and is having difficulty with using her walker. She is due to be discharged home tomorrow, and you need to now consult with a home health agency for the family because she lives alone and has requested in-home care. Consider the following diagnostic labels:
?Impaired physical mobility
?Acute pain

-What would be your next step to help Eloise in pain management?

A) Teach her about guided imagery.
B) Ask the physician to order acetaminophen.
C) Extend her Hydrocodone order to every 6 hours.
D) Ask Eloise about her perceptions and usual techniques.
E) Administer her pain medications routinely every 4 hours.

Answer 3

Ask Eloise about her perceptions and usual techniques.

Question 4

Eloise fell on her patio and sustained a left fractured femur. She was 1 day postoperative following fixation of the hip with three pins. The incision site is clean and dry with no sign of infection. She still describes her pain at 4 on a scale of 10 and has been requesting her medication every 4 hours. Hydrocodone 5 mg/500 mg is ordered every 4 to 6 hours, as needed. However, she does not want to ambulate even to the bathroom. She describes her fear of falling and is having difficulty with using her walker. She is due to be discharged home tomorrow, and you need to now consult with a home health agency for the family because she lives alone and has requested in-home care. Consider the following diagnostic labels:
?Impaired physical mobility
?Acute pain

-The family wants Eloise to go to a skilled nursing facility because they live in another state. What is your response?

A) Refer the family to the social worker.
B) Interview Eloise on her home environment.
C) Discuss her discharge plans with the physician.
D) Provide the family with information on local facilities.

Question 5

Eloise fell on her patio and sustained a left fractured femur. She was 1 day postoperative following fixation of the hip with three pins. The incision site is clean and dry with no sign of infection. She still describes her pain at 4 on a scale of 10 and has been requesting her medication every 4 hours. Hydrocodone 5 mg/500 mg is ordered every 4 to 6 hours, as needed. However, she does not want to ambulate even to the bathroom. She describes her fear of falling and is having difficulty with using her walker. She is due to be discharged home tomorrow, and you need to now consult with a home health agency for the family because she lives alone and has requested in-home care. Consider the following diagnostic labels:
?Impaired physical mobility
?Acute pain

-Which of the following NIC nursing interventions is appropriate?

A) Self-care assistance
B) Bleeding precautions
C) Behavior modification
D) Abuse protection support