Geriatric Assessment and Pressure Ulcers Quiz

Nurse Jamie is caring for Mrs. Lydia Ortega, an 85-year-old woman who is bedbound following a recent stroke. During a skin assessment, Nurse Jamie observes a localized area of redness over the sacral region that does not blanch when pressure is applied. Which of the following interventions is most appropriate?

• Massage the area to promote blood flow

• Document it as a Stage 2 pressure injury and apply a dressing

• Reposition the patient every 2 hours and monitor the area

• Leave the skin exposed to air and observe for healing

Mr. Ricardo Bautista, 76, is on his third post-operative day after abdominal surgery. He remains in bed most of the day and consumes only a clear liquid diet. Nurse Clara calculates his Braden Score as 17. Which of the following is the most appropriate nursing action?

• Apply dressings to all pressure points

• Begin repositioning the patient every two hours and encourage dietary progression

• Continue current care plan without changes

• Initiate wound debridement orders

Mr. Emilio Dizon, 70, with diabetes, reports numbness and tingling in both feet. Nurse Kim finds diminished sensation during assessment. Which nursing diagnosis should the nurse prioritize?

• Risk for constipation

• Risk for infection

• Risk for sensory-perceptual alteration

• Risk for impaired physical mobility

Mrs. Rosario Lim, 82, becomes confused and agitated after starting a diuretic. Nurse Bea suspects delirium. Which assessment tool should the nurse use to assess her cognitive status?

• Lawton IADL

• Braden Scale

• SPMSQ

• Geriatric Depression Scale

Mr. Carlos Tan, 79, presents with shortness of breath and fatigue. Auscultation reveals crackles, and he has a weak cough. What nursing diagnosis is most appropriate?

• Ineffective breathing pattern

• Ineffective airway clearance

• Activity intolerance

• Risk for aspiration

Ms. Melinda Cruz, 88, is brought in by her daughter due to missed meals and leaving the stove on. Her MMSE score is 23. How should the nurse interpret this finding?

• No cognitive deficit

• Mild cognitive impairment

• Moderate dementia

• Severe cognitive decline

Mr. Jerome Robles, 81, is recovering from hip surgery. Nurse Angel notes that the patient’s back is moist from perspiration. According to the Braden Scale, what score should the nurse assign for moisture?

• 1 – Constantly moist

• 2 – Very moist

• 3 – Occasionally moist

• 4 – Rarely moist

Mrs. Teresa Uy, 84, has a maroon, non-blanchable area on her heel. It is firm and slightly warmer than the surrounding skin. What type of pressure injury is this most likely to be?

• Stage 1 pressure injury

• Stage 2 pressure injury

• Deep tissue pressure injury

• Stage 3 pressure injury

Mr. Alberto Sy, 89, has nocturia and recently fell while trying to get to the bathroom. Which of the following interventions is most important to implement immediately?

• Encourage fluid intake during the day only

• Use a bedside commode and night light

• Start diuretics at night

• Insert a Foley catheter

Mr. Ernesto Chua, 80, has a BMI of 17 and low albumin levels. He eats less than half of meals and is NPO for several days. How should Nurse Mai score his nutrition on the Braden Scale?

• 1 – Very poor

• 2 – Probably inadequate

• 3 – Adequate

• 4 – Excellent