chronic rehab module 6&7 studying

centrally acting skeletal muscle relaxants

- control severe muscle spasticity - cause severe drowsiness and sedation, may not be effective - tizanidine

catechol o-methyltransferases (COMTs)

- entacapone - enzymes that inactivate dopamine - disease can be treated in several ways with one drug

a nurse assesses clients on a medical surgical unit. which client is at the greatest risk for pressure injury development? a. a 78 y/o requiring assistance to ambulate with a walker b. a 65 y/o with hemiparesis and incontinence c. a 26 y/o who is bedridden with a fractured leg d. a 44 y/o prescribed IV antibiotics for pneumonia

b

a nurse cares for a client with a spinal cord injury. with which interprofessional health team member would the nurse collaborate to assist the client with ADLs? a. social worker b. occupational therapist c. physical therapist d. case manager

b

a nurse is caring for a client who has a nonhealing pressure injury on the right ankle. which action would the nurse take first? a. draw blood for albumin, prealbumin, and total protein b. assess the right leg for pulses, skin color, and temperature c. prepare for and assist with obtaining a wound culture d. instruct the client to elevate the foot

b

a nurse is working with a client who has a painful rash consisting of grouped weeping and crusting lesions in distinct lines. what action by the nurse is most appropriate? a. demonstrate use of proper antifungal medicatiions b. instruct the client to report lesions near the eyes c. review appropriate hygiene measures d. have the client take long, hot baths to soak the lesions

b

the nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with alzheimer's disease. which statement by the caregiver indicates a need for further teaching? a. "i will limit the number of choices i provide for the client" b. "i will avoid communicating with the client to prevent agitation" c. "i can try to use gestures or pictures to communicate with the client" d. "i should use simple, short sentences and one-step instructions"

b

a nurse is assessing a client with a suspected diagnosis of multiple sclerosis. which assessment findings would the nurse expect? SATA a. resting tremors b. memory loss c. muscle spasticity d. fatigue e. diplopia (double vision) f. dysarthria (slurred speech)

b, c, d, e, f

the nurse is preparing a teaching plan for a client with migraine headaches. which of these foods or food additives may trigger a migraine & should be avoided? a. sugar b. beer c. smoked sausage d. pickles e. caffeine f. wine

b, c, d, e, f

the nurse is caring for a client in late-stage alzheimer's disease. which assessment findings will the nurse anticipate? SATA a. has difficulty driving b. ADL dependent c. incontinent d. wandering e. possible seizures f. immobile

b, c, f i had put b, c, e, f and i got 0.67/1 point

why should patients with MS be careful of increasing their body temperature?

because increased temp can lead to fatigue, diminished motor ability, and decreased visual acuity

a client contacts the clinic to report a life-long mole has developed a crust with occasional bleeding. what instructions by the nurse is most appropriate? a. "take monthly photographs of it so you can document any changes" b. "keep the lesion covered with a bandage and triple antibiotic ointment" c. "please make an appointment to be seen as soon as possible" d. "wash daily with warm water and gentle soap to prevent infection"

c

a client is admitted with a sudden decline in level of consciousness. what is the nursing action at this time? a. start a continuous IV heparin sodium infusion b. place the client on their side c. assess the client for hypoglycemia and hypoxia d. prepare for administration of a fibrinolytic agent

c

a client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. blood pressure is 190/110 mm Hg. what is the priority action? a. performing a bladder assessment b. insert an indwelling urinary catheter c. place the patient in a sitting position d. turn on a fan to cool the patient

c

a client with a large, irregularly shaped mole on the upper chest expresses concern about the cosmetic appearance of the lesion. which is the priority nursing intervention? a. refer to a dermatology HCP b. ask if there are any other bothersome lesions c. perform a head to toe skin assessment and document findings d. teach the importance of avoiding excessive sun exposure and tanning beds

c

a client with moderate dementia asks the nurse to find her son who is deceased. what is the nurses' most appropriate response? a. "we can call him in a little while if you want" b. "your son died over 20 years ago" c. "what did your son look like?" d. "i'll ask your husband to find him when he visits"

c

a nurse is caring for a client whose braden scale score is 9. what intervention demonstrates a lack of evidence-based knowledge? a. requests a referral to an RDN b. performs perineal cleansing every two hours c. raises the head of the bed no more than 45 degrees d. assesses the client's entire skin surface daily

c

a nurse performs a skin screening for a client who has numerous skin lesions. which lesion does the nurse evaluate first? a. thick, reddened papules covered by white scales b. large cluster of pustules in the right axilla c. irregular mole with multiple colors on the leg d. beige freckles on the backs of both hands

c

the nurse is caring for a 60 y/o female client who sustained a thoracic spinal cord injury ten years ago. for which potential complication will the nurse assess during this client's care? a. malabsorption b. delirium c. fracture d. anemia

c

the nurse is caring for a client who's been on biologic therapy for plaque psoriasis. which assessment finding requires immediate nursing intervention? a. increased itching b. temperature of 100 degrees F c. presence of new plaques on leg d. expression of impaired self-image

c

the nurse is caring for an older patient with receptive/sensory aphasia. which nursing action is most appropriate for communicating with the patient? a. refer the patient to the speech language pathologist (SLP) b. speak loudly to help the client interpret what is being said c. provide pictures to help the client understand d. ask the client to read messages on a whiteboard

c

mild/moderate/late stages of alzheimer's disease

mild; independent ADLs, denies presence of symptoms, forgetting names, misplacing items, short-term memory loss, difficulty recalling new info, small behavioral/personality changes, less engaged in social relationships, mild impaired cognitions and problems with judgment, decreased performance esp when stressed, unable to travel alone to new destinations, decreased sense of smell moderate; impairment of all cognitive functions, problems with handling or unable to handle money/finances, disoriented to time/place/event, possibly depressed/agitated, visuospatial deficits, less talkative, decreased vocab, nonfluent/aphasic, incontinent, psychotropic behaviors like delusions, hallucinations, paranoia, wandering, and trouble sleeping late; completely incapacitated, bedridden, totally dependent on ADLs, loss of mobility and verbal behaviors, agnosia, possible seizures and tremors

levodopa/combination of levodopa-carbidopa, safinamide

orthostatic hypotension, psychotic episodes, dyskinesia

priority problem for alzheimers's disease

potential for injury or falls due to wandering and poor ambulation. potential for elder abuse by caregivers

parkinson's disease stages

stage 1; initial. unilateral limb involvement, minimal weakness, hand/arm trembling stage 2; mild. bilateral limb involvement, masklike facies, slow/shuffling gait stage 3; moderate. postural instability, increased gait disturbances stage 4; severe. akinesia, rigidity stage 5; complete ADL dependence

braden scale

- 18 or less indicates at risk status for pressure injuries!! - sensory perception; ability to respond appropriately to pressure related discomfort - moisture; from fecal or urinary incontinence - activity; degree of physical activity - mobility; ability to change and control body position - nutrition; usual food intake patterns - friction and shear; loss of epidermis due to rubbing against sheets, chair, etc

1st/2nd/3rd intention healing

- 1st intention; clean laceration or surgical incision and approximated (in correct anatomic position). thin scar results - 2nd intention; prolongs repair process. increases infection risk. surgical incisions into nonsterile body cavities or contaminated traumatic wounds left open for several days. chronic pressure injury or venous ulcers. gradual filling of dead space 3rd intention; delayed primary closure. debris and exudate are removed and the wound is then healed by first intention

dopamine agonists

- apomorphine, pramipexol, ropinirole - orthostatic hypotension, hallucinations, sleepiness, drowsiness, can be mistaken for symptoms of PD

SCI symptoms

- bladder/bowel issues; UTI - autonomic dysreflexia (AD); sudden significant rise in systolic and diastolic bp with bradycardia - profuse sweating above the level of the lesion, esp face/neck/shoulders - goose bumps - flushing of the skin above the level of the lesion - blurred vision - nasal congestion - spots in visual field - feeling of apprehension - severe throbbing headache

dopamine receptor agonists

- bromocriptine mesylate - sometimes prescribed in the early course of PD - helpful in combination with levodopa for relieving dyskinesias or orthostatic hypotension

cholinesterase inhibitors

- can cause bradycardia, so monitor the patient's heart rate and report dizziness - donepezil, galantamine, rivastigmine - treats AD symptoms - may slow onset of cognitive decline

how is alzheimer's disease diagnosed?

- can only definitively be diagnosed at autopsy to confirm the presence of neurofibrillary tangles and neurotic plaques. - genetic testing for apolipoprotein EF, amyloid beta protein precursor, and a decrease in the pt's sBPP in the CSF

bedbugs

- cimex lecturlarius & cimex hemipterus - often live in mattresses and fabric upholstery and cracks and crevices of furniture - do not live on humans but feed on their blood at night - bite causes an itchy discomfort - bug is the size, shape, and color of an apple seed - when the bug feeds, it may double in size and have a red or black color - they feed for 5-10 mins and the human usually does not notice - secondary infections like cellulitis can occur

scabies

- contagious - caused by mites burrowing into skin - transmitted by close contact or bedding - curved, linear ridges in skin with intense itching - becomes unbearable at night - back and head are usually not affected - usually has 10-15 mites, but can have millions - ridges are common on the sides and webs of fingers and inner wrists - hypersensitivity reaction; excoriated erythematous papules/pustules, crusted lesions on penis/nipples/lower abdomen/butt/thighs/axillary folds

multiple sclerosis (MS)

- history of vision/mobility/sensory perception changes - muscle weakness/spasticity - fatigue, usually with continuous sensitivity to temperature - intention tremors when performing an activity - flexor muscle spasms - dysmetria; inability to direct/limit movement - paresthesias; numbness/tingling - hypoalgesia; decreased pain sensitivity - ataxia; decreased motor coordination - dysarthria; slurred speech - dysphagia; difficulty swallowing - diplopia; double vision - nystagmus; eyes make repetitive uncontrolled movements - scotomas; peripheral vision changes - decreased visual/hearing acuity - tinnitus - bowel/bladder dysfunction - alterations in sexual function - memory loss, impaired judgment, decreased problem solving ability, cannot perform calculations - depression

urticaria

- hives - give benadryl

pruritis

- itching - subjective condition similar to pain

pediculosis

- lice infestation - lice are oval and 2-4mm long - the female lays eggs at the hair shaft base - itching and excoriation from scratching - examine scalp for white flecks - matting and crusting of the scalp and a foul odor indicated a possible secondary infection - treatment includes topical sprays, creams, or shampoos. - fine tooth comb will remove lice but not get rid of the problem - pediculosis capitus; head lice - pediculosis corporus; body lice - pediculosis pubis; crab lice, intense itching in the vulvar region. can also infest axillae, eyelashes, and chest

n-methyl-d-aspartate (NMDA) receptor antagonists

- memantine - indicated for advanced AD, has been shown in some patients to slow deterioration

neurologic level/findings for sci

- most common is cervical C5 - in paraplegia, most common is T12/L1 - neurologic level = anatomic level - dermatomes and myotomes are the zones of motor/sensory function

assessment/measurement tips for wounds

- never restage for improving wounds, always "improving or healing stage x" - do not restage a pressure injury that's getting worse - key way to measure wound healing progression; length, width, and depth in mm/cm - tunneling; hidden wound areas extending from the primary wound - undermining; separation of skin layers of wound edges from granulation tissue - granulation tissue; early is pale pink, later is beefy red. healthy scar tissue is moist and spongy - eschar; necrotic tissue, layer of black, gray, brown collagen. may be dry and leathery in early stages or full of exudate and yellow/tan - cellulitis; inflammation of the skin and subcutaneous tissue extending beyond the area of injury - reddened areas that don't blanch; impaired capillary blood flow and early tissue damage - blanchable erythema of intact skin over a bony prominence; early sign of pressure injury - for patients with darker skin; assess blanching, skin temp, edema, pain, and induration

on/off phases for parkinson's disease

- on; good mobility - off; bad mobility -loss of response to the drug

psoriasis

- plaques form on skin during the hyperproliferation phase - cells shed every 4 days. normal is 28 - emolients; work to keep skin soft while minimizing itching/pain - corticosteroids; provide anti-inflammatory action - anthralin; hydrocarbon similar to tar. relieves chronic psoriasis. a strong irritant that can cause chemical burns if left on for too long or not completely washed off. - tar preparations; suppress inflammation and cell division. messy, cause staining on clothes, and smells bad - tazarotene; topical retinoid combined with topical corticosteroid therapy. teratogenic substance, so avoid with pregnancy - calcipotriene; synthetic vitamin D that regulates cell division but can mildly irritate the skin - ultraviolet (UV) irradiation; has been shown to be beneficial three times a week - photochemotherapy (PUVA); administration of psoralen, a photosensitizer, taken either orally or in a bath followed by uva radiation. not recommended! - oral systemic agents; vitamin A derivatives like methotrexate, folic acid, and retinoids - biologic agents; etanercept, a tumor necrosis factor (TNF) alpha inhibitor. report sign of tuberculosis or infection!

autonomic dysreflexia (AD)

- risk factors; bladder distention, UTI, epididymitis, tight clothing - immediately raise the HOB to reduce bp!!!! - check for urinary retention/catheter blockage - catheterize if indicated

skin cancer

- risk factors; overexposure to sunlight, occupational exposure to chemical carcinogens like arsenic, coal, tar, pitch, radioactive waste, and radium - cryosurgery; cell destruction by application of liquid nitrogen (-200C) - curetage & electrodessication; dermal curette scrapes away cancerous tissue and an electric probe destroys the remaining tissue - excision; surgical removal of small lesions. first line for squamous cell carcinoma

primary/secondary sci

- secondary results from primary - primary; the actual SCI - secondary; hemorrhage, ischemia, hypovolemia, impaired tissue perfusion, local edema

monoamine oxidase type B

- selegiline, rasagiline, mesylate -early/mild PD symptoms - often given with levodopa - avoid foods with tyramine!!! cheese, smoked/cured foods, sausage - avoid red wine

types of fluids

- serous; clear, watery, plasm - purulent; thick, yellow, green, brown, tan - serosanguineous; pale, watery, mix of red and clear, so pinkish - sanguineous; bright red active bleeding

SSRIs

- sertraline & paroxetine - for depression - do not take with triptan drugs - do not take St John's wort

intrathecal baclofen

- severe muscle spasticity - sedation, fatigue, hypotension, headache, changes in mental status - seizures and hallucinations if suddenly withdrawn!

priority for stroke

- transport patient to a stroke center!!!!!!!!! - ABCs

drug holidays for parkinson's disease

- up tp 10 days of taking no meds - used for drug toxicity or tolerance control - carefully monitor symptoms

candidiasis

- white plaque-like lesions appear on the tongue, palate, pharynx, cheeks/buccal mucosa - when wiped away, underlying surface is red, sore, and painful

types of burns

1. chemical burns; homes, manufacturing industries, or assault 2. electrical injury; electrical current enters the body, and tissue injury occurs. leads to the iceberg effect, where surface injuries may look small but the internal damage is significant 3. radiation burns; prolonged exposure to sun, x-rays, radiation therapy, and individuals who work in nuclear industries 4. smoke-related burns; inhalation. edema may impair breathing. assess the mouth, throat, and nose for soot 5. thermal burns; dry heat, explosions, contact with flames, moist/scalding heat or hot liquids due to steam 6. contact burns; hot metal tar or grease causes full-thickness wounds. could be from space heater or iron 7. acids/alkalines; most common chemical burns. can damage organs. found in everyday household cleaners

interventions for pressure injuries

1. do not massage the reddened skin or use donut shaped pillows for relief, because they can damage capillary beds and increase tissue necrosis. 2. determine the loss of mobility or joint motion or range. do not delegate this! 3. at each dressing change, compare existing wound features with those documented previously 4. dressings; remove the surface debris, protect exposed healthy tissue and create a barrier until the wound is closed 5. physical therapy; implements therapeutic strategies to redistribute or offload pressure, maximize overall function, and increase quality of life 6. nutrition therapy; adequate intake of calories, protein, vitamins, minerals, and water. severe protein deficiency inhibits healing and impairs host infection defenses. fats ensure cell membrane formation 7. electrical stimulation; application of low voltage currents to a wound area to increase blood vessel growth and granulation. delivered twice a day through a wound overlay. delivered in pulses. contraindicated in patients with pacemakers, wound over the heart, or skin cancer 8. negative pressure/vacuum assisted wound therapy (NPWT); increases blood flow, minimizes edema, and increases granulation. apply subatmospheric pressure. change dressing/tubing every 24-36 hours, and foam every 48-72 hours. 9. hyperbaric oxygen therapy (HBOT); administer high pressure o2 to raise tissue o2 content. usually for brown recluse spider bites, osteomyelitis, diabetic ulcers, burns, and necrotizing infections. use for 60-90min a session. 10. topical growth factors; normal body substances that stimulate cell movement and growth. this becomes deficient in chronic wounds 11. skin substitutes; engineered products to aid in wound closure 12. ultrasound-assisted therapy (USWT); energy by low frequency (40khz) sounds waves to debride.

3 stages of wounds care

1. emergent/resuscitation phase; monitor respiratory efforts closely. begins at injury onset and ends in 24-48 hours. priorities of care include securing the airway, supporting circulation and perfusion, maintaining body temp, keeping the patient comfortable with analgesics, and providing emotional support 2. acute/healing phase; 36-48 hours. when fluid shift resolves. lasts until the wound closes. continually assess cardiovascular and respiratory systems, nutrition, burn status, pain control, and psychosocial interventions 3. rehab/restorative phase; begins with wound closure, ends with the patient achieving their highest level of functioning

types of SCI

1. hyperflexion; sudden/forceful acceleration of the heard forward, causing extreme flexion of the neck. neck goes down 2. hyperextension; MVC hit from behind or falling on chin. neck goes up/back 3. axial loading/vertical compression; driving accidents, falls on butt, jump where pt lands on feet 4. excessive rotation; turning head beyond normal range 5. penetrating trauma; knife or bullet

3 phases of wound healing

1. inflammatory phase; begins at the time of injury or cell death and lasts 3-5 days. immediate responses are vasoconstriction and clot formation. after 10 mins, vasodilation occurs with increased capillary permeability and leakage of plasma into the surrounding tissue. WBCs migrate into the wound. signs and symptoms of local edema, pain, erythema, and warmth are present. 2. proliferative phase; begins about 4th day after injury and lasts 2-4 weeks. fibrin strands form a scaffold or framework. mitotic fibroblast cells migrate into the wound, attach to the framework, divide, and stimulate collagen secretion. collagen and ground substance build tough and inflexible scar tissue. capillaries in areas surrounding the wound form buds that grow into new blood vessels. this forms the granulation tissue in the wound, and it contracts. epithelial cells grow over the granulation tissue. 3. maturation phase; begins as early as 3 weeks after injury and may continue for a year or longer. collagen is reorganized to provide greater tensile strength. scar tissue gradually becomes thinner and paler in color. the mature scar is firm and inelastic when palpated.

risk factors for pressure injuries

1. lack of mobility 2. exposure to continuous moisture 3. undernourisment 4. aging skin 5. cognitive decline/impairment 6. decreased/impaired sensory perception due to diabetes mellitus or pvd

3 ways wounds heal

1. re-epithelialization; partial thickness wounds, superficial with minimum tissue integrity loss. damage to dermis and upper dermal layers. production of new skin cells by undamaged cells in the basal layer of epidermis. local inflammation causes fibrin clot formation and growth factors are released to stimulate cell division. the clot acts as a framework to guide cell movement. resurfacing across the area is only one cell layer thick at first. it then thickens, forms layers/stratifies, and produces keratin to resemble normal skin. takes 5-7 days. more rapid in skin that's hydrated, oxygenated, and has few microorganisms. 2. granulation; deep partial and full thickness wounds. damage extends into lower layers of dermis and subcutaneous tissue. scar tissue forms, new blood vessels form at the base of the wound, and fibroblasts deposit collagen. 3. wound contraction; pulls the wound edges inward. wound decreases in size at a uniformed rate. venous leg ulcers.

types of multiple sclerosis

1. relapse-remitting (RRMS); most common. mild or moderate. symptoms develop and resolve in a few weeks/months, and patient returns to baseline. 2. primary progressive (PPMS); steady/gradual neurologic deterioration w/o symptoms remission. no acute attacks, 40-60 y/o. 3. secondary progressive (SPMS); begins as RRMS but becomes progressive. half of pts with MS develop this within 10 years. 4. progressive relapsing (PRMS); frequent relapses with partial recovery, but not a return to baseline. less common. symptoms/deterioration over several years

intensity of burns

1. superficial burns; damage only the epidermis. healing occurs in 3-6 days 2. superficial partial-thickness burns; entire epidermis and variable portions of the dermis are destroyed. uncomplicated healing occurs in 10-21 days 3. deep partial thickness burns; extend into the deeper layers of the dermis. healing occurs in 2-6 weeks

wound dressings

1. wet-to-damp saline-moistened gauze; necrotic debris is mechanically removed but with less trauma to healing tissue 2. continuous wet gauze; wound surface is continually bathed with a wetting agent of choice, promoting dilution of viscous exudate and softening of dry eschar 3. topical enzyme preparation; proteolytic action on thick, adherent eschar causes breakdown of denatured protein and more rapid separation of necrotic tissue 4. moisture-retentive dressing; spontaneous separation of necrotic tissue is prohibited by autolysis 5. alginate; highly absorbent fabrics or yarns that are derived from natural polysaccharide fibers or seaweed. may be combined with collagen. forms a gel when it comes in contact with pressure injury. for stage 3/4 with moderate exudate 6. antimicrobial; medical-grade honey, chlorhexidine. or silver ions for PI with infection. 7. collagens; gels, pads, particles, pastes, powders, sheets, or solutions. made from bovine, equine, porcine, or avian sources. used with secondary dressings for stage 3/4 8. foam, including hydropolymers; sheets of foamed, polymer solutions, usually polyurethane, that have open cells that can hold fluid. for stage 2+ with moderate/heavy exudate 9. moist gauze; dry, woven or nonwoven sponges and wraps made of cotton, polyester, or rayon. cannot be dressed with advanced ones 10. hydrocolloid, 3M tegaderm; wafers, powders, or pastes. used in areas that require contouring like heels. used for noninfected stage 2 11. hydrogel; amorphous, impregnated, or in sheet form. maintain moist environment. used for noninfected stage 2/3/4 with minimal exudate 12. superabsorbent, 3M tegaderm; highly absorptive fiber layers like cellulose, cotton, or rayon. minimizes adherence to the wound while collecting exudate. for heavily exuding injuries 13. transparent films, 3M tegaderm; polymer membranes impermeable to liquid, water, and bacteria. you can see through the dressing. used for noninfected stage 2.

priority problem for SCI

AIRWAY MANAGEMENT - the cervical spinal nerves (C3-5) innervate the phrenic nerve controlling the diaphragm

pantoprazole, esomeprazole, omeprazole

help prevent stress ulcer development

a new nurse reads a client has a wound "healing by second intention" and asks what that means. which description by the charge nurse is most accurate? a. "the wound is an open cavity that will fill in with granulation tissue" b. "the wound was contaminated by debris and can't be closed at all" c. "the wound was stapled together after an infection was cleared up" d. "the wound edges have been approximated and stitched together"

a

a nurse cares for a client who has a stage 3 pressure injury with copious exudate. what type of dressing does the nurse use on this wound? a. multi-fiber superabsorbent dressing b. none, the wound is left open to the air c. wet-to-damp saline moistened gauze d. a transparent film

a

a nurse is assessing clients with pressure injuries. which wound description is correctly matched to its description? a. suspected deep tissue injury; nonblanchable deep purple or maroon b. stage 4; wound bed is obscured with eschar or slough c. stage 2; may have visible adipose tissue and slough d. stage 3; may have a pink or red wound bed

a

a nurse is caring for a client who has a halo fixator device with a vest for a complete cervical spinal cord injury. which assessment finding will the nurse report to the primary HCP? a. purulent drainage from pin sites on the client's forehead b. painful pressure injury under the collar c. inability to move legs & feet d. oxygen saturation of 95% on room air

a

after teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? a. "i'll use my incentive spirometer every two hours while i'm awake" b. "i'll drink thinned fluids to prevent choking" c. "i'll take cough medicine to prevent excessive coughing" d. "i'll position myself on my right side so i don't aspirate"

a

during a client's neurologic assessment, the nurse finds the client is arousable only with vigorous and painful stimulation. how does the nurse document this patient's level of consciousness? a. stuporous b. lethargic c. comatose d. alert

a

the nurse is caring for a client treated with alteplase following a stroke. which assessment finding is the highest priority for the nurse to report to the primary HCP? a. client has a new onset of mild headache b. client's blood pressure is 194/120mm Hg c. client has left hemiparesis d. client continues to be drowsy

a

the nurse is preparing to measure the depth of a client's tunneled wound. which of the following implements should the nurse use to measure the depth accurately? a. a sterile, flexible applicator moistened with saline b. a sterile tongue blade lubricated with water soluble gel c. an otic curette d. a small plastic ruler

a

the nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. which statement by the daughter indicates that the client likely had an embolic stroke? a. client has a long history of atrial fibrillation b. client's symptoms occurred slowly over several hours c. client becomes increasingly lethargic and drowsy d. client reported severe headache before other symptoms

a

the nurse is teaching the daughter of a client who has middle-stage alzheimer's disease. the daughter asks "will the sertraline my mother is taking improve her dementia?" how would the nurse respond about the purpose of the drug? a. "it will not improve her dementia, but can help control emotional responses" b. "it is used to improve short-term memory but will not improve problem solving" c. "it is used to halt the advancement of alzheimer's disease, but will not cure it" d. "it will allow your mother to live independently for several more years"

a

the primary HCP prescribes donepezil for a client diagnosed with early-stage alzheimer's disease. what teaching about this drug will the nurse provide for the client's family caregiver? a. "report any client dizziness or falls because the drug can cause bradycardia" b. "donepezil will prevent the client's dementia from progressing as usual" c. "observe the client for nausea and vomiting to determine drug tolerance" d. "monitor the client's temperature, because the drug can cause a low grade fever"

a

which of the following are advantages of negative pressure wound therapy? a. increase cell growth, removal of drainage, protection for bacteria b. more frequent dressing changes and less expensive c. dries out the wound bed and allows airflow d. negative pressure restricts blood flow and prevents wound drainage

a

which of the following types of wound drainage should alert the nurse to the possibility of infection? a. foul-smelling drainage that is grayish in color b. drainage that appears to be mostly fresh blood c. large amounts of drainage that is clear and watery d. copious wound drainage that is blood-tinged

a

which statement by a client who had a transient ischemic attack (TIA) and is at risk for stroke indicates a need for further teaching? a. "i'm glad i can keep eating protein like red meat" b. "i'll try to walk at least 20-30 minutes a day" c. "i'm going to talk to my doctor about a weight loss plan" d. "i plan to include more fruits and vegetables in my diet"

a

you're educating a group of nursing students about the different stages of a pressure injury. which statement is correct about a stage 3 pressure injury? a. the skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue b. a hallmark of a stage 3 pressure injury is that the skin will be intact but not blanch c. the wound edges will never roll away (epibole) as with a stage 2 pressure injury d. there is full loss of skin tisue that can extend to the muscle, bone, or tendon

a

the nurse performs an initial neurologic assessment to an older client. which assessment findings would the nurse expect to be the result of normal physiological aging? SATA a. decreased coordination b. hearing loss c. long-term memory loss d. recent memory loss e. decreased balance control

a, b, d, e

the nurse is caring for a patient diagnosed with epidural hematoma. which nursing intervention should the nurse implement? SATA a. ensure that the pulse oximeter reading is higher than 93% b. administer mild sedative c. maintain the head of the bed at 60 degrees d. perform deep nasal suction every two hours e. administer stool softeners daily

a, b, e

the nurse is preparing to teach a client who has been prescribed a levodopa-carbodopa preparation for parkinson's disease. what health teaching will the nurse include for the client and family teaching? SATA a. "move slowly when changing positions from sitting to standing" b. "take your medications after meals to help prevent nausea" c. "report any hallucinations the client might have" d. "note any changes in mental or emotional status" e. "pay attention to whether your tremors improve or worsen"

a, c, d, e

when preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? SATA a. nits can be removed with a fine-tooth comb b. parasites eventually die off without treatment c. wash bed linens in hot water to remove lice and eggs d. lice can live on clothing items and any surface with fabric e. lice can infest any place on the body with hair, including eyelashes and axillae

a, c, d, e

a nurse teaches the spouse of a client who has alzheimer's disease. which statements should the nurse include in this teaching related to caregiver stress reduction? SATA a. "establish advanced directives early" b. "use discipline to correct inappropriate behaviors" c. "set aside time each day to be away from the client" d. "trust that family and friends will help" e. "seek respite care periodically for longer periods of time"

a, c, e

the nurse assesses a client who has parkinson's disease. which signs and symptoms would the nurse recognize as a key feature of this disease? SATA a. muscle rigidity b. long, extended steps c. tachycardia d. slow movements e. postural instability

a, d, e

the nurse assesses a client with a diagnosis of early-stage alzherimer's disease. which assessment findings would the nurse expect for this client? SATA a. forgetfulness b. hallucinations c. wandering d. urinary incontinence e. personality changes

a, f

a client returns from the post anesthesia care unit (PACU) after a surgical removal of a frontal lobe tumor. in what position will the nurse place the patient at this time? a. turn the patient from side to side to prevent aspiration b. elevate the head of the bed to at least 30 degrees at all times c. keep the patient flat in bed or up 10 degrees, and reposition from side to side d. keep the patient in a high-fowler position in bed at all times

b

the resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steri strips. which signs or symptoms would warrant transferring the resident to the emergency department? a. 4 cm area of bright red drainage on the dressing b. pupils that are equal, react to light, and accommodate c. a weak pulse, shallow respirations, and cool pale skin d. complaints of a headache that's resolved with medication

c

you're working on a medical surgical floor. select the following patients that are at risk for a pressure injury. SATA a. a 55 y/o female who has controlled type 2 diabetes mellitus and is ambulating three times a day b. a college soccer player with a rotator cuff injury awaiting surgery c. a 35 y/o male with a BMI of 13.6 that is incontinent of stool and has a right leg splint d. a 19 y/o female who is quadriplegic e. an older patient with a very large abdominal incision who needs help with repositioning f. a 45 y/o with a braden scale score of 7

c, d, e, f

a nurse plans care for a client who is immobile. which interventions would the nurse include in this client's plan of care to prevent pressure sores? SATA a. limit fluids and proteins in the diet b. reposition the client who is in a chair every two hours c. use a lift sheet to help with repositioning d. keep the client's heels off bed surfaces e. use a rubber ring to decrease sacral pressure when up in the chair f. elevate the head of the bed to 45 degrees g. place a small pillow between bony surfaces

c, d, g

biphosphonates

ca2+, may prevent osteoporosis

a 23 y/o client has been hit on the head with a baseball bat. the nurse notes clear fluid draining from his ears and nose. which of the following nursing interventions should be done first? a. insert nasal and ear packing with sterile gauze b. position the client flat in bed c. suction the nose to maintain airway patency d. check the fluid for dextrose with a dipstick

d

a client diagnosed with parkinson's disease will be starting ropinirole for symptom control. which statement by the client indicates a need for further teaching? a. "i should take the drug at the same time each day for the best effects" b. "this drug should help decrease my tremors and help me move better" c. "i need to change positions slowly to prevent dizziness or falls" d. "i know the drug will probably (make) help me prevent constipation"

d

the nurse assesses clear fluid coming from the nose and ears of a patient admitted to the emergency department after a fall. the fluid is found to be cerebral spinal fluid. based on this information, the nurse plans care for a client with which type of fracture? a. depressed b. linear c. open d. basilar

d

the nurse is teaching a client about what to expect immediately after a cerebral angiography exam. which statement by the client indicates a need for further teaching? a. "i'll have a pressure dressing on my groin for a couple hours" b. "i'll have to keep my leg straight for a while after the procedure" c. "the nurses will check circulation in my injected leg frequently" d. "i can use heat on my groin to decrease any discomfort"

d

the paraplegic patient is being admitted to a medical unit from home with a stage 4 pressure injury over the right ischium. which assessment tool should be completed on admission to the hospital? a. monitor the patient with the glasgow coma scale b. functional independent measure (FIM) c. initiate a brudzinski flow sheet d. braden scale

d

when teaching a community group about burn prevention, which education will the nurse include? a. "have a smoke detector in one central spot in the home" b. "if you use home o2, turn it down when you're smoking" c. "set your water heater temperature below 160F/71C" d. "plan several ways of escape from your home in case the primary exits are blocked"

d

a nurse plans care for a client with a halo fixator. which interventions would the nurse include in this client's plan of care? SATA a. loosen the pins when sleeping b. remove the vest for client bathing c. decrease the patient's oral fluid intake d. assess the pin sites for signs of infection e. assess the chest and back for skin breakdown

d, e

friction versus shear

friction; surfaces rub the skin and irritate and tear the fragile epithelial tissue. this occurs when the patient is dragged or pulled across the bed linens. shear; the skin itself is stationary, but the tissues below shift or move. this occurs when the patient slides down in bed. the outer layer of skin remains immobile because it remains attached to the sheets due to friction. it stretches the skin.