Exam 1

______ is a CNS depressant. It acts on neurotransmitters in the brain and decreases neuronal excitability. It creates an addictive effect with GABA.

alcohol

How do you assess a client's remote memory?

ask the client to state a fact from their past that is verifiable (their birth date or their mother's maiden name)

A ______ ______ injury is suspected when intact skin has a localized purple discoloration and does not blanch when pressed. A thin blister or eschar can develop very quickly.

deep tissue

______ is a disorder characterized by sad or despondent mood or loss of interest in usual activities

depression

______ is the area of loss of the superficial layers of the skin, also known as the denuded area.

excoriation

Justice

fair and equal treatment for all

What are the effects alcohol has on the respiratory system?

increased risk for pneumonia, bronchitis, tuberculosis

Cravings may be heightened by ______ when abusing substances. This is a result of long-term changes in brain neurotransmission that occur after repeated detoxifications

kindling

______ drainage involves more than 75% of the dressing and may completely saturate the dressing prior to scheduled changes

large

What are the common symptoms of a girl with ADHD?

less aggression and impulsiveness but more anxiety, mood swings, social withdrawal, rejection, cognitive and language problems

The ______ metabolizes 95% of ingested alcohol. a. small intestine b. kidney c. liver d. stomach

liver

assault

making a threat to a client's person

Where is alcohol absorbed?

mouth, stomach, digestive tract

______ agonists attach to CNS receptors altering perception of and response to pain.

opioid

______ ______ disease is a disorder in which arteriosclerosis and atherosclerosis affect circulation to peripheral tissues particularly the lower extremities.

peripheral vascular disease

A ______ injury is an ischemic lesion of the skin and underlying tissue caused by external pressure that impairs the flow of blood and lymph.

pressure

Arterial or Venous Ulcer? Skin temp: normal

venous

The nurse is teaching a patient with atherosclerosis about their condition. Which patient statement indicates the teaching was successful? a. "I have plaque building up in my coronary arteries, which is restricting the blood flow to my heart." b. "Plaque is building up in my pulmonary artery, which is restricting blood flow to my heart." c. "Plaque is building up in my heart vessel valves, which is restricting the blood flow to my heart." d. "There is plaque building up in my femoral artery, which is restricting the blood flow to my heart."

"I have plaque building up in my coronary arteries, which is restricting the blood flow to my heart."

A patient diagnosed with peripheral vascular disease (PVD) asks the nurse, "What activities should I avoid doing with my legs and feet?" Which statement by the nurse is most helpful for this patient? a. "Take hot showers each morning to promote circulation." b. "You should only swim in cool water." c. "Wear knee-high stockings on each foot." d. "You should avoid sitting with your legs crossed."

"You should avoid sitting with your legs crossed."

What are examples of goals a patient will have in regards to alcohol abuse?

-Admit alcohol controlling his or her life -Agree to enter an alcohol treatment facility or outpatient program -Experience no (further) complications as a result of alcohol abuse or alcohol withdrawal -Obtain optimal nutritional status -Remain sober -Participate in a support group after discharge

In the planning phase, what are examples of short-term goals for a person suffering from substance abuse?

-Admit having substance abuse problem and having lost control of life as a result -Seek help to stop using substance -Experience no complications of drug withdrawal -Enter a drug rehabilitation program to change behavior

What are examples of short term goals for a patient with a substance abuse problem?

-Admit having substance abuse problem and having lost control of life as a result -Seek help to stop using substance -Experience no complications of drug withdrawal -Enter a drug rehabilitation program to change behavior

What are common manifestations of abrupt alcohol withdrawal?

-Anxiety -Tachycardia -Hypertension -Diaphoresis -Nausea, vomiting -Tremors -Sleeplessness -Irritability

How can a nurse promote safety for a client receiving treatment for a substance abuse problem?

-Assess level of disorientation -Consider higher level of care if patient cannot withdraw safely in home or community setting -Obtain drug history and urine, blood samples -Place patient in quiet, private room -Frequently orient patient to reality, environment -Ensure that patient has no access to potentially harmful objects -Monitor vital signs every 15 minutes until stable

How can a nurse promote patient safety in an outpatient or home setting?

-Assess patient's orientation, cognition -Have patient or others in setting monitor vital signs using reliable home equipment: signs frequently during first day of detox, several times/day after that -Teach patient/others signs and symptoms of severe withdrawal -Administer or teach patient/others to administer scheduled medications -Monitor for signs of alcohol intoxication -Suggest patient remain in quiet room to decrease excessive stimuli -Determine specific risks to patient safety Make sure patient is oriented to reality, environment

What diagnostics tests are used to diagnose secondary hypertension and would be ordered after the cholesterol panel?

-CT scan -renal function tests -intravenous pyelogram

What are examples of therapies for a patient who has a substance abuse problem?

-Detoxification -Aversion therapy -Group, individual, family counseling -Psychotropic medication -Cognitive-behavioral therapy -Self-help groups

What are expected outcomes for a patient suffering from substance abuse?

-Experiences no complications from withdrawal -Admits problem with substance abuse and seeks help -Enters substance abuse program -Can describe choices that contributed to substance abuse -Attends daily support group meetings -Remains substance free for appropriate period of time

What are expected outcomes of a patient with a substance abuse problem?

-Experiences no complications from withdrawal -Admits problem with substance abuse and seeks help -Enters substance abuse program -Can describe choices that contributed to substance abuse -Attends daily support group meetings -Remains substance free for appropriate period of time

In the planning phase, what are examples of long-term goals for a person suffering from substance abuse?

-Explore impact of addiction on family, job, friends -Describe, recognize use of denial -Change thinking, behavior -Regularly attend support group -Remain free of substance and maintain sobriety

What factors related to PVD would increase the risk for infection in wounds to the lower extremities?

-Impaired arterial circulation impairs body's ability to provide sufficient oxygen and nutrients to the cells in the lower extremities and the ability to remove metabolic waste products diminishes -Congested venous circulation also prevents the blood from mounting effective inflammatory and immune responses, significantly increasing the risk for infection in the ulcerated tissue

A female client is undergoing diagnostic testing for coronary heart disease. The nurse should assess for which symptoms that are indicative of heart​ disease? (Select all that​ apply.) A. Headache B. Indigestion C. Chronic fatigue D. Abdominal fullness E. Insomnia

-Indigestion -Chronic fatigue -Abdominal fullness

A client who exercises for 30 minutes every day and maintains a normal body weight develops primary hypertension. The client asks how this could have happened. Which finding in the​ client's health history should the nurse include in the response to the​ client? (Select all that​ apply.) A. Insulin resistance B. Working as an air traffic controller C. High magnesium intake D. ​Age: 62 years E. Family history of hypertension

-Insulin resistance -Working as an air traffic controller (stress) -Age: 62 years -Family history of hypertension

Manifestations of peripheral atherosclerosis include:

-Intermittent claudication -Rest pain -Paresthesia -Diminished or absent peripheral pulses -Pallor with extremity elevation (redness of skin or rubor when dependent) -Thin, hairless skin -Thickened toenails -Areas of discoloration or skin breakdown -May also induce rupture of abdominal aortic aneurysms and possible infection and sepsis

Manifestations of CVI include:

-Lower extremity edema that worsens with standing -Itching, dull leg discomfort or pain that increases with standing -Thin, shiny, atrophic skin -Cyanosis and brown skin pigmentation of lower leg and foot -Possible weeping dermatitis -Thick, fibrous (hard) subcutaneous tissue -Recurrent ulcerations of medial or anterior ankle -Necrosis and fibrosis of subcutaneous tissue cause the affected area of the leg to feel hard and somewhat leathery -Even the slightest trauma to the area can produce serious tissue breakdown

A client newly diagnosed with heart failure is prescribed​ digitalis, a positive inotropic drug. Which sign and symptom would the nurse instruct the client to report to the healthcare​ provider? (Select all that​ apply.) A. Nausea B. Weight loss C. Confusion D. Weight gain E. Vision changes

-Nausea -Weight loss -Confusion -Vision Changes

What are red flags that require immediate attention in a child suspected of having ASD?

-No babbling or communication gestures by 12 months -No single word by 16 months -No spontaneous two words by 24 months -Loss of language or social skills previously achieve

How can a nurse promote patient safety during withdrawal of a patient with a substance abuse problem?

-Observe for withdrawal symptoms, monitor vital signs -Provide adequate nutrition, hydration -Assess level of consciousness (LOC) frequently -Orient, reassure patient safety in presence of hallucinations -Explain all interventions before approaching patient -Administer medications per schedule -Provide positive reinforcement of appropriate thinking, behavior or recognition that delusions are not based in reality -Use simple step-by-step instructions, face-to-face interaction -Express reasonable doubt if patient relays suspicious or paranoid beliefs -Do not argue with patient experiencing hallucinations, delusions -Talk to patient about real events, real people -Respond to patient's feelings, reassure patient about safety from harm

How can a nurse promote patient safety during acute withdrawal?

-Observe patient for withdrawal symptoms -Assess BAL routinely and look for escalating signs of withdrawal -Administer scheduled medications according to protocol -Assess patient's level of orientation frequently -Explain all interventions before approaching patient -Provide positive reinforcement when patient's thinking, behavior are appropriate -Express reasonable doubt if patient relates suspicious or paranoid beliefs, reinforcing accurate perception of people, situations -Do not argue with patient experiencing delusions or hallucinations -Talk to patient about real events, real people Reassure patient about being safe from harm

What are expected outcomes for a patient receiving treatment for alcohol abuse?

-Patient undergoes withdrawal without physiologic complications -Patient controls anxiety to extent of refraining from drinking when anxiety rises -Patient displays new coping mechanisms -Patient does not start using alcohol again -Patient experiences no new complications as result of sobriety -Patient accepts responsibility of how behavior affects family unit

An interprofessional team for a patient receiving treatment for alcohol abuse would consist of:

-Physicians -Psychologists -Counselors -Nutritionists -Assistive personnel

A client has been diagnosed with secondary hypertension. Which condition should the nurse expect to find in the​ client's medical​ history? (Select all that​ apply.) A. Pregnancy B. Kidney disease C. Asthma D. Diabetes E. Lupus

-Pregnancy -Kidney disease -Diabetes

What are the 2 goals of the health promotion efforts in regards to substance abuse?

-Preventing drug use among children, adolescents -Reducing risks among adults

When dehiscence or evisceration occurs, the nurse should:

-Quickly support the wound with a large sterile dressing soaked in sterile normal saline -Place the patient in bed with knees bent to decrease pull on the incision -Notify the surgeon

How can a nurse promote healthy self-esteem with a patient undergoing alcohol abuse treatment?

-Spend time with patient, convey attitude of acceptance -Encourage patient to accept responsibility for own behaviors, feelings -Encourage patient to focus on strengths and accomplishments, not weaknesses and failures -Encourage participation in therapeutic group activities -Teach assertiveness techniques and effective communication techniques

The nurse is creating a plan of care for a client with hypertension. Which instruction should the nurse​ include? (Select all that​ apply.) A. Following a​ low-fat, no-sodium diet B. Using alcohol in moderation C. Ensuring that the diet includes at least 2 servings of milk products daily D. Beginning aerobic exercises E. Reducing smoking

-Using alcohol in moderation -Ensuring that the diet includes at least 2 servings of milk products daily -Beginning aerobic exercises

To treat a client with a suspected deep tissue​ injury, the nurse should apply:

-a moisturizing barrier​ cream -a nonadhesive protective​ dressing -consider support surfaces that will remove all pressure from the area

What are the most important lab values of a client with ADHD?

-abnormal patterns in two settings needed for diagnosis (home, school, or daycare) -screening test

Goals for clients with a healing wound center around:

-adequate​ nutrition -hydration -infection​ prevention -promotion of optimal wound healing

What are psychobiological interventions?

-administering prescribed medications -providing teaching to the client/family about medications -monitoring for adverse effects and effectiveness of pharmacological therapy

What are physiologic effects of chronic long-term use of marijuana?

-airway constriction, inflammation -increased incidence of acute, chronic bronchitis -decreased spermatogenesis and testosterone levels in men -suppresses follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin in women, which interferes with breastfeeding

What are the effects alcohol has on the liver?

-alcoholic hepatitis -cirrhosis -cancer -hepatomegaly -fatty liver

The client who experiences an infection in a wound would receive​:

-antibiotics -debridement -dressing changes

A complication of left heart failure is cardiogenic pulmonary edema. Signs and symptoms include:​ anxiety, orthopnea,​ pink, frothy​ sputum, dyspnea,​ hoarseness, and cough

-anxiety -orthopnea -pink -frothy​ sputum -dyspnea -hoarseness -cough

What patient teaching will you provide the patient with PVD to reduce the risk of infection?

-apply lotion to dry areas -proper wound care -keeping the wound covered -use a bed cradle -keep wound covered

It is important for a nurse to identify illnesses that may trigger depression in their clients. What are examples of these illnesses?

-autoimmune -oncologic -metabolic -endocrine

What are 3 examples of a nonpharmacologic therapy used to help heal a large surgical wound?

-biosurgery -specialty bandages -hyperbaric oxygen therapy

Alcohol consumed in excess can lead to what?

-craving alcohol -diminished ability to function -life-threatening conditions

The first phase of heroin withdrawal usually lasts 10 days. What are common side effects in this phase?

-cravings -lacrimation (the flow of tears) -rhinorrhea (runny nose) -yawning -diaphoresis (sweating)

A nurse caring for a patient with depression should focus on safety ad meeting functional needs until the condition improves. What are 3 examples of these functional needs?

-daily hygiene -sleep -nutrition

Alcohol used in moderation can have positive effects. What are 2?

-decrease coronary artery disease -protects against stroke

What are 3 common problems related to ADHD?

-decreased attention span -impulsiveness -increased motor activity

What are common medications used to treat alcohol withdrawal?

-diazepam -carbamazepine -clonidine -chlordiazepoxide -phenobarbital -naltrexone

What are common symptoms of ADHD?

-difficulty completing tasks -constant fidgeting -frequently loud and interrupts -sleep disturbances -difficulty with social relationships in school, with parents, and siblings

What are common medications used to treat help with alcohol abstinence?

-disulfiram -naltrexone -acamprosate

What are protective factors of depression?

-eat healthy -regular exercise -avoid smoking -adequate sleep -stress management

Symptoms of chronic venous insufficiency include:

-edema of the lower extremities -hyperpigmentation

Nursing interventions for PVD include:

-elevate the legs when resting or​ asleep -avoid crossing the legs or putting pressure on the back of the​ knees -put on hose after the legs have been elevated

What are the symptoms of primary hypertension?

-elevated BP -headache -nocturia -visual disturbances

What are the stereotypical manifestations of someone with ASD that are indicative of rigid and obsessive behavior?

-head banging -twirling in circles -biting self -flapping hands or arms -may be self-stimulating or self-destructive

What are the two major processes that occur during the inflammatory phase of wound healing?

-hemostasis -phagocytosis

What are 3 common problematic physiologic effects of opiate use?

-hyperalgesia (increased sensitivity to pain) -hypogonadism (testosterone deficiency) -sexual dysfunction

Risk factors for pressure injuries include:

-immobility and inactivity -inadequate nutrition -fecal and urinary incontinence -decreased mental status -diminished sensation -advanced age -excessive body heat -diabetes -cardiovascular disease

What are two short term physiologic effects of marijuana use?

-increase in heart rate -bronchodilation

Risk factors associated with PVD and CVI include:

-increased cholesterol​ levels -excess body weight or​ obesity, and -physical inactivity -Clients age 50 and older

What are the phases of wound healing?

-inflammatory -proliferative -maturation or remodeling

The second phase of heroin withdrawal usually lasts months. What are common side effects in this phase?

-insomnia -irritability -fatigue -GI hyperactivity -premature ejaculation

What are conditions with high co-occurence with ASD?

-intellectual differences -mood or other mental health disorders -seizures -immune dysfunctions -GI issues

What are characteristics of a nurse-client relationship?

-it is goal directed -behavioral change is encouraged -a termination date is established

Why are mental health and development disorders in children and adolescents difficult to diagnose?

-lack of the ability or necessary skills to describe what is happening -a wide variation of "normal" behavior, especially in different developmental stages

What is the temporal lobe responsible for?

-language -sensory input

Why is an older adult client at risk for developing a pressure injury?

-loss of lean body mass -epidermal thinning -decreased skin elasticity -increased skin dryness

Manifestations of CVI include:

-lower extremity edema that worsens with​ standing -itching, dull leg discomfort or pain that increases with​ standing -thin,​ shiny, atrophic​ skin -cyanosis and brown skin pigmentation of lower leg and​ foot -possible weeping​ dermatitis -thick, fibrous​ (hard) subcutaneous​ tissue -recurrent ulcerations of medial or anterior ankles

Chronic alcohol use can damage other systems. What are the other complications?

-myocardial disease -erosive gastritis -acute and chronic pancreatitis -sexual dysfunction -increased risk of breast cancer

What are key assessments when taking care of a patient with substance abuse problems?

-observation and patient interview -•history of past substance use •medical and psychiatric history •psychosocial issues

What does the mini-mental state examination assess?

-orientation to time and place -attention span and ability to calculate by counting backward by 7 -registration and recalling of objects -language, including naming of objects, following commands, and ability to write

What are protective factors of ASD?

-prenatal care (folic acid and good health) -genetic counseling if familial tendency

What are the most important lab values of a client with ASD?

-presence of specific criteria in DSM-5 -screening test

Preventing a pressure injury involves:

-providing adequate nutrition -maintaining skin hygiene -avoiding skin trauma -providing support devices -providing mechanical devices for reducing pressure on body parts

Manifestations of a skin infection include:

-restlessness -purulent drainage -sweating and chills -foul smelling wound bed

What are severe manifestations of alcohol withdrawal?

-seizures -convulsions -delirium tremens

What are the effects alcohol has on the CNS system?

-seizures -neuropathies -sleep disturbances -alcoholic dementia

What are the risk factors of peripheral vascular disease?

-smoking -hypertension -High cholesterol -Diabetes -Family history of vascular disease -Obesity -Physical inactivity -Patients over the age of 50 -Occupations that require prolonged standing/sitting

What is the frontal lobe responsible for?

-social behaviors -motor function -problem solving -other higher functions

What are the 3 core characteristics of ASD?

-social deficits -language impairment -repetitive behaviors

What are common developmental abnormalities that indicate ASD in a child before the age of 3?

-social interaction -language used in social interactions -imaginative play

Clinical manifestations of a myocardial infarction ​ (MI) include:​ tachypnea, anxiety,​ vomiting, and electrocardiogram​ (ECG) changes in the Q wave.

-tachypnea -anxiety -vomiting -electrocardiogram​ (ECG) changes in the Q wave -ST segment​ elevation

Independent nursing interventions for the client with an alteration in tissue integrity include:

-teaching the signs of wound​ infection -reviewing the process to discard soiled​ dressings -instructing on cleaning and dressing the foot wound

In reevaluating a plan of care for a patient receiving treatment for alcohol abuse, a nurse should consider:

-the patient's physiologic and mental health -coping responses -legal and occupational involvement -housing -peers social and spiritual support.

Wernicke Korsakoff syndrome is a combination of Wernicke's encephalopathy which consists of:

-the triad of ophthalmoplegia -ataxia -confusion

There is an increased occurrence of ASD in children with genetic abnormalities. What are some examples of them?

-tuberous sclerosis -fragile X syndrome -down syndrome -congenital rubella syndrome -neurofibromatosis

What are common medications given to treat nicotine abstinence?

-varenicline -rimonabant

A stage __ pressure injury has intact skin with localized redness that does not blanch when pressed.

1

Stage __ (mild) heart failure is when the client has no limitations of physical activity and no shortness of breath with normal physical activity. a. 1 b. 2 c. 3 d. 4

1

The first noticed symptom of ASD is delayed speech. Absence of babbling or other communication by __ year(s) of age is a red flag.

1

In Stage __​ (moderate), a client has increased physical limitations with less than normal physical activity resulting in​ fatigue, shortness of​ breath, or​ palpitations; the client is comfortable at rest. a. 1 b. 2 c. 3 d. 4

3

The inflammatory phase of wound healing is initiated immediately after injury and lasts for how many days?

3-6 days

The albumin level determines nutritional​ status; a value below __ g/dL indicates poor nutrition.

3.5

For a patient who is bedridden, shearing force can be reduced by elevation of the head of the bed to no more than __ degrees. Patients with respiratory disorders may find it easier to breathe in Fowler position.

30

Stage __​ (severe) is the most debilitating and the client experiences symptoms of cardiac insufficiency at rest. a. 1 b. 2 c. 3 d. 4

4

A client with stage __ (mild) heart failure has some physical limitations due to​ fatigue, shortness of​ breath, or​ palpitations; the client is comfortable at rest. a. 1 b. 2 c. 3 d. 4

2

A stage __ pressure injury has a shallow open wound or blister without sloughing.

2

The first noticed symptom of ASD is delayed speech. Absence of two-word phrases by __ year(s) of age is a red flag.

2

A client who has heart failure should not consume more than​ ______ mg of sodium per day.

2,000

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? a. A client who has schizophrenia with delusions of grandeur. b. A client who has manifestations of depression and attempted suicide a year ago. c. A client who has borderline personality disorder and assaulted a homeless man with a metal rod. d. A client who has bipolar disorder and paces quickly around the room while talking to themselves.

A client who has borderline personality disorder and assaulted a homeless man with a metal rod. (A client who is a danger to himself or others is a candidate for a temporary emergency admission)

What assessment findings would cause you to believe a pressure injury is infected?

A pressure injury would appear infected if it were warm, red, odorous, swollen, or draining. The patient may have fever, chills, or an increased white blood cell count. There may be pain at the wound site.

An EF of less than​ __% is a maternal risk factor for major cardiac complications.

40

What is the relapse rate for substance abuse?

40-60%

Up until age __, men have a greater risk for hypertension than do women.

45

Heavy alcohol use is drinking ≥ __ drinks in one session on ≥ 5 days in past 30 days.

5

Between ages 45 and __, men and women have an equal risk for hypertension.

64

At age __ and older, women have a greater risk for hypertension than do men.

65

In the absence of hypoxemia, as indicated by a partial pressure of oxygen in arterial blood (PaO2) of __ to __ mm Hg, oxygen therapy is unlikely to help relieve dyspnea.

83-100

Normal SaO2

95-100%

Difficulty completing tasks that require focused attention, hyperactivity, hyperkinesis, and impulsivity are all characteristics of what disorder?

ADHD

Familial tendency, family stress, poverty, and poor nutrition may be contributing factors of ______.

ADHD

The pathophysiology of ______ is still unclear. However, studies suggest it may involve a deficit in dopamine and norepinephrine. A manifestation of the disorder is a delay in brain maturation in the area of self-regulation.

ADHD

While there is no way to prevent ______, it is recommended that women avoid smoking, drugs, and alcohol during pregnancy. Prenatal care strongly advised.

ADHD

______ is a disorder characterized by difficulty completing tasks that require focused attention, hyperactivity, hyperkinesis, and impulsivity.

ADHD

Imbalances in neurotransmitters contribute to the development of mental disorders. Norepinephrine imbalance is implicated in which of the following disorders?

ADHD, MDD, hypotension

An ABI (ankle-brachial blood pressure index) tests for peripheral vascular disease that may predict ______.

CAD (coronary artery disease)

______ results when venous blood collects and stagnates in the lower leg.

CVI

A patient recently diagnosed with peripheral vascular disease states to the nurse, "My legs burn when I am relaxing on the couch. I can't seem to find a comfortable position." How should the nurse respond to the patient's concern? a. "The pain you're referring to is called intermittent claudication. Does it improve with movement?" b. "The pain you're referring to is called intermittent claudication. Is it usually worse with activity?" c. "The pain you're referring to is called rest pain. Does it improve if you elevate your legs above your heart?" d. "The pain you're referring to is called rest pain. Does it improve when you hang your legs off the couch?"

"The pain you're referring to is called rest pain. Does it improve when you hang your legs off the couch?"

In adults, known risk factors for ADHD include:

-Antisocial behavior -Substance abuse -Involvement in serious accidents -Academic underachievement -Low occupational success

The maturation or remodeling phase of wound healing begins about day 21 and can extend for how long after the injury?

1-2 years

The nurse is evaluating a patient with chronic peripheral venous disease (PVD) and claudication following a change in treatment plan. The patient reports that for the past several nights burning pain is waking them from sleep. How should the nurse interpret these findings? a. The claudication is resolving. b. The new treatment plan is effective. c. A new problem is developing that requires further evaluation. d. The disease is progressing and tissue perfusion is altered.

The disease is progressing and tissue perfusion is altered.

Depression manifestations mnemonic

SIG E CAPS S- Sleep disturbance (too much or insomnia) and sad mood I- Interests diminished in pleasurable activities G- Guilt feeling; feelings of worthlessness E- Energy decreased or fatigue and (self)-Esteem loss C- Concentration diminished and indecisiveness A- Appetite changes (decreased or increased) with weight changes P- Psychomotor retardation (slowing) or agitation S- Suicidal thoughts and behaviors and thoughts of death

You are caring for a child who was involved in a bicycle accident resulting in below-the-waist paraplegia. How will you teach the parents to reduce the risk of pressure injuries?

The parents will be taught to help the child change position often; to make sure the child sits with equal pressure, especially on bony areas; and to instruct the child to shift position often in the wheelchair.

The nurse is caring for a patient with chronic venous insufficiency (CVI) who has a past medical history of thrombophlebitis. The nurse should recognize that this patient was at a high risk for developing CVI for which reason? a. Thrombophlebitis may create a toxin that damages veins. b. Thrombophlebitis may damage valves of deep veins. c. Thrombophlebitis may alter coagulation that damages deep veins. d. Thrombophlebitis may increase nitric oxide concentration, which damages veins.

Thrombophlebitis (inflammation of the vein caused by a thrombus) may damage valves of deep veins.

What nursing interventions can be implemented to reduce the risk of infection of a pressure injury?

To reduce possibility of infection, the nurse will keep the wound clean, administer treatment as ordered for wound care, and position the patient off the wound.

The nurse is assessing a patient and suspects peripheral vascular disease (PVD). Which test should the nurse anticipate being ordered to confirm this diagnosis? a. Arterial blood gas (ABG) b. Lung scan c. Segmental pressure measurement d. Electrocardiogram (ECG)

Segmental pressure measurement

A client recently diagnosed with hypertension has a family history of hyperaldosteronism. Which diagnostic test should the nurse expect to be​ ordered? A. Creatinine clearance B. Serum creatinine C. Serum potassium D. Renal function panel

Serum potassium

The nurse is caring for a client with a history of atherosclerosis. The client has chest pain that occurs with physical exertion or stress and is relieved with sublingual nitroglycerin. Which disorder should the nurse recognize the client is most likely​ experiencing? A. Prinzmetal angina B. Myocardial infarction C. Acute coronary syndrome D. Stable angina

Stable angina (Stable angina is a predictable form of​ angina, which usually occurs when the work of the heart is increased by physical​ exertion, exposure to​ cold, or stress)

Compare the pain experienced during exercise by a patient with PVD to that of a patient with angina.

With angina, pain occurs with activity that creates a great demand for oxygenation of diseased myocardial tissue and ischemia occurs. When oxygen demands are reduced at rest, chest pain goes away. Intermittent claudication is the characteristic pain associated peripheral atherosclerosis, activity increases the oxygen demand to diseased peripheral tissues. When this demand is unmet, ischemia occurs and results in pain.

What are 3 screening tools for substance abuse?

-Brief Drug Abuse Screening Test (B-DAST) -Objective Opiate Withdrawal Scale (OOWS) -Subjective Opiate Withdrawal Scale (SOWS)

What are common therapies for a person suffering from substance abuse?

-Detoxification -Aversion therapy -Group, individual, family counseling -Psychotropic medication -Cognitive-behavioral therapy -Self-help groups

What are long term goals for a patient with a substance abuse problem?

-Explore impact of addiction on family, job, friends -Describe, recognize use of denial -Change thinking, behavior -Regularly attend support group -Remain free of substance and maintain sobriety

What are 3 screening tools for alcohol abuse?

-MAST -CAGE questionnaire -CIWA-Ar

What are the common brand names of opiates?

-Vicodin -Percocet -OxyContin -Opana

What are common medications used to treat nicotine withdrawal from tobacco use?

-bupropion -nicotine replacement therapy -varenicline

What are the signs and symptoms of an infection?

-change in wound color -pain -drainage -positive culture of wound -fever -elevated WBC

During the health history portion of the nursing assessment for the client with​ PVD, the nurse will assess:

-client history of coronary artery disease​ (CAD) -current medications and​ diet -any complaints of pain

What are the most important lab values of a client with depression?

-complete blood count (CBC) and basic metabolic panel (BMP) -thyroid panel (T3, T4, TSH) -urine/blood drug screen

What are the effects alcohol has on the reproductive system?

-erectile problems -deceased testosterone -decreased sex drive -menstrual irregularities

An​ 86-year-old man visits the clinic and asks about risk factors for heart disease. Which modifiable risk factors would the nurse discuss with this​ client? (Select all that​ apply.) A. Exercise B. Smoking C. Ethnicity D. Sex E. Nutrition

-exercise -smoking -nutrition

What is the pertinent lab work for pressure injuries?

-hemoglobin -protein (especially albumin) -lymphocyte count

What are common medications used to treat opioid withdrawal?

-methadone substitution -clonidine -buprenorphine -naltrexone -levo-alpha-acetylmethadol

What are common examples of opiates?

-morphine -meperidine -codeine -hydrocodone -oxymorphone -oxycodone

What are the labs used to rule out other causes of a child's behavior for a client suspected of having ASD?

-neuroimaging -lead screening -DNA analysis -electroencephalography

What are factors that heighten a patient's risk of wound dehiscence?

-obesity -poor nutrition -multiple trauma -failure of suturing -excessive coughing -vomiting -dehydration -comorbidities such as diabetes

What are 6 questions that elicit a pattern of substance use behavior?

-past alcohol, substance abuse, polysubstance abuse -when patient first used alcohol -medical history of blackouts, delirium, or seizures -history of withdrawal syndrome, overdoses, or complications from alcohol use -arrests for driving under the influence or criminal acts while using alcohol -family history

Signs of digitalis (a positive inotropic drug) toxicity include:

-poor​ appetite -anorexia -nausea and​ vomiting -headache -altered​ vision -confusion

What are the 3 major types of exudate?

-serous -purulent -sanguineous

What are typical speech pattern abnormalities of a person with ASD?

-using "you" in place of "I" -echolalia (repetition of another person's spoken word) -repeating questions instead of answering them -fascination with rhythmic or repetitive songs and verses

affect

a client's affect is an objective expression of mood (a flat affect or a lack of facial expression)

mood

a client's mood provides info about the emotion that the client is feeling

Hippocampus

a neural center located in the limbic system; helps process explicit memories for storage

malpractice

a type of professional negligence

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? Select all that apply. a. To assess cognitive ability, I should ask the client to count backward by sevens. b. To assess affect, I should observe the client's facial expression. c. To assess language ability, I should instruct the client to write a sentence. d. To assess the client's abstract thinking, I should ask the client to identify our most recent president's.

a, b, c

The nurse is performing an assessment on a​ 57-year-old client with newly diagnosed heart failure. The product of which factors determine a​ client's cardiac​ output? A. Stroke volume and urinary output B. Heart rate and urinary output C. Stroke volume and heart rate D. Heart rate and ejection fraction

Stroke volume and heart rate

Explain the relationship between physical exercise and pain in the patient with PVD.

Pain is the primary symptom of peripheral atherosclerosis. Intermittent claudication (a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity) is characteristic of PVD. The pain is often accompanied by weakness and is relieved by rest. Eventually rest pain may also occur during periods of inactivity. It is often described as a burning sensation in the lower legs. Rest pain increases when the legs are elevated and decreases when the legs are dependent (e.g., hanging over the side of the bed). The legs also may feel cold or numb along with the pain. Sensation is diminished, and the muscles may atrophy.

Which client reaction should the nurse expect during a coronary artery​ spasm? A. Gradual increase in systolic blood pressure B. Acute reduction in level of consciousness C. Sudden onset of acute chest pain D. Gradual increase in peripheral edema

Sudden onset of acute chest pain

Addiction mnemonic: dependence

TWO 6 PACK T - Tolerance W - Withdrawal O - Occupational, social, or recreational activities given up or reduced 6 -P - Persistent desire or unsuccessful efforts to cut down or control substance use A - Amount of use is excessive C - Continues substance use despite having persistent or recurrent physical or psychological problems K - Keeps spending a lot of time in search, use, or recovery from the substance.

The nurse is planning care for a patient with peripheral vascular disease (PVD) who is hospitalized due to increased pain associated with intermittent claudication. Which independent nursing intervention should the nurse implement? a. Assess patient pain every 12 hours using standard scale. b. Encourage the patient to walk the halls, regardless of pain. c. Teach the patient guided imagery. d. Administer pain medications as ordered.

Teach the patient guided imagery.

LOC: lethargic (somnolent)

The client is able to open their eyes and respond but is drowsy and falls asleep readily.

LOC: stuporous

The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. The client might not be able to respond verbally.

A client recently admitted to the coronary care unit​ (CCU) with left heart failure complains of sudden​ dyspnea, anxiety, and feelings of​ "drowning." What is the most likely cause of these​ changes? A. Hyperglycemia B. Pulmonary embolism C. Myocardial infarction D. Cardiogenic pulmonary edema

Cardiogenic pulmonary edema

ADHD (adults) manifestations mnemonic

DISTRACTED D - Distractibility I - Impulsivity S - School History R - Rating Scales A - Accidents C - Commitments T - Time Management E - Employment D - Decisions

Addiction mnemonic: abuse

DRiNK D- Dangerously driving a vehicle or machine when impaired by substances Ri- Role failure in home, school, or work because of recurrent substance use N- No respect for the law, leading to legal problems K- Keeps using a substance despite persistent or recurrent social or interpersonal problems

The nurse is teaching a group of adults about chronic venous insufficiency (CVI). Which should the nurse identify as the most common cause of CVI? a. Congestive heart failure (CHF) b. Deep vein thrombosis (DVT) c. Scleroderma d. Varicose veins

DVT

What is the most common cause of chronic venous insufficiency?

DVT

An​ OB/GYN nurse is counseling women with heart failure about pregnancy and risk factors. The nurse recommends that the women prevent pregnancy. Which is the most important risk factor that contributes to this​ recommendation? A. Cholesterol level of 220​ mg/dL B. Ejection fraction​ (EF) of​ 38% C. Blood pressure of​ 126/80 mmHg D. Previous miscarriages

Ejection fraction​ (EF) of​ 38%

The nurse is planning care for a patient with peripheral vascular disease (PVD) who is scheduled to have revascularization surgery to improve circulation to the lower extremities. Which independent nursing intervention should the nurse include in the plan of care to promote patient tissue perfusion? a. Encourage regular exercise. b. Elevate lower extremities above the heart. c. Warm lower extremities using heating pad. d. Administer medication as ordered.

Encourage regular exercise.

African Americans are more at risk for heart failure. What are the most important risk factors in this​ population? (Select all that​ apply.) A. Hypotension B. Low levels of HDL C. Obesity D. Renal insufficiency E. Hypertension

Hypertension, Renal​ insufficiency, Obesity, and Low levels of HDL​ (which increases risk of​ atherosclerosis)

A nurse is evaluating lab results on a​ 70-year-old client. The nurse notices an increased level of brain natriuretic peptide​ (BNP). What does this​ indicate? A. Reduced cardiac workload B. Increased left ventricular pressure C. Decreased gas exchange in lungs D. Decreased vascular congestion

Increased left ventricular pressure

While Wernicke encephalopathy is reversible, it is considered a medical emergency and must be treated immediately to prevent ______ syndrome, since that is not reversible.

Korsakoff

If Wernicke's encephalopathy is left untreated, it can progress to what?

Korsakoff syndrome

What does the cerebellum control?

balance and movement

A ______ ______ suspends bed linens over the legs, preventing them from placing pressure on extremities and injured tissues. Minimizing pressure on the tissues promotes capillary blood flow.

bed cradle

During the early stages of hypoxia, what clinical indicator is usually elevated?

blood pressure

What does the brain stem control?

breathing, heart rate, blood pressure (involuntary actions)

Breakdown of RBCs in the congested tissues causes ______ (brown/rubor) skin pigmentation in peripheral vascular disease.

brown

Substance ______ disorder is a cluster of cognitive, behavioral, physiologic symptoms that indicate continued use of a substance despite significant negative consequences. It may involve permanent brain changes.

abuse

Care of a client who has MDD in the ______ (acute/continuation/maintenance) phase will show severe clinical findings of depression. Treatment is generally 6 to 12 weeks in duration.

acute

People with an ______ can have a genetic predisposition. There is often a stigma with this disorder that makes them discriminated against.

addiction

Various factors have been linked to ______. Biological, genetic, psychologic, and sociocultural factors are the main considerations. Even the dopamine reward system is hypothesized.

addiction

______ is defined as a psychologic or physical need for a substance or process to the extent that the individual will risk negative consequences to meet the need.

addiction

Why are obese patients at increased risk of wound infection and slower healing?

adipose tissue usually has a minimal blood supply

Negative outcomes of ______ use in those under legal drinking age include an interference with normal brain development, increased risk of developing an alcohol use disorder, and an increased risk of sexual assaults.

alcohol

______ is a term describing successful closure of a wound with little or no tissue loss.

approximated

Absent​ pulses, cool skin on the feet and​ toes, and gangrene are signs of ______ (arterial/venous)​ problems.

arterial

Arterial or Venous Ulcer? Edema: absent or mild

arterial

Arterial or Venous Ulcer? Location: toes, feet, shin

arterial

Arterial or Venous Ulcer? Skin appearance: normal to atrophic, pallor on elevation, rubor on dependency

arterial

Arterial or Venous Ulcer? Skin temp: cool

arterial

Arterial or Venous Ulcer? Ulcer appearance: deep, pale

arterial

Arterial or Venous Ulcer? gangrene: may occur

arterial

Arterial or Venous Ulcer? pain: usually severe, intermittent claudication, rest pain

arterial

Arterial or Venous Ulcer? pulses: decreased or absent

arterial

Wounds on the​ toes, absence of hair on the​ legs, cool​ extremities, and thick toenails are all features of ______ (venous/arterial) problems.

arterial

Where does plaque tend to form in the arteries?

arterial bifurcations

______ is an arterial disorder characterized by thickening, loss of elasticity, and calcification of arterial walls.

arteriosclerosis

How do you assess a client's recent memory?

ask the client to recall recent events (visitors from the current day) or the purpose of the current mental health appointment or admission

How do you assess a client's immediate memory?

ask the client to repeat a series of numbers or a list of objects

PVD arises primarily from _____ and other disorders that impair cardiovascular function.

atherosclerosis

______ is a condition in which fatty deposits build up and block coronary arteries. These buildups are made of cholesterol, fatty substances, cellular waste products, calcium, and fibrin.

atherosclerosis

______ is a form of arteriosclerosis in which deposits of fat and fibrin obstruct and harden arteries.

atherosclerosis

______ disorder is characterized by impaired communication and social interaction patterns and repetitive, restrictive, and stereotyped behaviors.

autism spectrum disorder

______ is a disorder characterized by impaired communication and social interaction patterns, as well as, repetitive, restrictive, and stereotyped behaviors.

autism spectrum disorder

A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion. Select all that apply. a. The DSM-5 includes client education handouts for mental health disorders. b. The DSM-5 establishes diagnostic criteria for individual mental health disorders. c. The DSM-5 indicates recommended pharmacological treatment for mental health disorders d. The DSM-5 assists nurses in planning care for client's who have mental health disorders. e. The DSM-5 indicates expected assessment findings of mental health disorders.

b, d, e

Normal respiration rate

12-20 breaths per minute

Temporary emergency admission to mental health care is not to exceed __ days.

15

The proliferative phase of wound healing extends from day 3 or 4 to about day __ post injury.

21

Children as young as __ can be diagnosed with ADHD.

3

Rapid loss of blood and the onset of shock indicate ______ (internal/external) hemorrhage.

external

What are common abnormal responses to sensory stimuli that a person with ASD may experience?

extreme aversion to touch, loud noises, or bright lights

______ is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces

exudate

negligence

failing to provide adequate care in a personal or professional situation when one has an obligation to do so

T or F. ASD is more common in females.

false

A client in ______ position has pressure on the​ heels, pelvis,​ sacrum, and vertebrae.

fowler

______ supplements have been shown to slow the progression of PVD and a very low-fat or vegetarian diet, not a high-protein diet, decreases cholesterol and atherosclerosis.

garlic

Treatment of Wernicke's encephalopathy incolves the prompt administration of thiamine, followed by ______.

glucose

______ tissue forms in the proliferative phase of wound healing.

granulation

What does the medulla control?

heart rate and breathing

A ______ is a localized collection of blood underneath the skin that may appear as a bruise. It can place pressure on blood vessels and obstruct blood flow.

hematoma

______ level is used to measure oxygen delivery to the skin.

hemoglobin

______ is a term used to describe rapid or excessive bleeding.

hemorrhage

______ is the cessation of bleeding due to the formation of blood clots and a scab.

hemostasis

Severe liver damage from chronic alcohol use can progress from fatty liver to ______ or cirrhosis.

hepatitis

Alcohol disrupts activity in the ______, which is responsible for memory. Therefore, large amounts of alcohol consumed rapidly will cause blackouts. a. cerebellum b. hippocampus c. amygdala d. prefrontal cortex

hippocampus

veracity

honesty when dealing with a client

Women are often misdiagnosed throughout the lifespan because ADHD in women presents with inattentiveness, depression, and stress rather than ______.

hyperactivity

Salt substitutes should be avoided with potassium-sparing diuretics because they often contain potassium and can result in ______.

hyperkalemia

In the late stages of hypoxia, patients are likely to develop ______.

hypotension

Intermittent ______ is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity.

caludication

The​ Frank-Starling mechanism occurs as the result of​ the heart muscle being​ stretched; active tension is created by altering the overlap of thick and thin filaments. This increase in contractile force leads to increased _____ ______.

cardiac output

Statins such as atorvastatin​ (Lipitor) are used to decrease ______. Generalized muscular tenderness and pain is a concerning side effect.

cholesterol

Modeling, operant conditioning, and systematic desensitization are all examples of ______ and ______ therapies.

cognitive and behavioral

Why is a client with type I diabetes mellitus at risk for developing a pressure injury?

compromised oxygen delivery to the tissues

Korsakoff syndrome manifests as aphasia and ______, which is when a person creates stories to fill in the gaps in their memory which they believe to be true.

confabulation

false imprisonment

confining a client to a specific area physically, verbally, or using a chemical restraint when it is not part of the client's treatment

Care of a client who has MDD in the ______ (acute/continuation/maintenance) phase will show an increased ability to function. Treatment is generally 4 to 9 months.

continuation

______ occurs when a health care team members displaces characteristics of people in their past onto a client.

countertransference

Oxygen, especially when delivered long-term and/or without sufficient humidification, is extremely drying and can cause ______ in the nasal and oral mucosa.

cracks

What 4 things should a nurse emphasize when providing patient education to a patient receiving treatment for alcohol abuse?

importance of balanced diet, adequate sleep, healthy recreational activities, and caring support system

A patient is admitted with impaired tissue healing of the lower extremities due to peripheral vascular disease (PVD). The nurse applies a bed cradle. Which effect should the nurse expect from this intervention? a. Decreased shearing force b. Improved capillary blood flow c. Lowered risk of infection d. Diminished risk of deep vein thrombosis (DVT)

improved capillary blood flow

Why is a client with a history of anorexia nervosa at risk for developing a pressure injury?

inadequate nutrition, which leads to weight loss, muscle atrophy, and loss of subcutaneous tissue

Diuretics ______ (increase/decrease) urine output and ______ (increase/decrease) blood volume.

increase; decrease

What is the cause of swelling at the site of injury?

increased vascular permeability and leakage of fluid out of the vessel

Swelling, wound distention, sanguineous drainage, and hematoma indicate ______ (internal/external) hemorrhage.

internal

______ causes tissue necrosis and eventual ulceration.

ischemia

Abnormal amounts of collagen may appear resulting in a hypertrophic scar or ______.

keloid

A client in the ______ position has pressure on the knee and ilium.

lateral

______ are used to determine if an infection is present.

leukocytes

substance overdose

life threatening condition requiring emergency hospitalization

Alcohol interferes with the ability to form new ______-term (long/short) memories.

long

Men who drink ≤4 drinks on any one day and ≤14 drinks per week are considered ______ (low/high) risk for alcohol dependence.

low

Women who drink ≤3 drinks on any one day and ≤7 drinks per week are considered ______ (low/high) risk for alcohol dependence.

low

fidelity

loyalty and faithfulness to the client and to one's duty

______ is when tissues become softened by prolonged wetting or soaking.

maceration

Care of a client who has MDD in the ______ (acute/continuation/maintenance) will experience a remission of manifestations. This phase can last for years.

maintenance

______ is a synthetic opiate use to treat chronic pain and opiate addiction.

methadone

______ drainage covers less than 25% of the dressing.

minimal

______ anxiety decreases problem-solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious. a. mild b. moderater c. severe d. panic

moderate

______ drainage involves 25-75% of the dressing without leakage prior to scheduled dressing changes.

moderate

Weakness of the upper arms is an atypical symptom indicative of ______ ______ in women

myocardial infarction

A ______ ______ mask delivers oxygen concentrations of 24-40%.

nasal canula

decerebrate rigidity

neck and elbow extension, wrist and finger flexion

A ______ mask delivers oxygen concentrations of 60% to 80%.

nonrebreather

A ______ (neurotransmitter) deficiency affects attention and behavior.

norepinephrine

Administering oxygen therapy with a nonrebreather mask has which of the following advantages?

offers the highest oxygen concentration of the low-flow systems

Risk factors for CAD include non-modifiable factors such as:

older age (over age 45 years in men and over age 55 years in women), family history of early heart disease, and race

Increased heart rate is a manifestation of ______.

pain

The conditions that can cause secondary hypertension include:

pregnancy after 20 weeks of​ gestation, diabetes, and kidney disease

What are two types of abnormal posturing in a client who is comatose?

decorticate rigidity and decerebrate rigidity

Individuals with depression often have ______ (increased/decreased) gray matter volume and lower metabolic activity in the medial prefrontal cortex.

decreased

Individuals with depression often have ______ (increased/decreased) limbic system activity.

decreased

The serum potassium level will be ______ (increased/decreased) with hyperaldosteronism.

decreased

______ is an unintended separation of wound margins due to incomplete healing. It usually involves an abdominal wound in which the layers below the skin also separate.

dehiscence

Alcohol, sedatives, hypnotics, anxiolytics, and cannabis are all examples of CNS ______.(depressants/stimulants)

depressants

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? a. chlordiazepoxide b. bupropion c. disulfiram d. carbamazepine

disulfiram

The pathophysiology of ADHD is unclear, however, studies suggest it may result from a deficit in what two neurotransmitters?

dopamine and norepinephrine

A client with heart failure is prescribed an​ angiotensin-converting enzyme​ (ACE) inhibitor. What is the most important side effect that may interfere with​ compliance? A. Diarrhea B. Dry cough C. Rash D. Visual disturbances

dry cough

Rest pain increases when the legs are ______ (elevated/dependent) and decreases when the legs are ______ (elevated/dependent). The legs may also feel cold or numb along with the pain.

elevated, dependent

The description by the client that something​ "gave way" indicates a dehiscence with possible ______.

evisceration

______ is a protrusion of internal viscera through a surgical wound.

evisceration

The type of hypertension most often found in the older child and adolescent is ______ (primary/secondary) and is associated with family history, obesity, and diabetes.

primary

______ (primary/secondary/tertiary) intention healing is healing that occurs where the tissue surfaces have been closed and there is minimal or no tissue loss. It is characterized by the formation of minimal granulation tissue and scarring.

primary

A client in the ______ position has pressure on the zygomatic bone.

prone

______ exudate is a large quantity of cells and necrotic debris that form an opaque milky discharge that is thicker than serous exudate (aka pus or suppuration) a. serous b. purulent c. sanguineous d. serosanguineous

purulent

______ exudate is produced by pyogenic bacteria. It can be a tinge of blue, green, or yellow.

purulent

______ is the replacement or renewal of destroyed tissue cells by cells that are identical or similar in structure and function.

regeneration

Pain, in the form of intermittent claudication, is the primary symptom of PVD and is often relieved by ______.

rest

During the implementation phase of caring for a client suffering from substance abuse, a nurse should promote patient ______ and provide patient education.

safety

To increase the​ client's blood​ flow, one goal is to prevent the aggregation of platelets in the arteries. ______ ______​ (aspirin) is a pharmacologic measure to control the aggregation.

salicylic acid

______ exudate is a large amount of red blood cells that form a bright or dark red discharge indicating new or old damage to capillaries (aka hemorrhagic exudate) a. serous b. purulent c. sanguineous d. serosanguineous

sanguineous

Wound tissues that are moist, with no measurable exudate, are said to have ______ drainage

scant

______ (primary/secondary) hypertension is more often found in younger children and is associated with kidney, heart, or endocrine abnormalities.

secondary

______ (primary/secondary/tertiary) intention healing is healing that occurs when a wound's edges cannot or should not close. An example would be a pressure ulcer.

secondary

A client diagnosed with primary aldosteronism has​ polyuria, weakness,​ paresthesia, and an elevated blood pressure. Which condition should the nurse expect as the most likely cause for the elevated blood​ pressure? A. Hypertensive crisis B. Stroke C. Primary hypertension D. Secondary hypertension

secondary hypertension

______ exudate is a clear or blood-tinged discharge commonly seen in surgical incisions. a. serous b. purulent c. sanguineous d. serosanguineous

serosanguineous

A ______ (neurotransmitter) deficiency affects mood, sexual behavior, sleep cycles, hunger, and pain perception.

serotonin

______ exudate is a watery, clear or straw-colored discharge that accompanies mild inflammation a. serous b. purulent c. sanguineous d. serosanguineous

serous

A ______ mask delivers oxygen concentrations of 40-60%.

simple

Instructions on skin hygiene and the use of moisturizers are independent nursing interventions to promote ______ ______.

skin integrity

The highest modifiable risk factor for CAD is:

smoking

Many individuals work with a ______. They are a recovering alcoholic with several years of sobriety and provide peer support.

sponsor

The nurse reviews alginate dressings with a new nurse. For which type of pressure injury should the nurse identify this dressing is​ used? (Select all that​ apply.) A. Stage 4 without eschar B. Stage 4 with eschar C. Stage 1 D. Stage 2 E. Stage 3

stage 2, 3, and 4 without eschar

Cocaine, amphetamines, inhalants, hallucinogens, and caffeine are all examples of CNS ______. (depressants/stimulants)

stimulants

Medical history and ______ level are important assessment information.

stress

______ ______ is the amount of blood exerted from the left ventricle per beat and can be altered by factors of​ preload, contractility, and afterload

stroke volume

______ abuse is the use of any chemical in a manner inconsistent with medical or culturally defined social norms.

substance

______ (primary/secondary/tertiary) intention healing is healing that occurs after closing a wound that has been left open for 3-5 days to allow edema or infection to resolve. It is also known as delayed primary intention.

tertiary

autonomy

the client's right to make their own decisions. However, the client must accept the consequences of those decisions. The client must also respect the decisions of others.

beneficence

the quality of doing good; can be described as charity

Wernicke Korsakoff syndrome is caused by ______ deficiency and is commonly seen in chronic alcoholism.

thiamine

What are narcotic analgesics (derived from natural or synthetic opiates) used for?

to relieve pain

battery

touching a client in a harmful or offensive way is considered battery (giving an injection against the client's will)

A ______ relationship occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client's personal life.

transference

When the healthcare provider believes that a client has experienced a myocardial infarction​ (MI), diagnostic tests will include cardiac​ markers, including a ______ test, which measures the levels of troponin T or troponin I proteins in the blood. These proteins are released when the heart muscle has been damaged.

troponin

T or F. A patient with PVD should not elevate their lower extremities because this decreases circulation to them.

true

T or F. African Americans with hypertension more often have low renin levels and altered ability to excrete sodium at normal blood pressure levels.

true

T or F. Alcohol withdrawal delirium can progress to death.

true

T or F. Application of a​ moisture-retaining protective dressing is appropriate for a pressure injury without eschar or after the eschar has been surgically removed.

true

T or F. As heart failure​ worsens, BNP levels​ rise, and as the heart​ stabilizes, BNP levels decrease

true

T or F. A​ side-lying position or keeping the head of bed elevated more than 30 degrees can put pressure on specific body areas.

true

T or F. Beta-adrenergic blocking agents are contraindicated in patients with asthma, chronic lung disease, bradycardia, or heart block.

true

T or F. Biofeedback is used to improve peripheral​ circulation

true

T or F. Chronic use of alcohol leads to a cross-tolerance to general anesthetics, barbiturates, benzodiazepines, and other CNS depressants.

true

T or F. ECG changes such as ST segment elevation are associated with a myocardial infarction​ (MI), indicating that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately.

true

T or F. Edema increases the distance between the capillaries and the cells. It slows the diffusion of oxygen to the tissue cells and of metabolites away from the cells.

true

T or F. Hypertension often has no observable signs or symptoms. The nurse should ask about morning headaches or cervical pain.

true

T or F. In the early stages of hypoxia, heart rate rises and arterial oxygen saturation falls below 94%.

true

T or F. Men are more likely to have drug problems, but progression of addiction is faster among women

true

T or F. Mental health and development disorders are not always easily diagnosed, potentially resulting in delayed or inadequate treatment interventions.

true

T or F. Mentally healthy children and adolescents trust others, view the world as safe, accurately interpret their environments, master developmental tasks, and use appropriate coping skills.

true

T or F. Moist dressings are used for venous stasis​ ulcers, not dry dressings.

true

T or F. Prinzmetal​ (variant) angina occurs unpredictably and often at night

true

T or F. Substance use is a frequent comorbid condition with other mental disorders.

true

T or F. There is a strong association with preterm birth and ADHD.

true

T or F. Use of elastic compression stockings is essential to healing of venous stasis ulcers.

true

T or F. When eschar has​ formed, surgical debridement and removal of necrotic material is necessary.

true

T or F. When used in moderation. Alcohol can have positive effects.

true

T of F. Substance addiction should be treated like any other chronic illness.

true (relapse serves as a trigger for renewed intervention)

A person with ______ (stable/unstable) angina is not getting enough blood flow and oxygen to the heart muscle and this is a direct risk factor for a myocardial infarction.

unstable

The stress response leads to ______ (vasoconstriction/vasodilation), increasing pain. Stress reduction techniques, when combined with other measures to promote blood flow, can help reduce pain.

vasoconstriction

What causes redness at a site of injury?

vasodilation which brings an increase of RBCs to the site

Arterial or Venous Ulcer? Edema: may be significant

venous

Arterial or Venous Ulcer? Location: over medial or anterior ankle

venous

Arterial or Venous Ulcer? Skin appearance: brown discoloration, stasis dermatitis, cyanosis on dependency

venous

Arterial or Venous Ulcer? Ulcer appearance: superficial, pink

venous

Arterial or Venous Ulcer? gangrene: does not occur

venous

Arterial or Venous Ulcer? pain: usually mild, aching pain

venous

Arterial or Venous Ulcer? pulses: normal

venous

Brown pigmentation of the skin of the lower extremity and edema are features of ______ (venous/arterial) problems.

venous

Elevation promotes ______ (arterial/venous) return from the extremity, increasing circulation and relieving pain.

venous

Chronic ______ ______ is a disorder of inadequate venous return over a prolonged period of time making it difficult for blood to return to the heart.

venous insufficiency

Intentional Torts Against Persons

willful actions that damage a client's property or violate client rights

Why is it important to normalize thiamine first before giving glucose when treating a patient with Wernicke's encephalopathy?

without thiamine pyrophosphate, most of the glucose will become lactic acid and that can lead to metabolic acidosis

A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? a. Assist the client with systemic desensitization therapy. b. Teach the client appropriate coping mechanisms. c. Assess the client for comorbid health conditions. d. Monitor the client for adverse effects of medications.

Monitor the client for adverse effects of medications.

A patient started a new treatment plan for chronic peripheral venous disease (PVD) and claudication a week prior to the nurse's visit. The patient states, "For about a week or so, I've been waking up in the middle of the night and my legs have felt like they were on fire." Which intervention by the nurse is most appropriate? a. Explain that this is an expected clinical manifestation of the condition. b. Notify the healthcare provider. c. Encourage the patient to increase daily walking. d. Instruct the patient to elevate the legs while sleeping.

Notify the healthcare provider (Pain at rest is a sign that the disease is progressing and that perfusion is altered.)

Contrast appropriate nursing interventions to prevent pressure injuries in patients age 6, 30, and 80 with limited mobility.

Nursing interventions for all age groups are similar and should include a systematic skin inspection at least daily; prompt cleaning after toileting; minimizing skin exposure to moisture; and use of proper positioning, transferring, and turning techniques. Care for all patients depends on nutrition, injury, or surgery and the patient's ability to care for self.

Normal PaCO2

35-45 mmHg

normal cardiac output

4-8 L/min

People with ______ often have impairments in language, cognition, and social skills that make them seem different from other people.

ASD

______ has a possible genetic component. Children with certain genetic abnormalities have an increased occurrence and familial tendency. Advanced age of both parents is another risk factor.

ASD

______ results from defects in genes and gene expression in all areas of the cell-cycle expression. There is an atypical brain construction. An MRI will also show abnormalities of neurons of the cerebral cortex

ASD

ADHD (children) manifestations mnemonic

ATENTION A = Annoying T = Temperamental E = Energetic N = Noisy T = Task incomplete I = Inattentive O = Oppositional N = Negativism

ASD manifestations mnemonic

AUTISTIC PEOPLE A- Affect isolation U- Unrelated to others T- Twiddle I -I/You confusion in speech S - Self-mutilation T - Temper tantrums I - Inconsistent development C - Concrete thinking P - Perceptual difficulties E - Echolalia O - Orderly P - Physical motor disorder L - Lack language skills E - Excessive activity

The nurse is preparing a bulletin featuring peripheral vascular disease (PVD). Which should the nurse include as a risk factor for developing PVD? a. Female sex b. Age 50 or older c. Being underweight d. Drinking alcohol

Age 50 or older

While assessing an 82-year-old patient the nurse finds that the patient's systolic pressure is consistently high, while the diastolic pressure is within normal limits. Which statement correctly explains this phenomenon?

Aging decreases arterial compliance, resulting in increased pressure within the vessels.

milieu therapy

An inpatient treatment approach involving professionals and staff members encouraging a person with a severe mental disorder to engage in prosocial and therapeutic activities.

The nurse is reviewing the pharmacologic profile of a client with a non-healing wound. Which class of medications should the nurse question as it can delay wound​ healing? A. Proton pump inhibitor B. Cardiac glycoside C. Opioid D. Anti-inflammatory

Anti-inflammatory

What type of drugs interfere with healing?

Anti-inflammatory drugs (e.g., steroids, aspirin) and antineoplastic agents interfere with healing

The nurse is admitting a client to the coronary care unit​ (CCU) and is assessing risk factors for heart failure. What is the most concerning risk​ factor? A. Body mass index​ (BMI) of 18.0 B. Blood pressure of​ 188/122 mm/Hg C. Influenza D. Total cholesterol of 184​ mg/dL

Blood pressure of​ 188/122 mm/Hg (hypertension is a major risk factor because the heart must work harder for effective blood circulation)

Which nursing intervention should the nurse recommend to promote tissue perfusion in a patient with peripheral vascular disease (PVD)? a. Tell patient to elevate their lower extremities above their heart. b. Advise patient to cross their legs when they sit. c. Encourage patient to exercise. d. Direct patient to ice lower extremities.

Encourage patient to exercise

A nurse should teach the HALT acronym to assist their patient in recognizing behaviors that lead to relapse. What is the HALT acronym?

H-hungry A-angry L-lonely T-tired

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? a. Coordinate holistic care with social services. b. Identify the client's perception of their mental health status. c. Include the client's family in the interview. d. Teach the client about the current mental health disorder.

Identify the client's perception of their mental health status. (Assessment is the priority action when using the nursing process approach to client care. Identifying the client's perception of their mental health status provides important info about their psychosocial history.)

A nurse is assessing a client and notices pitting edema in the lower legs. The client has a history of mild congestive heart failure​ (CHF), which is controlled with​ medication, and reports that the swelling has become worse lately. Which could the increased edema​ indicate? A. The client has not been compliant with medications. B. The client has a possible progression of CHF. C. The client has increased physical activity. D. The client has been under stress.

The client has a possible progression of CHF.

LOC: alert

The client is responsive and able to fully respond by opening their eyes and responding to a normal tone of voice and speech. The client answers questions spontaneously and appropriately.

LOC: comatose

The client is unconscious and does not respond to painful stimuli

What is the HEADSSS standardized testing tool?

Home environment Education/employment Activities Drug and substance use Sexuality Suicide/depression Safety

decorticate rigidity

flexion and internal rotation of upper-extremity joints and legs

To avoid progressing to​ hypertension, clients with prehypertension should:

follow their treatment​ regimen, maintain a healthy weight and​ diet, reduce salt​ intake, reduce saturated and total fat​ intake, engage in regular physical​ activity, use​ stress-management techniques, and avoid baths that are too hot