Exam 3

Normal Hct levels

38.8 to 50 percent for men and 34.9 to 44.5 percent for women...

The nursing instructor is talking with the students about the care of a patient with multiple myeloma who is experiencing bone destruction. What would the instructor tell the students the patient should be assessed for signs of? A) Hypercalcemia B) Hyperproteinemia C) Elevated serum viscosity D) Elevated RBC count

A) Hypercalcemia

When caring for a patient who has had a stroke a priority is reduction of intracranial pressure (ICP). What position is indicated to assist with this goal? A) Head turned to the right side B) Elevation of the head of the bed C) Head turned to the left side D) Extension of the neck

B) Elevation of the head of the bed...

The staff educator is precepting a nurse new to the unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What would the staff educator and the new nurse monitor this patient for? A) Increased cardiac markers B) Hypotension C) Tachycardia D) Excessive sweating

B) Hypotension

A patient with a right tibial fracture is being discharged home after having a cast applied. The nurse gives instructions to the patient and his family. What instruction should the nurse provide in relationship to the patient's cast care? A) Cover the cast with a blanket until the cast dries. B) Keep your right leg elevated above heart level. C) Use a knitting needle to scratch itches inside the cast. D) A foul smell from the cast is normal.

B) Keep your right leg elevated above heart level.

The nurse is caring for a patient w/increased intracranial pressure (IICP) caused by a traumatic brain injury. Which clinical manifestation would indicate that the patient is experiencing increased brain compression causing brainstem damage? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea

D) Bradypnea

A patient has returned to the unit after having a parathyroidectomy. What drug is kept at the bedside for emergency use? A) Digitalis B) Ergocalciferol C) Amphojel D) Calcium gluconate

D) Calcium gluconate

A patient with a seizure disorder is presenting having a generalized seizure. An appropriate nursing intervention during the seizure would include what? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing.

D) Loosen the patient's restrictive clothing.

Osteomyelitis-due to diabetic ulcer? nursing diagnosis

Pain Imbalanced Nutrition, Less Than Body Requirements Ineffective Thermoregulation Impaired Skin Integrity Disturbed Body Image Risk for Infection...

What do you use a back traction thing for?

Reduce movement of muscles

A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV solution will be started initially? 1. warmed lactated Ringer's solution 2. dextrose 5% with saline solution 3. dextrose 5% with water 4. normal saline solution 5. 0.45% saline solution What medication for pain for burn patient?

1. warmed lactated Ringer's solution. Warmed lactated Ringer's solution is the IV solution of choice because it most closely approximates the body's extracellular fluid composition. It is warmed to prevent hypothermia.

Cushings-priority nursing diapnosis

1.Risk for Infection r/t immunosuppression...2. Excessive fluid volume r/t altered water and mineral metabolism...3. Disturbed body image r/t altered appearance

The nurse is planning care for a 52-year-old male client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? 1. Risk for Infection 2. Decreased cardiac output 3. Impaired physical mobility 4. Imbalanced nutrition: less than body requirement

2. Decreased cardiac output. An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility is also an appropriate nursing diagnosis for the client with Addison's disease, but it isn't a priority in a crisis. Imbalanced nutrition: Less than body requirements is also an important nursing diagnosis for the client with Addison's disease but not a priority during a crisis.

Normal WBC count

4,500-10,000 mcl...

A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What would the nurse's primary assessment focus on? A) Cardiac and respiratory status B) Seizure activity C) Urinary output D) Fluid and electrolyte balance

A) Cardiac and respiratory status

The nurse is caring for a patient who had a right extremity below the knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 3 months after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in the chair for at least 8 hours of the day

A) Encouraging the patient to turn from side to side and to assume a prone position

You are caring for a patient who is to begin receiving external radiation for a malignant tumor of the head and neck. While doing patient education, what side effects should the nurse discuss with the patient that should be assessed because of the radiation treatment? A) Impaired nutritional status B) Pink oral mucosa C) Diarrhea D) Alopecia

A) Impaired nutritional status

A patient comes to the clinic complaining of fatigue and pica. Laboratory findings reveal a low serum iron level and a low ferritin level. What would the nurse suspect that the patient will be diagnosed with? A) Iron deficiency anemia B) Pernicious anemia C) Sickle cell anemia D) Hemolytic anemia

A) Iron deficiency anemia

You are caring for a patient who has had a right hip replacement. What should the nurse follow when caring for a patient who has just had hip replacement surgery? A) Keep the hips in abduction. B) Keep hips flexed at 95 degrees. C) Elevate the head of the bed to a high Fowler's position. D) Seat the patient in a low chair.

A) Keep the hips in abduction.

The nurse is doing discharge teaching with a patient who has a C6 spinal cord injury and their family. A family member asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A) The sudden increase in blood pressure can raise the ICP or rupture a cerebral blood vessel. B) The suddenness of the onset of the syndrome tells us the body is struggling to maintain its norm. C) Spinal cord patients cannot maintain their neurologic responses and bring their body back to its normal state. D) The sudden, severe headache can create enough stress in the body cause problems.

A) The sudden increase in blood pressure can raise the ICP or rupture a cerebral blood vessel.

A patient diagnosed with multiple sclerosis has been admitted to your unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would you include as an expected outcome of this medication? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Limits severity and duration of exacerbations

B) Decreased muscle spasms in the lower extremities

A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. What may this be a sign of? A) Edema B) A pressure ulcer C) Compartment syndrome D) Disuse syndrome

C) Compartment syndrome

A patient is being admitted to the Neuro ICU following an acute head injury. The patient has cerebral edema. The nurse would expect to administer what priority medications to reduce cerebral edema? A) Hydrochlorothiazide (HydroDIURIL) B) Lasix (Furosemide) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)

C) Mannitol (Osmitrol)

When caring for a patient with altered level of consciousness the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII? A) Palpate trapezius muscle while patient shrugs should against resistance. B) Administer the whisper or watch-tick test. C) Observe for symmetry of facial movements, such as a smile. D) Note any hoarseness in the patient's voice.

C) Observe for symmetry of facial movements, such as a smile.

The nurse caring for a female patient diagnosed with an ischemic stroke knows that effective positioning of the patient is important. How might the nurse effectively position the patient? A) Hip joint should be kept in a flexed position. B) Maintain the patient in a supine position. C) Place the patient in prone position for 15 to 30 minutes several times a day. D) Keep the patient in semi-Fowler's position.

C) Place the patient in prone position for 15 to 30 minutes several times a day.

A patient who underwent a total hip replacement is being routinely turned. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Use measures other than turning to prevent pressure ulcers. C) Prevent internal rotation of the affected leg. D) Keep the hip flexed by placing pillows under the patient's knee.

C) Prevent internal rotation of the affected leg

A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A) Glucose in the urine B) Albumin in the urine C) Urine specific gravity of 1.001 to 1.005 D) Leukocytes in the urine

C) Urine specific gravity of 1.001 to 1.005

The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

D) Wrap cool towels around the affected extremity intermittently. Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

Diabetes insipidus- nursing diagnosis

Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss....

Normal Hbg levels

For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter....

Following a thyroidectomy? 10 degrees, roll of blanket

Provides patient in semi-Fowler position, and chock the head / neck with a small pillow....

SIADH-fluid overload

Vasopressin is used as medication...cancer is a major cause of SIADH.

T4-priority for treatment Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds

a. Headache and rising blood pressure

The male client is receiving external radiation to the neck for cancer of the larynx. The most likely side effect to be expected is: a. dyspnea b. diarrhea c. sore throat d. alopecia

c. sore throat