final adulth health 1

A public health nurse that is assessing a pt that lives with a family members that has bruising on their body comes into the clinic, a family member then explains that the bruises are from falls and nurse thinks its from abuse, what does the nurse do

1st, the nurse should report the finding to the supervisor.

What age is greatest risk for pressure injuries

65 year old.

For cranial nerve V/5 unable to feel facial pain, what is this called

facial neuroglia

A nurse is caring for 4 clients, which does she assess 1st

gas exchanges for abnormalities 1st, a opioid overdose

A nurse is doing a surgically interview, glucosamine, APAP and ginkgo, and nurse tells pts to stop taking which one

gingko is to be stopped 2 weeks before the surgery

What type/class of medication do you use with a pt who is in alkalosis for acid loss

Diuretic

For a confused older adult what scale do you use that will tell us their pain

Faces

Who would a nurse refer to if a pt cannot feed themselves

OT

The student nurse learns that the most important function of inflammation and immunity is which purpose

Providing protection against invading organisms

When planning delegation tasks to AP, a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation

The AP has the knowledge and skill to perform the task, Means the right person

Its an Older adult's 1st time being seen for geriatric care, and nurse asks about supplemental herb use for what

To do medication reconciliation for possible interactions.

Which pt has the highest risk for cardiovascular disease is

a pt with DM

72 year old women what would a sign of cancer

be loss tone in the ligaments

A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer. Which factor in the client's history helped the nurse form this conclusion

exposed to radiation

Pulmonary embolize

is a blood clot in the lungs you would see pt on warfin or heparin PE sometimes causes hypoxia

Cranberry juice is beneficial because

it can prevent bladder infections.

What is a instinctive spirometer

it's a slow inhaler to prevent pneumonia and aids in deep breathing

What are plantar flexion contractions

its foot drop, its foot that needs to be put in a boot at times.

A nurse just gave the wrong medication to the the wrong pt, what does the nurse 1st do

Assess

What are the 4 pillars of ethical principals

Autonomy - respect for the patient's right to self-determination Beneficence - the duty to 'do good' Non-Maleficence - the duty to 'not do bad' Justice - to treat all people equally and equitably.

acidosis side effects are

Diarrhea acidosis

The nurse understand which information under centered care

Definition of pt recognize the client as a source of his or her care.

What is risk factors for metabolic acidosis

Diarrhea, AKI,

Risk factors for cataracts are

age

Pt is admitted for sepsis what do you always do

always do culture 1st the especially in little and older pts

MRSA antibiotic resistance, if a pt has mrsa give them

antibiotics

When a nurse interviews a pt is taking a daily dosage of supplements what do we want to know most

ask what they are taking the supplements for

How is a that has chronic kidney disease would have a reduce erthypoticin (erythropoietin)

because of the decreased RBC in the chronic disease

What are the common side effects for these 3 medications Garlic Ginger and Ginkgo

bleeding

The nurse is assessing for reproductive health problems,what are those

bleeding, pain, masses, discharge.

Signs and symptoms of lactose intolerances

bloating diarrhea gas

If a pts serum K is not within normal ranges, what does the nurse do

call the provider to inform of results, prior to admn medications

Ginkgo adverse effect

can cause bleeding

If your pt is on airborne precautions, what do you follow

can they ambulate in the hall no, do they need to wear a mask yes n95, and be in a negative pressure room and we need to stand six feet away

If you are a nurse in ophthalmology clinic who do we see 1st

cataracts surgery follow up.

What are signs and symptoms of malnutrition

cold intolerance, decreased vital capacity, mental status, dry flaky skin

Pupliary construction is assessed through

cranial nerve 3

What are age related GI changes

decreased GI mobility, large intestine pertussis, decreased observation, decrease gastric bile juices, decreased need to pass stool, pancreatic vessels classification, decreased fat digestion

What does a pulmonary emboli cause

decreased perfusion; hypoxemia; and if large enough right sided heart failure

Post recover care for colonoscopy

do vitals q 15-30 minutes, asses for rectal bleeding, no need for pain meds, encourage to pass gas, no driving

Giving antibiotics what has to occur for it to be given

dosage, length, route, med,

Some ways to teach kidney health

drink water daily, encourage q 2 hours, provide peritoneal care after voiding , asses for UTI, Leave the bathroom light on at night

68 yr postmenopausal pt that is bleeding from vaginal canel indicates

endometrial cancer.

What ppe do you take off 1st

gloves

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination XI

have patient shrug their shoulders against resistance.

A nurse is assisting a pt to the bathroom and the pt is starting to fall what do we do

help pt to the ground to get help.

How to help falls in older pts

railings , avoid rugs, why is it good to put a nightlight in a pts room: to see better

Pulmonary Embolism

life-threatening blood clot in the lungs caused by an embolus from a vein in the lower extremity or from clots that form from a major surgery

A patient has had lung cancer and is suspected to have metastasis. On what system should the nurse focus the assessment to determine this complication

liver most common for lung metastasis

Risk falls is a older client that is disorientated

make sure you are rounding hourly and teaching the client about the call light and do not pull up the side rails.

What are risk factors that affect immunity

medications corticosteroid's, age, malnourished, nutritional status, substance abuse pt

An older adult that was AAO and is now agitate wje should do what

move them closer to the nurse's station.

A nurse is caring for a total hip arthoplasty and pt is on PCA pump for morphine, what does the nurse do

need to assess 1st. auscultate bowel sounds for gastric mobility

I don't have to go to the hospital after using Epinerphine is said by the pt is this correct

no

When a pt has lung cancer and has one metastasis to the liver, is it now liver cancer

no it's the still lung cancer however its just metastasis

Preprocedure for pulmonary function testing includes

none its PRN

If a pt has hearing loss we want to make sure to

not yell, assess if they have you get *hearing aids, assess do they have assistant device

Assessing a client blueish tint what do you check

o2, respirations everything with o2

AIDS pts can have thrush from

oral candidiasis

Older pt who is at a risk for falls, what are some interventions

place bedside table closer to pt, when bed or wheelchair is not in use place in locked, give pt information on how to be safer teach balance and exercise stretching to the pt

What are complications of immobility

pressure injury in bony prominences in the heel in the sacrum , skin infections, skin integrity

Pt who has stage 3 pressure ulcer what can be included in the plan of care

reposition q 2 hours

Autonomy

respect for the patient's right to self-determination

Major Adverse effects of morphine are

respirations, GI mobility 12-20 normal, pt being sleepy is normal finding

5 rights of delegations

right task, right circumstance, right person, right direction/communication, and right supervision/evaluation

Presence of edema can be seem in a pt that

shoes are fitting more tightly

If a patient is malnourished and does not want to eat and is mentally ill, how can we as a nurse help

sit and eat with them

What is the nursing management for a pulmonary emboli

stabilizing the cardiopulmonary system and anticoagulant therapy

What are risk factors for osteoarthritis

stress on the joints, weight obesity, old age, smoking for 30 years

A nurse is preparing for a catchier

tell me more about what your fears are.

What cranial nerve will cause a pt not be able to shrug their shoulders or move their neck

the spinal accessory 11 crainal XI

Nurse is setting goals for pts with AIDS at end of life, what is it that a client will need help with

their pain.

alkalosis for acid loss causes

vomiting

What shows fluid overload

weight gain over 5 lbs

Fluid overload

weight gain, edema, decreased skin turgor, distended neck veins, decreased O2 then 90%

pertussis

whooping cough, pt is put on droplet precaution

4 things that a home health nurse will find on a pt that are NOT normal findings are

worst thing that needs to be address 1st is a dysphagia

If I palpate the pts skin and it stays in indented is that pitting edema

yes

It a pt is on contact precautions can a pt go to CT scan

yes they can we just need to tell the radiology dept and make sure they are informed.

How can you prevent Glaucoma

you can prevent it, you can have intraocular pressure measured 1-2 times a year.