Nurse Refresher Mid Term

A. A growing number of people live to a very old age.

A gerontologic nurse is aware of the demographic changes that affect the provision of health care. Which of the following phenomena is currently undergoing the most rapid and profound change? A. A growing number of people live to a very old age. B. More families are having to provide care for their aging members. C. Adult children find themselves participating in chronic disease management. D. Elderly people are having more accidents, increasing the cost of health care.

A. By protecting older adults against shearing injuries

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? A. By protecting older adults against shearing injuries B. By protecting older adults against excessive sweat accumulation C. By avoiding the use of ice packs to treat muscle pain D. By avoiding the use of moisturizing lotions on older adults' skin

A. Decreased kidney mass D. Decreased renal blood flow E. Decreased excretion of potassium

A gerontologic nurse is teaching students about high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply: A. Decreased kidney mass B. Increased conservation of sodium C. Increased total body water D. Decreased renal blood flow E. Decreased excretion of potassium

A. Frequent handwashing reduces transmission of pathogens from one client to another.

A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice? A. Frequent handwashing reduces transmission of pathogens from one client to another B. Waterless products should be avoided in situations where running water is unavailable C. Bar soap is preferable to liquid soap D. Wearing gloves is known to be an adequate substitute for handwashing

B. Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen? A. Oxygen may cause the client to hyperventilate and become acidotic B. Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia C. The client's calcium will rise dramatically due to pituitary stimulation D. Oxygen will increase the client's intracranial pressure and create confusion

Inefficient tissue perfusion

A nurse has a client who recently had a knee replacement. There is a hematoma at the surgical site and decreased pedal pulse. What would the nursing diagnosis be?

A. Refusing to administer pain medication as prescribed

A nurse has been providing ethical care for many years and is aware of the need to maintain the ethical principle of nonmaleficence. Which of the following actions would be considered a violation of this principle? A. Refusing to administer pain medication as prescribed B. Discussing a DNR order with a terminally ill client C. Providing more care for one client than for another D. Assisting a semi-independent client with ADLs

C. NANDA

A nurse has begun creating a client's plan of care shortly after the client's admission. The nurse knows that it is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis? A. National League for Nursing (NLN) B. Joint Commission C. NANDA D. American Nurses Association (ANA)

D. Physically repelling pathogens E. Preventing fluid loss

A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all that apply: A. Producing antibodies B. Absorbing electrolytes C. Maintaining acid-base balance D. Physically repelling pathogens E. Preventing fluid loss

B. Keep the client's hips in abduction at all times

A nurse is caring for a client who is postoperative day 1 right hip replacement. How should the nurse position the client? A. Seat the client in a low chair as soon as possible B. Keep the client's hips in abduction at all times C. Elevate the head of the bed to high Fowler's D. Keep hips flexed at no less than 90 degrees

D. Hip fracture

A nurse is caring for an older adult client who has become increasingly frail and unsteady on her feet. During the assessment, the client indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this client is at high risk for what health problem? A. A femoral fracture B. Tearing of a meniscus or bursa C. Pelvic dysplasia D. Hip fracture

B. It is good you asked and you have a right to know, your information helps us to provide you with the best possible care, and your records are in a secure place.

A nurse is conducting a health assessment of an adult client when the client asks, Why do you need all this health information and who is going to see it? What is the nurse's best response? A. Your health information is placed on secure websites to provide easy access to anyone wishing to see your medical records. This ensures continuity of care. B. It is good you asked and you have a right to know, your information helps us to provide you with the best possible care, and your records are in a secure place. C. Please do not worry. It is safe and will be used only to help us with your care. It's accessible to a wide variety of people who are interested in your health. D. Health information becomes the property of the hospital and we will make sure that no one sees it. Then, in 2 years, we destroy all records and the process starts over.

B. Instill the medication in the conjunctival sac.

A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action? A. Apply the medication evenly to the sclera. B. Instill the medication in the conjunctival sac. C. Keep the eyes closed for 1 to 2 minutes after administration. D. Maintain a supine position for 10 minutes after administration.

D. This is an aspect of the client's religious practice

A nurse on a medical unit is conducting a spiritual assessment of a client who is newly admitted. In the course of this assessment, the client indicates that she does not eat meat. Which of the following is the most likely significance of this client's statement? A. The client does not understand the principles of nutrition B. This is an example of the client's coping strategies C. This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition D. This is an aspect of the client's religious practice.

18

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does this client most likely have, measured as a percentage?

D. Perform hand hygiene

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care? A. Don non latex gloves B. Slowly remove the soiled dressing C. Assess the drainage in the dressing D. Perform hand hygiene

C. Glasgow Coma Scale

A client exhibiting an altered level of consciousness due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool? A. Mental status examination B. Cranial nerve function C. Glasgow coma scale D. Monro-Kellie hypothesis

C. Colonization

A client has a concentration of S. Aureus located on his skin. The client is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages? A. Bacteremia B. Infection C. Colonization D. Disease

A. Fluid status

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate priority concern when planning this client's care? A. Fluid status B. Nutritional status C. Risk of infection D. Psychosocial coping

A. Generalized seizure

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A. Generalized seizure B. Focal seizure C. Absence seizure D. Unclassified seizure

C. Contact the primary provider immediately

A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action? A. Assess the client's joint function symmetrically B. Arrange for a STAT assessment of the client's serum calcium levels C. Contact the primary provider immediately D. Perform active range of motion exercises

A. Place a pillow in the axilla when there is limited external rotation

A client has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? A. Place a pillow in the axilla when there is limited external rotation B. Place client's hand in pronation C. Assist the client in acutely flexing the thigh to promote movement D. Place the client in the prone position for 30 minutes per day

Headaches Vomiting Drowsiness Dizziness Confusion Progressive loss of consciousness

A client has increased intracranial pressure caused by a traumatic brain injury. What symptoms may suggest brain compression, causing brain damage?

A. Mannitol

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? A. Mannitol B. Hydrochlorothiazide C. Furosemide D. Spirolactone

D. A new floater in vision.

A client is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the client, the nurse instructs the client to immediately call the office if the client experiences what? A. A scratchy feeling in the eye. B. Slight morning discharge from the eye. C. Any appearance of redness of the eye. D. A new floater in vision.

A. Surgical intervention

A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care? A. Surgical intervention B. Antioxidant supplements, vitamin C and E, beta-carotene, and selenium. C. Corticosteroid eye drops D. Eyeglasses or magnifying lenses.

A. Promote truthful communication C. Teach the client coping strategies E. Provide positive reinforcement

A client is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply: A. Promote truthful communication B. Avoid asking the client to make decisions C. Teach the client coping strategies D. Administer benzodiazepines as prescribed E. Provide positive reinforcement

C. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. Elevation of the arm and hand can lead to further complications associated with edema. B. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder C. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. D. Passively exercising the affected extremity is avoided in order to minimize pain.

D. An area matching the color and texture of the skin at the surgical site is selected

A client requires a full-thickness graft to cover a chronic wound. How is the donor site selected? A. Any area that is not normally visible can be used B. The largest area of the body without hair is selected C. An area matching the sensory capability of the skin at the surgical site is selected D. An area matching the color and texture of the skin at the surgical site is selected

Delayed onset of respiratory complications

A client suffered a burn two days ago and now complains of shortness of breath. What is going on?

B. Position the client upright during feeding

A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Withhold liquids until the client has finished eating B. Position the client upright during feeding C. Arrange for the client to receive a low residue diet D. Suction the client following each meal

A. Decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety.

A client with chronic back pain says that he is having problems at work and has been absent from work about once every two weeks. He says that he is short tempered with other workers, feels tired all the time, and is worried about losing his job. In the plan of care, what should the goals be for the plan of care to focus on? A. Decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety B. Evaluate other work options to decrease the risk of depression and ineffective coping C. Decrease the client's need to work and increase his sleep to 8 hours per night D. Increase the client's pain tolerance in order to achieve psychosocial benefits

C. Bone densitometry

A clinical nurse is caring for a client with a history of osteoporosis. What diagnostic test will best allow the care team to assess the client's risk of fracture? A. Arthroscopy B Bone scan C. Bone densitometry D. Arthrography

B. Secondary prevention

A community health nurse has scheduled a hypertension clinic in a local shopping mall in which shoppers have the opportunity to have their blood pressure measured and learn about hypertension. This nursing activity would be an example of which type of prevention activity? A. Tertiary prevention B. Secondary prevention C. Primary prevention D. Disease prevention

B. Not contributing to society C. Draining economic resources D. Competing with children for resources

A gerontologic nurse has been working hard to change the negative perceptions of the elderly. What negative perceptions of older adults have been identified in the literature? Select all that apply: A. Being the cause of social problems B. Not contributing to society C. Draining economic resources D. Competing with children for resources E. Dominating health care research

Hormone made by the hypothalamus, tells your kidneys how much water to conserve. Constantly regulates the amount of water in your blood.

ADH

A type of seizure that involves brief, sudden lapses in attention Staring off

Absence Seizure

A. Enhancing the nurse's clinical decision making C. Planning the best nursing actions to assist the client D. Increasing the accuracy of the nurse's judgments E. Helping identify the client's priority needs

Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing? Select all that apply. A. Enhancing the nurse's clinical decision making B. Identifying the client's individual preferences C. Planning the best nursing actions to assist the client D. Increasing the accuracy of the nurse's judgments. E. Helping identify the client's priority needs

A. These programs emphasize the need for evidence-based practice

A nurse on a medical-surgical unit has asked to represent the unit on the hospital's quality committee. When describing quality improvement programs to nursing colleagues and members of other health disciplines, what characteristic should the nurse cite? A. These programs emphasize the need for evidence-based practice B. These programs identify specific incidents related to quality C. These programs establish consequences for health care professional actions D. These programs seek to justify health care costs and systems

D. Helping the client achieve specific outcomes

A nurse on a postsurgical unit is providing care based on a clinical pathway. When performing assessments and interventions with the aid of a pathway, the nurse should prioritize what goal? A. Balancing risks and benefits of interventions B. Staying accountable to the interdisciplinary team C. Documenting the client's response to therapy D. Helping the client achieve specific outcomes

A. An older client has less subcutaneous tissue and less muscle mass than a younger client

A nurse will conduct an influenza vaccination campaign of an extended care facility. The nurse will be administering intramuscular (IM) doses of the vaccine. Of what age-related change should the nurse be aware when planning the appropriate administration of this drug? A. An older client has less subcutaneous tissue and less muscle mass than a younger client. B. An older client has more subcutaneous tissue and less durable skin than a younger client. C. An older client has a higher risk of bleeding after an IM injection than a younger client. D. An older client has more superficial and tortuous nerve distribution than a younger client.

Disturbed body image. Teach client how to use prosthesis

A patient has a third degree facial burn and ends up needing a prosthesis. What would an appropriate nursing diagnosis be?

Renin-angiotensin aldosterone system is compensating

A patient has increased heart rate, a foley catheter and only 40 ml of urine. This has to do with what sympathetic reaction?

Hypocalcemia

A patient has intermittent spasm in wrist and increased muscle tone. What is this a sign of?

The patient

A patient is DNR. Son is against this. Who do you listen to?

D. 5% Dextrose

A patient's order for IV fluid states the D5W is to be infused. Which of the following IV fluids should be given? A. 5% Dextrose with Normal Saline B. 5% Dextrose with Lactated Ringer's Solution C. 5% Dextrose with 0.45% Sodium Chloride D. 5% Dextrose

Management of chronic conditions and disability

A public health nurse has been commissioned to draft a health promotion program that meets the health care needs and expectations of the community. What factor is most likely to influence the nurse's choice of intervention? A. Management of chronic conditions and disability B. Increasing need for self care among a younger population C. A shifting focus to disease management D. An increasing focus on acute conditions and rehabilitation

B. Black

A workplace explosion has left a 40 year old man with full thickness burns over 75% of his body. Despite his injuries, the man is conscious. How would this person be triaged? A. Yellow B. Black C. Red D. Green

Gown, gloves, and mask. Disinfect with bleach

C-diff

Sharp, sudden pain, suspect compartment syndrome and contact Dr.

Compartment syndrome

An injury in which a broken bone pierces the skin, causing a risk of infection.

Compound fracture

Typically caused by a loss of bone mass (osteoporosis) that occurs as a part of aging. Occurs when one or more bones in the spine weaken and crumple.

Compression fracture

Precautions used for infections, diseases, or germs that are spread by touching the patient or items in the room. Wear a gown and gloves (MRSA, VRE, RSV)

Contact Isolation

Rapid access to client information by everyone involved in client care; improves client care and communication.

Informatics benefits Rapid access to client information by everyone involved in client care; improves client care and communication.

B. The nurse and the physician jointly making clinical decisions

Nursing continues to recognize and participate in collaboration with other health care disciplines to meet the complex needs of the patient. Which of the following is the best example of a collaborative practice model? A. The nurse making a referral on behalf of the client B. The nurse and the physician jointly making clinical decisions C. The nurse accompanying the physician on rounds D. The nurse attending an appointment with the client

A. Metabolic alkalosis

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance? A. Metabolic alkalosis B. Respiratory acidosis C. Hypercalcemia D. Metabolic acidosis

B. The state of being connected in body, mind, and spirit

The public health nurse is presenting a health promotion class to a group of new mothers. How should the nurse best define health? A. The state of having fulfillment in all domains of life B. The state of being connected in body, mind, and spirit C. Possessing psychological and physiologic harmony D. Being disease free or having existing diseases stabablized

Ask patients about OTC and herbal medications, they can have interactions with prescriptions.

What is an important step concerning pharmacology and administering medications? Ask patients about OTC and herbal medications, they can have interactions with prescriptions.

Five or more medications; risk of falls or drug interactions

What is polypharmacy and what is a client at risk for?

When the nurse and the physician work together

What is the best example of a collaborative practice model?

Pain management

What is the best way to promote mobility?

Handwashing

What is the best way to stop the spread of germs?

With increased intracranial pressure, someone may have ineffective cerebral tissue perfusion. There is no where for the fluid to go. They are most likely going to have altered level of consciousness, decreased motor coordination, inability to speak. Expected out come is the ability to obey commands.

What is the expected outcome for a client with increased intracranial pressure?

Airway, breathing, circulation. Then fluid resucitation

What is the priority care plan for a client with burns?

Gabapentin

What medication is used for neuropathy?

Wrap cool wet towels around burn.

What nursing intervention would be appropriate for a client suffering from a burn?

CDC

What organization is notified of infectious disease outbreak?

CT scan

What type of diagnostic test would show internal injuries?

Diminished protection

What vulnerability results from age related loss of subcutaneous tissue?

Hypernatremia

What would cause a release in ADH (anti-diuretic hormone)

We want to promote pain management to ensure mobility. Medicate prior to physical therapy

When a client has had a procedure, what do we want to promote?

Respiratory

When a patient comes in contact with anthrax, what body system is a priority?

Call the doctor. You don't want to automatically stop the medication

When a patient is taking opioid medication and you notice decreased respirations, what is the first thing you do?

C. Vesicant

When assessing clients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A. Nerve agent B. Blood agent C. Vesicant D. Pulmonary agent

A. Medication effects C. Poor lighting D. Sensory impairment

When implementing a comprehensive plan to reduce the incidence of falls on a gerontologic unit, what risk factors should the nurse identify? Select all that apply: A. Medication effects B. Overdependence on assistive devices C. Poor lighting D. Sensory impairment E. Ineffective use of coping strategies

Lumbar puncture

Which diagnostic test is contraindicated with a client with increased intracranial pressure?

C-Diff

Which disease do you need to make sure to use soap and water after coming in contact? (Not hand sanitizer)

D. Infiltration

While assessing a client's peripheral IV site, the nurse observes edema around the insertion site. How should you document this complication related to IV therapy? A. Air emboli B. Phlebitis C. Fluid overload D. Infiltration

B. Confusion

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with postictal state? A. Body rigidity B. Confusion C. Urinary incontinence D. Epileptic cry

Transfer safely before discharge

With a client recovering from total hip replacement, what would the goal for discharge be?

B. Cholinergics

The nurse on the medical surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? A. Loop diuretics B. Cholinergics C. Potassium-sparing diuretics D. Antibiotics

Respiratory alkalosis

What acid base imbalance will a client who is hyperventilating have?

a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.

Advanced Directive

Wearing a mask (Measles, chicken pox, severe acute respiratory syndrome (SARS), TB) Required to protect against airborne transmission of infectious agents

Airborne precautions

D. The resources that the client is likely to require

An ED nurse is triaging clients according to a triage severity rating. When assigning clients to a triage level, the nurse will consider the clients' acuity as well as what other variable? A. Whether the client is known to ED staff from previous visits B. The likelihood of a repeat visit to the ED in the next 7 days C. The client's ability to participate in care D. The resources that the client is likely to require

D. The day that the client is admitted

An adult client with a history of diabetes is scheduled for a transmetatarsal amputation. When should the client's discharge of planning begin? A. The day of estimated discharge B. Once the nursing care plan has been finalized C. The day prior to discharge D. The day that the client is admitted

D. To provide an optimal learning environment with minimal distractions

An adult client's current goals of rehabilitation focus primarily on self care. What is a priority when teaching a client who has self care deficits in ADL's? A. To help the client become aware of the requirements of assisted living centers B. To describe evidence base for any chosen interventions C. To ensure that the client is able to perform self care without any aid from caregivers D. To provide an optimal learning environment with minimal distractions

B. Medicare has a copayment for many of the services it covers. This requires the client to pay a part of the bill.

An elderly client, while being seen in an urgent care facility for a possible respiratory infection, asks the nurse if Medicare is going to cover the cost of the visit. What information can the nurse give the client? A. Medicare will only pay the cost for acute-care services if the client has a very low income. B. Medicare has a copayment for many of the services it covers. This requires the client to pay a part of the bill. C. Medicare will not pay for the cost of acute-care services so the client will be billed for the services provided. D. Medicare pays for 100% of the cost for acute-care services, so the cost of the visit will be covered.

B. Administer an analgesic as prescribed to facilitate the client's mobility

An elderly woman diagnosed with osteoarthritis has been referred for care. The client has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention will best promote the client's mobility? A. Motivate the client to walk in the afternoon rather than the morning B. Administer an analgesic as prescribed to facilitate the client's mobility C. Have another person with osteoarthritis visit the client D. Encourage the client to push through the pain in order to gain further mobility

A. The total body surface area (TBSA) affected by the burn.

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to the injury? A. The total body surface area (TBSA) affected by the burn. B. The source of the burn C. The length of time since the burn D. The location of burned skin surfaces

D. Centers for Disease Control and Prevention (CDC)

An infectious outbreak of unknown origin has occurred in a long term care facility. The nurse who oversees care at the facility should report the outbreak to what organization? A. American Nurses Association (ANA) B. American Medical Association (AMA) C. Environmental Protection Agency (EPA) D. Centers for Disease Control and Prevention (CDC)

D. Self-care deficit related to fatigue and joint stiffness

An older adult client has a diagnosis of rheumatoid arthritis (RA) and has been achieving only modest relief with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). When creating this client's plan of care, which nursing diagnosis would most likely be appropriate? A. Ineffective airway clearance related to chronic pain B. Anxiety related to chronic joint pain C. Risk for hopelessness related to body image disturbance D. Self-care deficit related to fatigue and joint stiffness

C. Tell me about your medications: How do you usually get them each day?

An older adult is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to his primary care clinic by wheel chair for follow-up care of hypertension and other health problems. The nurse should modify his health history to include which question? A. Tell me about where you live: Do you feel your needs are being met, and do you feel safe? B. What limitations are you dealing with related to your health and being in a wheelchair? C. Tell me about your medications: How do you usually get them each day? D. Your wheelchair would seem to limit your ability to move around. How do you deal with that?

Increased time for wound healing

What age related change would effect a client's course of treatment with a pressure ulcer?

Drug toxicity. They have a decreased metabolism. With pain management, always apply the nursing process

What are the elderly at risk of regarding pain management?

Muscle cramps in arms and legs, muscle spasms Cardiac dysrhythmias Critical for nerve cell conduction Hyperactive deep tendon reflexes Parasthesia of extremities Confusion Moodiness and anxiety Hypercalcemic tetany and seizures Positive Chvosteks and Trousseau's signs

Hypocalcemia symptoms

Thyroid

What body structure can be palpated?

Receptive- Cant comprehend what is being said. Expressive- Cannot get thoughts out Global is both Help provide board with common themes of communication

Aphasia

Respiratory Shallow, ineffective respirations resulting from profound weakness of skeletal muscles Diminished breath sounds Neuromuscular Anxiety, lethargy, confusion, coma Loss of tactile discrimination Generalized skeletal muscle weakness Deep tendon hypoflexia Eventual flaccid paralysis

Hypokalemia

90

At an annual physical, a patient weighs 198 pounds, which is the equivalent of ________ kilograms

B. It supports safety precautions for the nurse when making a home care visit

At the beginning of a day that will involve several home visits, the nurse has ensured that the health care agency has a copy of the nurse's daily schedule. What is the rationale for this action? A. It allows the agency to keep track for billing purposes. B. It supports safety precautions for the nurse when making a home care visit C. It allows for greater flexibility for the nurse and his or her colleagues for changes in assignments. D. It allows the client to cancel or change appointments with minimal inconvenience.

Hypotension Dysrhythmias Tetany Memory loss, confusion Seizures Tremors Hyperactive deep tendon reflexes Positive Chvosteks and Trousseau's signs

Hypomagnesemia

Muscle cramps Muscle twitching Headache Dizziness Confusion Convulsions Coma

Hyponatremia symptoms

Hypotension Decreased cardiac output Cardiomyopathy Cyanosis Respiratory failure Muscle weakness, malaise, anorexia

Hypophosphatemia

Excess Potassium intake Retention of Potassium Excessive release of Potassium Excessive Potassium IV infusion

Causes of Hyperkalemia

Inadequate intake Increased utilization Metabolic disorders Alkalosis Excessive loss of potassium Renal loss, renal disease

Causes of hypokalemia

A. Assessing and analyzing family history data for genetic risk factors D. Identifying individuals and families in need of referral for genetic testing E. Ensuring privacy and confidentiality of genetic information

Critical thinking and decision-making skills are essential parts of nursing in all venues. What are examples of the use of critical thinking in the venue of genetics-related nursing? Select all that apply A. Assessing and analyzing family history data for genetic risk factors B. Providing a written report on genetic testing to an insurance company C. Notifying individuals and family members of the results of genetic testing D. Identifying individuals and families in need of referral for genetic testing E. Ensuring privacy and confidentiality of genetic information

A. Milk C. Poultry E. Liver

The nurse is providing discharge teaching to a client who had hypophosphatemia during his time in the hospital. The client has a diet prescribed that is high in phosphate. What foods should you teach this client to include in his diet? Select all that apply A. Milk B. Beef C. Poultry D. Green vegetables E. Liver

Keloid- a raised scar after an injury has healed Ulcer- a sore Fissure- split or crack to form a long, narrow opening Erosion- the gradual destruction of tissue by physical or chemical action

Define: Keloid Ulcer Fissure Erosion

Used for diseases or germs that are spread in tiny droplets caused by coughing or sneezing (pneumonia, influenza, whooping cough, bacterial meningitis). Wear a surgical mask when in the room

Droplet precautions

Main symptoms involve muscle activity, such as jerking, loss of muscle tone or repeated movements.

Focal seizure

A. Hypocalcemia

The nurse is called to a client's room by a family member who voices concern about the client's status. On assessment, the nurse finds the client tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. The nurse also identifies 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this client's signs and symptoms? A. Hypocalcemia B. Hyponatremia C. Hypophosphatemia D. Hyperchloremia

tonic clonic body, arms, and legs will contract, extend, straighten out, followed by post-ictal period (confusion) flipping around

Generalized seizure

Diagnostic tool used to determine level of consciousness

Glasgow coma scale

A fracture in a young, soft bone in which the bone bends and breaks.

Greenstick fracture

Hemhorragic (bleed) Early sign is altered level of consciousness

Hemhorragic Stroke

Administer drops in conjunctival sac, while holding lacrimal duct.

How do you administer eye drops?

R-respiratory O- opposite M-metabolic E-equal Compensated- pH normal PAC02 and HC03 abnormal Partially compensated-All numbers abnormal

How to read ABG's

Decreased peristalsis Muscle weakness or flaccidity Cardiac dysrhythmias Confusion, personality changes Altered consciousness Coma

Hypercalcemia

***Potassium effects the heart*** Cardiovascular: Irregular heart rate Decreased BP Dysrhythmias: VFib, arrest Respiratory: Nothing until late Early Phase: Muscle twitches, cramps, paresthesia and irritability Late Phase: Profound weakness, ascending flaccid paralysis with arms and legs

Hyperkalemia

Cardiac arrhythmias Hypotension, bradycardia Hypoactive deep tendon reflexes Depressed respirations Depressed neuromuscular activity

Hypermagnesemia

Thirst, dry mucous membranes Tachycardia Hyperactive reflexes Agitation Confusion Lethargy

Hypernatremia symptoms

Anorexia Positive Chvostek or Trousseau's sign Decreased mental status Hyperreflexia Muscle weakness, cramps, spasms Paresthesia Tetany Papular eruptions

Hyperphosphatemia

Slow discontinuation of corticosteroids therapy can halt the progression of osteoperosis

If a client suffers from osteoporosis, what should be done in regards to their use of corticosteroid therapy?

Occurs when the broken ends of the bone are jammed together by the force of the injury.

Impacted fracture

A. Home health nurse B. Physical therapist D. Social worker

In 2 days the nurse is scheduled to discharge a client home after left hip replacement. The nurse has initiated a home health referral and met with a team of people who have been involved with this client's discharge planning. Knowing that the client lives alone, who would be appropriate people to be in on the discharge planning team? Select all that apply A. Home health nurse B. Physical therapist C. Pharmacy technician D. Social Worker E. Meals-on-Wheels provider

C. Evaluation

In response to a client's report of pain, the nurse gives a PRN dose of hydromorphone. In what phase of the nursing process should the nurse determine whether this medication has had the desired effect? A. Assessment B. Data collection C. Evaluation D. Analysis

C. To identify diseases that may be genetic.

In the course of performing an admission assessment, the nurse has asked questions about the client's first and second order relatives. What is the primary rationale for the nurse's line of questioning? A. To determine how many living relatives the client has. B. To identify the family's level of health literacy C. To identify diseases that may be genetic D. To identify potential sources of social support.

Diabetes. Perform a fingerstick.

What can mimic alcohol intoxication? What can you do to confirm that it is not alcohol?

No tissue perfusion Primary assessment is cardiac and respiratory

Ischemic stroke

C. By palpating the client's skin.

The nurse is performing a comprehensive assessment of a client's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessments in what way? A. By examining the client under a Wood light B. By inspecting the client's skin in direct sunlight C. By palpating the client's skin D. By performing percussion of major skin surfaces

D. A decrease in muscle mass and bone density.

The nurse is planning an educational event for the nurses on a subacute medical unit on the topic of normal, age related physiologic changes. What phenomenon should the nurse address? A. A decrease in cognition, judgment, and memory B. The disappearance of sexual desire for both men and women. C. An increase in sebaceous and sweat gland function in both men and women. D. A decrease in muscle mass and bone density.

To reduce the incidence of hospital acquired infections

National patient safety goal

pH 7.35-7.45 CO2 35-45 HCO3 22-26

Normal values for pH, C02, and HC03

C. Thorough and evidence-based education initiatives

Nurses in acute care settings must work with other health care team members to maintain quality care while facing pressures to care for patients who are hospitalized for shorter periods of time than in the past. To ensure positive health outcomes when patients return to their homes, what action should the nurse prioritize? A. Promotion of health literacy during hospitalization B. Close communication with primary providers C. Thorough and evidence-based education initiatives D. Participation in continuing education initiatives

2

Order: Prozac 40 mg b.i.d., morning and noon Supply: Prozac 20 mg per tablet Give: ________ tablet(s)

1.2

Order: Solu-Medrol 75 mg IM b.i.d. Supply: Multi-dose vial of Solu-Medrol 500mg Directions: Reconstitute with 8mL of bacteriostatic water to yield 125 mg/2mL Give ____________ mL

Confusion; roll them to their side and let them sleep.

What happens during the postictal stage of a seizure and what does the nurse do for the client?

Hypocalcemia-most common Hypomagesemia Hyperphosphatemia

Positive Chvostek sign

B. Increasing mean and median age of the population

Professional nursing expands and grows because of factors driven by the changing needs of health care consumers. Which of the following is a factor that nurses should reflect in the planning and provision of healthcare? A. Gradual increases in the cultural unity of the population B. Increasing mean and median ages of the population C. Decreased access to health care information by individuals D. Decreasing consumer expectations related to health care outcomes.

Helps with continuity of care

What is a benefit of a referral system?

Responsible for regulating the body's blood pressure. Stimulated by low blood pressure or certain nerve impulses, the kidneys release an enzyme called renin.

Renin-angiotensin-aldosterone system (RAAS)

Decreased urine output Altered LOC, fatigue, headache, diarrhea, anorexia, nausea and vomiting Seizures Edema will not accompany the fluid volume excess (third spacing) -results in water retention and hyponatremia

SIADH

Air emboli- air in vein Phlebitis- inflammation of vein Infiltration- fluid goes out of vein into interstitial fluid

Terms: Air emboli Phlebitis Infiltration

D. It threatens the client's autonomy

The care team has deemed the occasional use of restraints necessary in the care of a patient with Alzheimer's disease. What ethical violation is most often posed when using restraints in a long-term care setting? A. It is not normally legal B. It exacerbates the client's disease process C. It limits the client's personal safety D. It threatens the client's autonomy

B. Effective adaptation skills D. Increased life experience E. Resiliency during change

The case manager is working with an 84 year old client newly admitted to a rehabilitation facility. When developing a care plan for this older adult, which factors should the nurse identify as positive attributes that enhance coping in this age group? Select all that apply. A. Decreased risk taking B. Effective adaptation skills C. Avoiding participation in untested roles D. Increased life experience E. Resiliency during change

D. Evaluation

The client admitted with right leg thrombophlebitis is to be discharged from an acute care facility. Following treatment with a heparin infusion, the nurse notes that the client's leg is pain free, without redness or edema. Which step of the nursing process does this reflect? A. Implementation B. Diagnosis C. Analysis D. Evaluation

B. Acute

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? A. Rehabilitation B. Acute C. Immediate resuscitative D. Emergent

B. Air ducts and vents should be sealed

The emergency response team is dealing with a radiation leak at the hospital. What action should be performed to prevent the spread of the contaminants? A. Waste must be promptly incinerated B. Air ducts and vents should be sealed C. The ventilation systems should be deactivated D. Floors must be scrubbed with undiluted bleach

C. Metabolic acidosis with a compensatory respiratory alkalosis

The emergency room nurse is caring for a trauma client. Your client has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? A. Respiratory acidosis with no compensation B. Metabolic alkalosis with a compensatory alkalosis C. Metabolic acidosis with a compensatory respiratory alkalosis D. Metabolic acidosis with no compensation

C. Reinforce teaching about the pain scale number system.

The nurse is assessing a client's pain while the client awaits a cholecystectomy. The client is tearful, hesitant to move, and grimacing, but rates his pain as a 2 on a 0-to-10 pain scale. How should the nurse best respond to this assessment finding? A. Administer analgesic and then reassess. B. Reassess the client's pain in 30 minutes. C. Reinforce teaching about the pain scale number system. D. Remind the client that he is indeed experiencing pain.

High risk of infection

What is a nursing priority in regards to a patient with an open fracture?

D. There is a need to inform his primary care provider and pharmacist about the herbal remedies.

The home health nurse is making an initial home visit to an older client who is a widower. The client takes multiple medications for the treatment of varied chronic health problems. The client states that he has also begun taking some herbal remedies. What should the nurse be sure to include in the client's teaching? A. It is safest to avoid the use of herbal remedies. B. Herbal remedies are often cheaper than prescribed medications. C. Herbal remedies are consistent with holistic health care. D. There is a need to inform his primary care provider and pharmacist about the herbal remedies.

A. Call the client to obtain permission to visit

The home health nurse receives a referral from the hospital for a client who needs a home visit for wound care. After obtaining the referral, what action should the nurse first take? A. Call the client to obtain permission to visit B. Have community services make contact with the client C. Obtain a physician's prescription for the visit D. Arrange for a home health aide to initially visit the client

Depressed respirations

The most consistent diagnosis related to hypermagnesemia and respiratory is:

C. Maintain head of bed elevated at 30 to 45 degrees.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? A. Position the client in prone position B. Position the client supine C. Maintain the HOB elevated at 30 to 45 degrees D. Maintain bed in Trendelenburg position

B. Monitor for signs of drug toxicity due to a decrease in metabolism.

The nurse has been frequently assessing an older adult's pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a client of this age, what principle should the nurse best apply? A. Administer analgesics every 4 to 6 hours as prescribed to control pain. B. Monitor for signs of drug toxicity due to a decrease in metabolism. C. Monitor for an increase in absorption of the drug due to age-related changes. D. Monitor for a paradoxical increase in pain with opioid administration.

B. Ensuring high-quality client care

The nurse has integrated the principle of evidence-based practice into care. EBP has the potential to help the nurse achieve what? A. Increasing career satisfaction B. Ensuring high-quality client care C. Enhancing the public's esteem for nursing D. Obtaining federal grant money

B. 5 minutes

The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye? A. 30 seconds B. 5 minutes C. 1 minute D. 3 minutes

A. Palpation

The nurse is beginning a shift on a medical unit and is performing assessments appropriate to each client's diagnosis and history. When assessing a client who has an acute staphylococcal infection, what is the most effective technique for assessing the lymph nodes of the client's neck? A. Palpation B. Inspection C. Percussion D. Auscultation

B. How the presence of pain affects clients and families D. Resources that can assist the client with pain management E. The advantages and disadvantages of available pain-relief strategies

The nurse is caring for a client admitted to the medical-surgical unit after an injury. The client states "I hurt so bad. I suffer from chronic pain anyway, and now it is so much worse. When planning the client's care, what variables should the nurse consider? A. The influence of the client's cognition on her pain B. How the presence of pain affects clients and families C. The difference between acute and intermittent pain D. Resources that can assist the client with pain management E. The advantages and disadvantages of available pain-relief strategies

A. Diminished deep tendon reflexes

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? A. Diminished deep tendon reflexes B. Acute flank pain C. Cool, clammy skin D. Tachycardia

A. Valid and reliable research D. The nurse's expertise and judgment E. The client's preference

The nurse is caring for a client in the emergency department and is implementing evidence-based practice (EBP). What considerations should inform the nurse's evidence-based care? Select all that apply. A. Valid and reliable research B. The nurse's preferences C. Cost considerations D. The nurse's expertise and judgement E. The client's preferences

B. Fluid volume status

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health? A. Nutritional status B. Fluid volume status C. Calcium balance D. Potassium balance

D. The client will demonstrate the correct injection technique with today's teaching

The nurse is caring for a client with a newly diagnosed allergy to peanuts. What immediate goal should the nurse apply should the nurse apply to a nursing diagnosis of deficient knowledge related to appropriate use of an EpiPen? A. The nurse will teach the client's family member to administer the injection B. The client will return to the clinic within 2 weeks to demonstrate the injection C. The client will closely observe the nurse demonstrating the injection D. The client will demonstrate correct injection technique with today's teaching

B. Obeys commands with appropriate motor responses

The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document after providing interventions for this diagnosis? A. Registers normal body temperature B. Obeys commands with appropriate motor responses C. Pays attention to grooming and appearance D. Copes with sensory deprivation

A. Resting in an air conditioned room whenever possible.

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Resting in an air conditioned room whenever possible B. Taking a hot bath at least once daily C. Increasing the dose of muscle relaxants D. Avoiding naps during the day

C. He should likely take showers rather than baths, if possible.

The nurse is caring for an 85-year old who has been hospitalized for a fractured radius. The client's daughter has accompanied the client to the hospital and asks the nurse what her father can do for his very dry skin, which has become susceptible to cracking and shearing. What is the nurse's best response? A. Dry skin is an age-related change that is largely inevitable. B. Try to help your father increase his intake of protein C. He should likely take showers rather than baths, if possible D. Make sure that he applies sunscreen each morning.

A. Allergies B. Alcoholism E. Obesity

The nurse is completing a family history for a client who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems? A. Allergies B. Alcoholism C. Psoriasis D. Hypervitaminosis E. Obesity

D. They can experience acute pain in addition to chronic pain.

The nurse is creating a nursing care plan for a client with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of clients who live with chronic pain should be integrated into care planning? A. They often have an increased tolerance of pain. B. They often have a lower pain threshold than clients without chronic pain. C. They are typically more comfortable with underlying pain than clients without chronic pain. D. They can experience acute pain in addition to chronic pain.

D. Ambulate the client twice per day with partial assistance

The nurse is following the care plan that was created for a client newly admitted to the hospital unit. What aspect of the care plan should the nurse consider to be a nursing implementation? A. The client appears diaphoretic B. The client is at risk for aspiration C. The client will express an understanding of her diagnosis D. Ambulate the client twice per day with partial assistance

B. Rapid access to client information by everyone involved in the client's care

The nurse is involved in a program that aims to increase the use of health informatics. What is the most likely outcome of this program if it is successful? A. Centralization of care into the centers where there are more health professionals B. Rapid access to client information by everyone involved in the client's care C. Increased interprofessional collaboration D. Increased participation by clients in their care

D. Culturally sensitive materials, such as the Mediterranean Pyramid

The nurse is orienting a new nursing graduate to the medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should the nurse refer the colleague to obtain appropriate dietary recommendations for this client? A. A Greek cookbook that contains academic references B. Evidence based websites with multi cultural content C. Evidence based written resources with nutritional assessment D. Culturally sensitive materials, such as the Mediterranean Pyramid

C. Hypovolemia

The nurse is working on a burns unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of what imbalance? A. Hypercalcemia B. Hypermagnesemia C. Hypovolemia D. Metabolic alkalosis

C. Medication should be taken when pain levels are low so the pain is easier to reduce.

The nurse who is a member of the palliative care team is assessing a client. The client indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this client? A. The client will likely benefit from more distraction than pharmacologic interventions. B. Pain medication can be increased when the pain becomes intense. C. Medication should be taken when pain levels are low so the pain is easier to reduce. D. It is difficult to control chronic pain, so this is an inevitable part of the disease process.

690

The total fluid intake of the below is _________ mL 1 ounce= 30 mL Coffee 3 ounces Ginger Ale 10 ounces Water 6 ounces Broth 4 ounces

Metabolic alkalosis

What is a patient who has been in intermittent suctioning at risk for?

Make sure that clients know what resources are available to them.

What is a priority for a nurse that works within the community?

Ineffective airway clearance

What is an appropriate nursing diagnosis for community acquired pneumonia?

Hep B

Vaccine serious that healthcare workers should get