Review

The family of an elderly woman asks the nurse how to help their mother sleep better. The family's sleep is disturbed as a result, and the family is concerned that their mother is not getting restful sleep. Which questions would be important for the nurse to ask?

. Has there been any change in your mother's state of health? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels?

A client with a history of peptic ulcer disease arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 26, T 98, O2 sat 88%. Which primary healthcare provider prescription should the nurse perform first?

1. Correct: The client is showing signs of shock and needs all of the above interventions. However, go back to the ABC's. Oxygen needs to be initiated first because the O2 sat and the increased respiratory rate. 2. Incorrect: Fluids are needed to increase blood pressure and tissue perfusion. If O2 sats were above 90 then this would be the first priority. 3. Incorrect: The "coffee looking" contents indicate GI bleeding. The NG tube will empty the stomach and monitor the bleeding but is not the top priority to prevent harm to the client. 4. Incorrect: The client has an increased heart rate and if the oxygen and circulation are not improved, problems could occur. Attaching the client to an ECG monitor will allow you to monitor thew heart for arrthymias or impending damage due to decrease oxygen. Necessary but not the first priority.

What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy?

1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor Because lymphedema is a lifelong threat, teach the client hand and arm precautions to minimize the risk of injury, infection, and impaired circulation. All of these options are correct options to minimize these risks. Even a minor injury such as a pin prick or sunburn can cause painful swelling after lymph node removal.

The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint.

1., 2., & 3. Correct: Assessment for VTEs is accomplished by measuring the calf and thigh daily, observing swelling, noting unusual warmth of the leg, and asking the client about pain in the calf. Prevention of VTEs include the use of sequential compression devices for bedridden clients. This device helps promote venous return. Positioning the paralyzed leg with each distal joint higher than the proximal joint will prevent dependent edema. 4. Incorrect: A trochanter roll does not prevent VTEs. They are used for the prevention of external hip rotation. 5. Incorrect: Passive range of motion exercises should be done several times a day to promote venous return and muscle tone. Once a day is not adequate. 6. Incorrect: Routinely checking the Homan's sign can actually cause a clot to dislodge. The nurse should not perform this procedure.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider?

2. Correct: Breathlessness while talking indicates respiratory fatigue. Preparation for intubation needs to be made. 1. Incorrect: If the vital lung capacity drops below 800 mL, mechanical ventilation is warranted. 3. Incorrect: Imminent signs of respiratory failure include a heart rate greater than 120 beats per minute or less than 70 beats per minute. 4. Incorrect: Imminent signs of respiratory failure include a respiratory rate greater than 30 breaths per minute.

Which discussion points should a nurse plan to include when teaching a group of college students on prevention of sexually transmitted infections (STI)?

All of these topics should be included when discussing prevention of STIs. Safe sex practices include proper use of condoms. Abstinence is the best way to prevent STIs. Vaccines are available for some STIs such as human papillomavirus vaccine (HPV).

What foods should the nurse inform the client to avoid for three days prior to a guaiac test?

Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloupe, radish, and horseradish. All of these could cause a false positive reading for the guaiac test.

Which primary healthcare provider prescription should be implemented first?

Full thickness burns of both legs would result in a severe fluid volume deficit. A priority treatment for burns include fluid replacement; therefore, insertion of 2 large bore IVs is a priority.

Emphysema - permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls **airway resistance is increased, esp on expiration

Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels.

The nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include?

Meningococcal vaccine protects against bacterial meningitis and is recommended for students entering college. Influenza vaccine is recommended annually for protection against the viruses predicted to be most common for the season. Human papilloma virus vaccine is recommended for protection against the virus which causes cervical and anal cancers. 1. Incorrect: Rotavirus vaccine is recommended during infancy. Rotavirus is the most common cause of diarrheal disease among infants and children. 3. Incorrect: Herpes zoster vaccine is recommended for adults, over the age of 60 to reduce the risk of getting shingles.

A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first?

Place client on bedrest with left leg elevated. Osteomyelitis is a serious inflammation of bone tissue caused when bacteria or fungus has entered the body through an open wound, an infected prosthetic, or even animal bite. Symptoms include fever, chills, nausea, and fatigue with decreased mobility in the affected extremity. The client can quickly become septic as the illness spreads through the system. Bedrest along with massive doses of antibiotics are necessary to prevent the spread of the infection, resulting in possible bone death or even amputation. 1. Incorrect: Since the nurse is in the process of admitting this client, wound care is not a priority action. There are more urgent orders to be implemented in order to stabilize the client. 2. Incorrect: Intravenous antibiotics are generally prescribed for up to six weeks, and the client may need a PICC line to continue antibiotic therapy in the home setting. While starting an I.V. line for antibiotic administration is important, this is not the most crucial first action. 4. Incorrect: Lab tests can provide valuable diagnostic information about clients with osteomyelitis. The Healthcare provider would most likely order a complete blood count (CBC) and sediment rate, expecting elevations in both. Blood cultures would also confirm whether the infection has become systemic. However, a venipuncture can wait until a more important action has been completed.

advanced cirrhosis is admitted with dehydration and elevated ammonia levels

Protein must be limited because of elevated ammonia levels. Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client.

cystitis

Signs and symptoms of cystitis include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain. Flank pain is seen when the urinary tract infection progresses to the kidneys.

The nurse plans to teach a client how to manage the use of a behind the ear hearing aid. What teaching strategies should the nurse include?

The residual from the hair spray causes the hearing aid to become oily and greasy. The client should routinely inspect the hearing aid for damage, especially where damage is more likely: ear mold, earphone, dials, cord, and connection plugs.

Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung.

This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung.

Aplastic anemia

pancytopenia(RBC, WBC, and platelets are reduced), fatigue, and pale mucous membranes, DOE,

failure to capture pacemaker

sharp spikes at 72/min; QRS complexes at 50 beats/min - may be due to poor positioning of the pacer electrode and is referred to as lack of capture

A nurse is caring for a client on the second day after a thoracotomy. The client reports incisional pain. The nurse assesses the client and evaluates the vital signs. Based on the data documented in the chart, what action should the nurse take first?

3. Correct: The client described in this question is post thoracotomy. With ANY post-op client, the number one concern, especially as a brand new nurse, is preventing pneumonia. A thoracotomy is very painful and the client is unlikely to breathe deep unless the pain is relieved. Temperature of 100º F/37.8ºC, HR 92, respirations 24, bilateral crackles (indicating atelectasis) all reveal this client is heading for pneumonia. 1. Incorrect: Coughing and deep breathing exercises are exactly what the client needs, but the client will not cough and deep breathe if it hurts. Give pain medication first. 2. Incorrect: Acetaminophen is not potent enough to relieve pain. The goal is to "fix the problem". The problem is that the client is not properly deep breathing due to pain. 4. Incorrect: Assisting the client to ambulate is a good idea, but the nurse has to fix the problem, and the problem is that the client is not deep breathing.

A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform?

1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min. 1., 2., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring, watching for dysrhythmias, monitor I&O hourly to make sure kidneys are perfused. Limit activity to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output. 3. Incorrect: Position upright to promote optimal ventilation by reducing venous return and lessen pulmonary edema.

A child is brought into the emergency department (ED) after accidently ingesting 3 grams of acetylsalicylic acid. Initial assessment reveals lethargy, excessive sweating, hyperventilation, and hyperthermia. What interventions should the nurse initiate?

1., 2., 3., 4., & 5. Correct: This client has hyperthermia. Methods to decrease temperature include external cool down, such as with a tepid water sponge bath. Dehydration occurs early in aspirin poisoning due to vomiting and hyperventilation. IV fluid is needed to offset the dehydration. Gastric lavage and activated charcoal are needed to deactivate the aspirin. The child is at risk for seizures so pad the side rails for safety. Care is based on blood gas results. Metabolic acidosis is the imbalance of the most concern. 6. Incorrect: Although ipecac syrup was used commonly in the past to make a client vomit, it is rarely recommended today. It would not be suggested in aspirin poisoning due to the chance that the client might develop altered mental status or convulsions.

A client is to be discharged following cataract removal with lens implantation. What statement by the client indicates to the nurse that teaching has been successful? You answered this question Incorrectly 4. "My vision will be blurry for a couple weeks."

4. Correct: Following cataract removal, a new lens is sutured in place, which slightly alters the corneal curve. Newer surgical approaches involve the use of a "suture-less glue" but that method is less common. Although the client's vision will eventually improve and stabilize, minor blurring may exist during the 6 to 12 week healing period. After that time, any remaining visual issues can be corrected with glasses. 1. Incorrect: Only the operative eye is protected by an eye patch during the healing process. The primary healthcare provider will remove that covering at the first post-operative checkup. Covering both eyes would pose a greater safety risk and decrease the client's self care abilities. 2. Incorrect: Pain following cataract surgery is the sign of a serious complication and should be reported to the surgeon immediately. Clients may experience a small amount of serous drainage or scratchy sensation, but should not have pain. 3. Incorrect: Implantation of a new lens causes a mild astigmatism that will be permanent. The client may still need to use corrective lenses, even if just for reading.

The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? 1. Yes, bring the sleep apnea machine.

A client with sleep apnea is at risk for cardiac and respiratory complications postop due to decreasing oxygenation. So yes, the client needs to use the CPAP machine. Remember this client will also be receiving narcotics for pain and have a decreased activity level as well. All of these things can decrease oxygenation.

acute angina attack

transient abnormal PMI, tachycardia, transient diastolic murmur, pulsus paradoxus

A client receiving palliative care is reporting constipation. What intervention should the palliative care nurse provide first?

Increase fluid intake is correct. Dehydration is one of the most common causes of constipation. Fluids keep your stool soft and easy to pass. 1. Incorrect: Fiber should be increased. This is true but water is the first intervention that should be implemented. Fiber will increase bulk and help with passage of stool but fluids should be first. 2. Incorrect: Administering an enema would not be the first thing to try for constipation. Least invasive first. Avoid medicines as long as possible. 4. Incorrect: Docusate sodium is colace and a stool softener, although appropriate avoid medicines as long as possible.

What interventions should the nurse include in the care plan of a client admitted with Guillain-Barre syndrome?

Keep a sterile tracheostomy at the bedside. Monitor for heart rate above 120/min This client is at risk for respiratory paralysis as the disease progresses. An emergency tracheostomy may need to be performed so the nurse should watch out for imminent signs of respiratory failure. Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm. The nurse should assess for signs of respiratory distress and prepare for intubation if needed.

What potential contributing factors for stress urinary incontinence should a nurse assess for in an elderly female client?

Lack of estrogen Rising abdominal pressure Multiparous vaginal births During pregnancy and childbirth, the sphincter and pelvic muscles stretch out and are weakened. Increased age, decreased estrogen, and a history of multiple vaginal births/pregnancies are contributing factors for stress incontinence.

A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority?

Laryngospasm

A Holter monitor is a mobile diagnostic test utilized by the cardiologist to help determine a cause for this client's syncopal episodes or arrhythmias. Once the client has the monitor and electrodes removed, the primary healthcare provider will analyze the data before meeting with the client to discuss the findings. Regardless of any suggested treatment options, the cardiologist needs a follow up visit with the client. 2. Incorrect: Showering or tub bathing is not permitted while wearing the Holter monitor as this may interfere with the functioning of the equipment. Only a careful sponge bath is permitted. Clients are also instructed to avoid heavy machinery, electric razors, microwave ovens and even hair dryers since can also affect accuracy and performance of the monitor. 3. Incorrect: The purpose of wearing Holter monitor for 24-48 hours is to diagnose cardiac arrhythmias during ADL's or exercise. The client cannot remove the monitor at any time during that period since that would cause inaccurate readings, or even the loss of valuable data. The client is instructed to complete all routine daily activities during that time, including work or exercise, to help identify actions that contribute to the symptoms or cardiac irregularities.

The purpose of the Holter monitor is to detect cardiac irregularities over an extended period of time, in this case 48 hours. Although the monitor will record heart rate and rhythm for two days, it is vital for the client to keep a log or diary during that time, indicating the precise time and type of every activity. Additionally, this log needs to indicate any chest pain or palpitations the client experiences during that time, to assist the primary healthcare provider in diagnosing cardiac dysfunctions.

changes associated with menopause - dramatic decline in estrogen

loss of muscle mass, increased fat tissue leading to thicker waist, dryness of the skin and vagina, hot flashes, sleep abnormalities, and mood changes.

Myasthenia gravia - s/s of cholinergic crisis

signs of cholinergic crisis include DUMBELLS Diarrhea and abdominal cramping Urination increased Miosis (pinpoint pupils) Bradycardia Emesis (nausea and vomiting) Lacrimation Lethargy Salivation Muscles get weaker so BP would go down.

Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy?

sudden weakness or paralysis on one side of the face that causes it to droop (main symptom), drooling, eye problems (such as excessive tearing or a dry eye), loss of ability to taste, pain in or behind ear, numbness in the affected side of face, increased sensitivity to sound

vfib

check for apical pulse then start cpr, give epi after unsuccessful defib

Polcythemia vera

headaches, paresthesias, dizziness

pernicious anemia

macrocytosis, low levels of B12, SOB

Sickle cell anemia

vascular occlusion, fatigue, and joint pain

Neutropenic Precaution

1) Fresh fruits and vegetables have a high bacterial count and present an increased risk for infection. Asking dietary to remove fresh fruits and vegetables from meal trays is an important priority action by the nurse. 2) Avoiding venipunctures of any type, including IM injections, is an important precaution for neutropenia, in which infection is the main concern. However, the word "ALL" makes this statement to definite. The client may need an IV. Remember, nothing is that definite in the world.

A client has been admitted to the telemetry unit with a diagnosis of a cerebral vascular accident. What should the nurse assess to determine the client's risk for aspiration?

1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex 1., 2., 3., & 4. Correct: Assessing the ability of a client to swallow is something the nurse can and should do. A small amount of water should be given to the client as the nurse observes for coughing or gurgling. If the nurse suspects a client is having difficulty safely swallowing, further assessment by a speech and language therapist is recommended. To test for a gag reflex use a tongue depressor. Ask the client to open the mouth and look at their throat with a penlight. If the uvula and pharynx rise as the client says "aaahh" then the gag reflex is intact. If it does not rise, touch the back of the throat at the soft palate and watch for the rise in the pharynx in a gag response, If intact,the client should not be at risk for aspiration with eating. A client with a decrease level of consciousness is always at risk for dysphagia and aspiration. A cough reflex is assessed by administering a small sip of water and observing for a cough. if the client coughs, feeding should be withheld until further testing can be performed. 5. Incorrect: Assessing ability to follow commands does not identify a problem with swallowing. It does not provide a great deal of information about cognitive function. The other tests provide more information specific to aspiration.

Which comment by the client indicates understanding of possible complications of long term hypertension?

1. Correct: Hypertension is one of the leading causes of end stage renal disease. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications. 2. Incorrect: The appearance of the retina provides important information about the severity and duration of hypertension. Manifestations of severe retinal damage include blurred vision, retinal hemorrhage, and loss of vision. 3. Incorrect: Intermittent claudication is a complication of peripheral vascular disease (PVD). Hyper tension speeds up the process of PVD. 4. Incorrect: Lifestyle modifications include dietary sodium reduction, weight reduction, Dietary Approaches to Stop Hypertension (DASH) eating plan, moderation of alcohol consumption, regular physical activity, avoidance of tobacco use, and management of psychosocial risk factors

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident for assistive devices that will be needed upon discharge. Which resources should the case manager include for this client?

1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils

The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching?

2. Correct: In an upper GI series (sometimes called a barium swallow test), the client swallows barium contrast while x-rays are taken. 1. Incorrect: Laxatives are taken the night before a colonoscopy to ensure stool is cleared from the colon. Waiting to take the laxative the morning of the test would be ineffective and uncomfortable for the client. 3. Incorrect: Radiopaque dye injected before a CT (computed tomography) scan is not part of a GI series. This would be a totally different diagnostic test from the upper GI. 4. Incorrect: In a gastroscopy (sometimes called a gastric endoscopy), a scope is passed through the mouth to the stomach to visualize the inner lining of the upper GI tract.

A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful?

3. Correct: Hypothyroidism clients tend to have constipation due to decreased motility of the GI tract and need increased fiber and fluid intake. Popcorn is high in fiber. 1. Incorrect: People with hypothyroidism have a slow metabolism and do not need high protein but a well balanced diet. Almonds are high in protein. 2. Incorrect: Cheese and crackers are high in sodium. This client is at risk for CAD, so sodium should be limited. 4. Incorrect: This client does not need high potassium, which fried sweet potatoes have. The high potassium dietary approaches to stop hypertension (DASH) diet is only for healthy clients with hypertension.