Exam 4 Review

Cardiovascular Implementation for low mobility patient

- ↓ orthostatic hypotension: - ↓ cardiac workload - Prevent Thrombus Formation

Nursing Diagnosis: Implementation (Health Promotion) for immobile/low mobility patients includes:

-Bone health in patients with osteoporosis -Metabolic: provide high protein/calorie diet with Vit. B and C supplements -Respiratory: Encourage cough and deep breath with incentive spirometry every 1-2 hours

Implementation: Restorative and continuing care

-IADL's (instrumental activities of daily living), ROM exercise, walking: we only do what they can't do -ROM exercise -walking -SCDs

Integumentary changes due to immobility

-Pressure ulcers Inflammation Ischemia -Older adults at greater risk **Turn every 1-2 hrs**

Respiratory Implementation for low mobility patient

-cough and deep breathe q1h or q2h (incentive spirometry) -provide chest physiotherapy

Immobile patients are at high risk for developing what respiratory changes:

1) Atelectasis 2) Hypostatic pneumonia 3) Pulmonary emboli

An imaginary line connecting the highest point on each iliac crest would cross the ______________ vertebra.

4th lumbar

disuse osteoporosis

A decline is bone density that is associated with impaired mobility or immobilization of an extremity. Bones become brittle and weak and fracture easily. Causes high amount of calcium to be released in blood stream.

What is the dot? What is the line?

Center of gravity Line of gravity

Blood Stasis can lead to

Clot formation, Deep Vein Thrombosis

Nursing Diagnosis for immobility: most common

Impaired physical mobility

Nursing Diagnosis for immobility: Bladder

Impaired urinary elimination

Nursing Diagnosis for immobility: Psychosocial

Ineffective Coping/Social Isolation

Nursing Diagnosis for immobility: Respiratory

Ineffective airway clearance

Blood Stasis

Lack of circulation of blood due to a stop in blood flow often seen in immobile patients.

Which health promotion activities support a healthy lifestyle for clients with​ osteoarthritis? ​(Select all that​ apply.)

Maintaining a normal weight places less strain on the joints than carrying additional weight. Assistive devices such as grab​ bars, a shower​ chair, or​ long-handled grippers help the client to maintain an independent lifestyle in safety. ROM exercises assist the client to maintain maximal use of joint mobility and are an important component in the exercise plan. Although calcium intake is essential to prevent​ osteoporosis, especially in older​ adults, increasing calcium in the daily intake does not have a positive effect on osteoarthritis. Chairs and mattresses should provide support and help to maintain normal body alignment. Soft chairs and recliners do not provide such support.

When care is provided for a patient with an NG tube in place, which intervention is safest for the nurse to implement?

Mark the tube where it exists nose Once placement is confirmed, a red mark should be made or place tape on the tube to indicate where the tube exits the nose. The mark or the tube length is to be used as a guide to indicate whether displacement may have occurred. The tube should be taped to the nose, not to the ear. The tubing should be secured to the patient's gown, not to the bed, and should not be changed daily, but it may be irrigated daily.

In implementation: what can you do to ↓ cardiac workload

Medications: Beta blockers (reduce HR/BP) to reduce workload

Musculoskeletal Changes due to immobility:

Muscle effects: Lean body mass loss Muscle weakness/ atrophy Skeletal effects: Disuse osteoporosis Joint contracture

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:

Peritonitis

Integumentary: Implementation for low mobility patient

Reposition every 1-2 hrs If incontinent: ensuring barriers and cleaning ASAP

When providing care for a patient who is disoriented during a nasogastric (NG) tube placement, which intervention is important for the nurse to implement?

Request assistance with insertion

Nursing Diagnosis for immobility: Atrophy (contractures)

Risk for disuse syndrome

Nursing Diagnosis for immobility: Integumentary

Risk for impaired skin integrity

The nurse is preparing to administer an enema to a patient. Which type of enema is most likely to lead to circulatory overload?

Tap water

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?

Test for Murphy sign

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.

Test for the Blumberg sign

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?

The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).

The nurse has been directed to provide an enema for an elderly female patient who has very poor rectal sphincter control. Which position is most appropriate for this patient?

dorsal recumbent position on the bedpan

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the:

glenohumeral joint

In implementation: what can you do to ↓ orthostatic hypotension

have pt. sit on side of bed and slowly get it

The patient has a leg injury and is being fitted for a cane. The patient should be taught to:

hold the cane on uninvolved side

While examining your pt's head and face, you determine that CN I is intact when the pt follows your instructions and successfully:

identifies minty scent

Increased cardiac workload due to immobility is caused by:

increase of blood flowing into R. atrium increases preload when patient is lying static. this can lead to heart failure

A nurse encourages a patient to prevent venous stasis by:

increasing early ambulation

prone position

lying face down

supine position

lying face up

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the:

medial and lateral epicondyle

hypostatic pneumonia

pneumonia that results from fluid accumulation as a result of inactivity

The nurse knows that testing kinesthesia is a test of a person's:

position sense Kinesthesia, or position sense, is the persons ability to perceive passive movements of the extremities. The other options are incorrect.

Which activities related to urinary elimination may be delegated to a nursing assistive personnel (NAP)?

positioning the patient Nursing assistive personnel (NAP) may position the patient, focus lighting for the procedure, and enhance the patient's comfort during the procedure through measures such as holding the patient's hand or keeping the patient warm. The nurse uses sterile asepsis when inserting an indwelling or straight catheter to reduce the risk for bladder infection. The nurse evaluates possible alternatives to catheter use, and assessment is the responsibility of the nurse.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by:

projectile vomiting Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis.

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:

proximal to dista: midline outward

How to counteract osteoporosis

weight bearing exercise

The nurse is performing a focused interview with an older adult client. Which statements by the client are expected? Select all that apply. "I have been having loose stools every day for the last 3 years." "I know I just don't drink as much water as I should." "My belly seems softer and flabbier as I get older." "My mouth is always dry." "My heartburn gets worse the older I get."

"I know I just don't drink as much water as I should." "My belly seems softer and flabbier as I get older." "My mouth is always dry." Aging alters appearance of abdominal wall; Changes of the GI system occur with aging, but most do not significantly; affect function as long as no disease is present; Salivation decreases, leading to a dry mouth and decreased sense of taste; Esophageal emptying and gastric acid secretion are delayed; Incidence of gallstones increases with age; Although liver size decreases, most liver functions remain normal. However, drug metabolism is impaired; Aging adults frequently report constipation

Nursing Diagnosis: Implementation (Health Promotion) for immobile/low mobility patients includes: For Nurses

-prevention of work-related musculoskeletal injuries for ourselves as we work

sitting posture

1. Head in neutral position 2. Chin tucked or parallel to the floor 3. Elbows, knees, and hips flexed at 90 degrees 4. Feet flat on the floor or supported in a slightly inclined position 5. Forearms and lower back curve supported 6. Avoid slouching or a kyphotic posture

What diet do you want to encourage for mobility issues in implementation phase

1. High-protein (maintain skin integrity) 2. Small consumption of food = needs to be high calorie and high protein 3. Vitamin C: wound care and skin integrity 4. Vitamin B: energy production

An adult who opens her eyes in response to verbal stimuli, is disoriented, and pushes your hand away when you palpate a painful area has a Glasgow Coma Scale score of: 10 12 9 11

12

Of the 33 vertebrae in the spinal column, there are: 5 lumbar 5 thoracic 12 cervical 7 sacral

5 lumbar There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae in the spinal column.

The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? 15 12 24 6

6

A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains of:

A fracture causes sharp pain that increases with movement. The other types of pain do not occur with a fracture.

Sims position

A left side-lying position in which the upper leg (right leg) is sharply flexed so it is not on the lower leg (left leg) and the lower arm (left arm) is behind the person; semi-prone side position: Multiple pressure points

joint contracture

Abnormal and usually permanent condition of a joint, characterized by flexion and fixation and caused by disuse, atrophy, and shortening of muscle fibers.

During an interview the patient states, "I can feel this bump on the top of both of my shoulders. It doesn't hurt, but I am curious about what it might be." The nurse should tell the patient that it is his:

Acromion process

Musculoskeletal: Implementation for low mobility patient

Active or Passive ROM to prevent muscle atrophy and joint contractures Splints

A 40-year-old man has come into the clinic with complaints of extreme pain in his toes. The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest:

Acute gout

Elimination System: Implementation for low mobility patient

Adequate hydration ↑ fluids, fruit, vege, and fiber: prevent constipation

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

An enlarged spleen should not be palpated because it can easily rupture

What to do/ patient before positioning:

Ask pt. to help as much as possible: use muscles/helpful Determine pt. comfort level: tell exactly what you are doing (tuck chin) Determine if you need assistance - if immobile you need assistance. Protect yourself by working in teams/pairs

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurses next response should be to:

Ask the patient to lock her fingers and pull Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the persons position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.

What should the nurse do to verify nasogastric (NG) tube placement? (Select all that apply.) Ask the patient to speak. Obtain an x-ray of the placement. Aspirate back on the syringe. Auscultate the lung fields. Inspect the posterior pharynx.

Ask the patient to speak. Obtain an x-ray of the placement. Aspirate back on the syringe. Inspect the posterior pharynx. While a radiographic examination is the gold standard to verify NG tube placement, there are several steps the nurse can take to gauge correct placement. Ask the patient to speak. If the patient is unable to speak, the NG tube may have passed through the vocal cords. Inspect the posterior pharynx for the presence of a coiled tube. The tube is pliable and will coil up behind the pharynx instead of advancing into the esophagus. Aspirate gently back on the syringe to obtain gastric contents, observing color. Gastric contents are usually cloudy and green but sometimes are off-white, tan, bloody, or brown. Aspiration of contents provides the means to measure fluid pH and thus determine tube tip placement in the GI tract.

Part of the neurological exam is evaluating the response of the cranial nerves. To test cranial nerve VIII (CN VIII), the nurse should:

Assess the client's ability to hear the spoken word

assessing gait: look for

Base of support Stride Arm swing Posture

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds:

Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.

A 55-year-old female arrives to the ER with a right leg fracture. An x-ray is performed and shows a closed tibia fracture. A closed reduction is performed and a cast is put in place. The patient is ordered Morphine 2 mg IV every 4-6 hours as needed for pain. The patient calls on the call light to tell you the pain medication is not working and that it even hurts to slightly stretch the leg. What is your response to this statement by the patient? Select all that apply: A. Reassure the patient that this is normal after a bone fracture, and reposition the cast. B. Re-adjust the cast to ensure it fits snugly against the fracture. C. Perform neurovascular checks. D. Elevate the leg above heart level. E. Loosen and remove restrictive items. F. Notify the physician.

C. Perform neurovascular checks. E. Loosen and remove restrictive items. F. Notify the physician.

During an examination, a patient has just successfully completed the finger-to-nose and the rapid alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's ____________ function is intact.

Cerebellar

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? Cerebrum Cerebellum CNs Medulla oblongata

Cerebrum The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a persons level of consciousness.

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination?

Complete neurologic exam The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction.

pulmonary embolism

DVT causes blood clot that breaks off from a large vein and travels to the blood vessels of the lung, causing obstruction of blood flow. Can be fatal

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:

Decreased gastric acid secretions Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium.

Assessing patient for fall risk: look for

Depression Gait/balance impairment Using 4 or more meds

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply.

Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging.

Which symptom is the patient with fluid overload likely to exhibit? Oliguria Increased urine specific gravity Distended neck veins Increased skin temperature

Distended neck veins Cardiovascular signs of fluid volume excess include bounding pulse rate, normal blood pressure with or without orthostatic changes, third heart sound (S3), and distended neck veins. Oliguria is a renal sign of fluid volume deficit. Increased skin temperature is a sign of fluid volume deficit. Increased urine specific gravity is a renal sign of fluid volume deficit.

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should:

Document as normal and proceed A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span 2 to 3 cm larger or smaller than these values is considered abnormal. A liver span of 11 cm is within normal limits for this individual.

The nurse is completing passive ROM and bends pt. foot so toes point upward. Which skeletal movement has the nurse performed?

Dorsiflexion

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?

Dysfunction of the cerebellum

A nurse perfoms a neurologic assessment on a client with a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement?

Dysphagia Difficulty swallowing may occur as a result of the cranial nerves IX (glossopharyngeal) & X (vagus nerve).

How to counteract atrophy in immobile patients

Encourage any active movement that can be done: dorsiflex/plantar flex foot in bed. Every hour. Flexion of muscles. If can't move theirselves/paralyzed: Passive ROM is done

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?

Examine the tender area last

Asking a patient to read a Snellen Chart will evaluate his fifth cranial nerve. T/F

False The second cranial nerve (CN II) is responsible for visual acuity and can be evaluated with a Snellen Chart.

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient:

Flexing the hip

how to prevent foot drop

Foot pumps while laying down, splints, range of motion

The nurse is caring for a patient with paralysis. The nurse understands that foot drop is a common but preventable complication in these patients. Which statements are true about foot drop? Select all that apply. Footdrop is a type of debilitating contracture. The foot is permanently fixed in dorsiflexion position. The patient is unable to lift the toes off the ground. Patients with left- or right-side paralysis are at increased risk of developing footdrop. Footdrop can be treated with regular physiotherapy

Footdrop is a type of debilitating contracture. The patient is unable to lift the toes off the ground Patients with left- or right-side paralysis are at increased risk of developing footdrop. Footdrop is the most common type of debilitating contracture. The patient is unable to lift the toes from the ground, making it difficult to ambulate. Patients who have suffered a right- or left-sided paralysis are at increased risk of developing footdrop due to immobility. The foot is permanently fixed in plantar flexion. Once footdrop occurs, it cannot be treated. However, it can be prevented through regular physiotherapy.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the ____________ lobe.

Frontal The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

The nurse is palpating the right upper quadrant (RUQ) of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply.

Gallbladder, spleen

The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the:

Greater trochanter The greater trochanter of the femur is palpated when the person is standing, and it appears as a flat depression on the upper lateral side of the thigh. The iliac crest is the upper part of the hip bone; the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed; and the gluteus muscle is part of the buttocks.

In implementation: what can you do to prevent thrombus formation and thromboembolic disease (TED)

Heparin Subcut (5000 units QD/BID) Sequential Compression Devices (SCD) Hose Leg Exercises

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to:

Hop on one foot

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?

Hyperactive reflexes Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident).

The nurse has just completed an examination of a patients extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves?

III, IV, and VI

assessing joints: look for

Inspect: size, shape, color and symmetry. Compare bilateral findings. Palpate: edema, heat, tenderness, pain, nodules or crepitius Test Range of Motion: If limited ROM is foudn, measure ROM with goniometer

The nurse is explaining to a patient that there are shock absorbers in his back to cushion the spine and to help it move. Which parts of the spine is(are) the nurse referring to? Select all that apply.

Intervertebral discs Nucleus pulposus

A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often

Kidney inflammation Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct.

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is:

Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated

5 interventions to reduce falls in hospitalized pt.

Orient p. to surroundings Maintain bed in lowest position with wheels locked Ensure clear hallways Place call light and assistive devices w/in reach Raise side rails if needed Hourly rounding on pt.

Cardiovascular changes due to immobolity

Orthrostatic hypotension Increased cardiac workload Blood Stasis Thrombus Formation

compartment syndrome: 6Ps

Pain (earliest sign): more than normal Pallor: paleness distal end (toes), ischemia slow cap refill Paralysis (ask pt. to move toes) Pulse Deficit: late sign (mark where you hear pulse) Paresthia (tingling in toes/lower extremities: cut of blood/nerves) Poikilothermia (inability to regulate core body temperature, temp difference in broken limb)

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: Lack of coordination Ataxia Positive Romberg sign Negative Homan's sign

Positive Romberg sign Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis.

A client has undergone surgical repair via scleral buckling of a detached retina of the left eye with an injection of a gas bubble. The nurse should anticipate that the surgeon will prescribe the client to assume which postoperative position?

Prone position with operated eye up

Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate?

RLQ To the right of the umbilicus in the right lower quadrant is the ileocecal valve. This is where the small intestine connects to the large intestine, and it is normally very active with bowel sounds. Many nurses begin listening here for that reason. For the average adult, you'll hear five to 30 bowel sounds per minute.

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing?

Reflexes Questions regarding reflexes include such questions as, "What have you noticed about the infants behavior", "Are the infants sucking and swallowing seem coordinated", and "Does the infant grasp your finger?" The other responses are incorrect.

In advancing the nasogastric (NG) tube, which technique provides the safest outcome?

Rotate the tube if resistance is felt If resistance is met, try to rotate the tube and see whether it advances. If there is still resistance, withdraw the tube, allow the patient to rest, relubricate the tube, and insert it into the other naris. Advance the tube 2.5 to 5 cm (1 to 2 inches) with each swallow of water. If the patient is not allowed fluids, instruct him to dry swallow or suck air through a straw. Initially, instruct the patient to extend his neck back against the pillow; insert the tube slowly through the naris with the curved end pointing downward. Verify tube placement. Check agency policy for preferred methods.

A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms. The nurse should suspect:

Rotator cuff lesions

In which of the following positions should a nurse place a client following a craniotomy for evacuation of a subdural hematoma of the frontal lobe?

Semi-fowler's Head midline and the HOB elevated 30, allowing blood flow to the brain while allowing venous drainage, ↓ risk of IOP

The nurse is preparing to administer an enema to an adult patient who has normal sphincter control. For administration of the enema, the patient is placed in which position?

Sims

The nurse is palpating the left upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply. Spleen Liver Gallbladder Stomach Appendix

Spleen and Stomach The liver & gallbladder are located at the RUQ of the abdominal area.. The stomach & spleen are located at the LUQ. The appendix is located at the RLQ

How to counteract joint contracture in immobilized patient

Splints for wrist, hand, fingers, etc. that prevent contracture from forming and encouraging joint movement

Which statement concerning the areas of the brain is true? The cerebellum is the center for speech and emotions. The hypothalamus controls body temperature and regulates sleep. The basal ganglia are responsible for controlling voluntary movements. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

The hypothalamus controls body temperature and regulates sleep. The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.

Which of these statements about the peripheral nervous system is correct?

The periphreal nerves carry input to the CNS by afferent fibers and away from the CNS by efferent fibers

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? A problem exists with the sensory cortex and its ability to discriminate the location. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?

These findings are normal, resulting from aging Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect.

Measurement of the client's ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

Trigeminal

The nurse is mapping the client's abdomen into four quadrants. Which landmarks would the nurse use to perform this assessment? Select all that apply: Umbilicus. Midclavicular lines. Xiphoid process. Lower border of the right ribs. Iliac crests.

Umbilicus Xiphoid process

Urinary changes due to immobility

Urinary stasis, renal calculi (kidney stones), infection. Recumbent positions prevent the flow of urine out (no use of gravity); this increases the risk of infection and increases amount of calcium in bloodstream (disuse osteoporosis) = renal calculi formation. Hydration decreases due to lack of thirst with low mobility.

When evaluating the health care team member's ability to apply a condom catheter, it is most important for the nurse to provide further instruction for which intervention?

Using regular adhesive tape to hold the catheter in place

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response:

Very ominous sign and may indicate brainstem injury The patient is described to be in a decerebrate posture. These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with the successful performance of this action?

XII

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets really dizzy and feels like she is going to fall over. The nurse's best response would be:

You need to get up slowely when you've been lying or sitting long

sequential compression device (SCD)

a machine used to help improve circulation, reduce fluid build-up, and prevent blood clots; compression sleeves are placed around the legs and are inflated and deflated regularly> Increases venous return> Skin breakdown can occur: pressure ulcers = have to come off once a shift to evaluate the skin

Hoyer lift

a piece of equipment designed to raise a patient slowly above a surface to assist in transferring the patient to another surface

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?

acute alcohol intoxication

The nurse is applying a continuous passive motion (CPM) machine to the patient's leg. To do so, she must: (Select all that apply.) Select one or more of the following: provide analgesia 1 hour before starting the CPM. secure the patient's extremity tightly with Velcro straps. align the patient's joint with the CPM's mechanical joint. stop the CPM when in extension and place a sheepskin on the machine.

align the patient's joint with the CPM's mechanical joint. stop the CPM when in extension and place a sheepskin on the machine.

Moles on the abdomen:

are common

The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

b. Central and peripheral.

While perfoming a head-to-toe assessment., you perform the Romberg test. You do this to test the pt's:

balance

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?

cerebellum

atelectasis

collapsed lung; incomplete expansion of alveoli

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ___________ profile.

concave

During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!" Based on these symptoms, the nurse suspects that the patient has which condition?

duodenal ulcers Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may be relieved by more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.

When the nurse is testing the triceps reflex, what is the expected response?

extension of the forearm

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? extension adduction flexion abduction

flexion

Foot Drop makes it difficult to lift

front part of foot. Caused by compression of a nerve, causing weakness/paralysis of the muscles involved in lifting front part of foot

The nurse is caring for a patient with an ostomy. The nurse notes that the ostomy is putting out watery effluent. The nurse recognizes that this is indicative of which location?

ileal portion of the small intestine

What is used in respiratory implementation to "pop" open alveoli if patient has atelectasis. Helps keep alveoli open.

incentive spirometer medical procedure to encourage patients to breathe deeply by using a portable plastic device called a spirometer that gives visual feedback as the patient inhales forcefully. Helps alveoli "pop" open if they have atelectasis.

compartment syndrome

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles. Deep surgical cuts (fasciotomy) used to relieve pressure. Can hurt more than normal even with slight movement/stretch

The functional units of the musculoskeletal system are the:

joints Joints are the functional units of the musculoskeletal system because they permit the mobility needed to perform the activities of daily living. The skeleton (bones) is the framework of the body.

lithotomy position

lying on back with legs raised and feet in stirrups, hips and knees flexed, thighs abducted and externally rotated Used for: maternity/OBGYN units

dorsal recumbent position

lying on the back with the knees flexed Used for: inserting foley catheters in women

body alignment lying

multiple pressure areas:

Joints we should put full ROM into:

neck, shoulder, elbow, forearm, wrist, fingers & Thumb/ hip, knee, ankle/foot, and toes

The nurse is assessing a patient whose 24-hour output is 2400 mL. Which finding reflects the nurse's understanding of urine output?

normal output The average output range for adult urinary output averages between 2200 and 2700 mL in 24 hours.

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?

normal reflexes A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

A patient is admitted to the hospital for a hard hit to the head during a flag football game. He mentions that he's been having trouble seeing when you are in the middle of his assessment. You suspect that the patient may have damaged his:

occipital lobe

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is CORRECT? Severe nystagmus in both eyes:

occurs with disease of the vestibular system, cerebellum, or brainstem. End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

knee-chest position

patient is lying face down with the hips bent so that the knees and chest rest on the table Used for: maternity

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?

plantar reflex present With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

A patient is complaining of pain in his joints that is worse in the morning, better after he moves around for a while, and then gets worse again if he sits for long periods. The nurse should assess for other signs of what problem?

rheumatoid arthritis

Positioning first priority

safety: for pt. and nurse

For the patient who cannot sit upright, the next best position to prevent aspiration during medication administration is:

side-lying

Which structure is located in the left lower quadrant of the abdomen?

sigmoid colon

78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his right arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His right leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?

spastic hemiparesis With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident.

The area of the nervous system that is responsible for mediating reflexes is the:

spinal cord

urinary stasis

stagnation of urinary flow

The nurse has completed the musculoskeletal examination of a patients knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

swelling from fluid in the suprapatellar pouch

side lying

the client rests on the side with body weight on the dependent hip and shoulder

Supported Fowler's Position

the head of the bed is elevated 45 to 60 degrees, and the patient's knees are slightly elevated without pressure to restrict circulation in the lower legs

compression stockings

treatment of superficial venous thrombophlebitis in a low-risk, stable pt includes use of: a. compression stockings

During an abdominal assessment, the nurse would consider which of these findings as normal?

tympanic percussion note in the umbilical region

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include

tympany, hyperresonance, and dullness Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.

renal caluli are due to

urinary stasis and calcium buildup in bloodstream due to disuse osteoporosis increases (bone breakdown) combined with less hydration (water intake) due to immobility.

During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as:

vertigo