4th Semester Final Exam
Battery
Intentional and wrongful physical contact with a person that involves an injury or offensive contact
Nutrition discharge teaching for the client newly diagnosed with chronic obstructive pulmonary disease (COPD)
Nutrition ➡ Promote adequate nutrition because increased work of breathing increases caloric demands. ➡ Proper nutrition also aids in the prevention of infection. ➡ Increase fluid intake - Encourage the client to drink 2 to 3 L/day to thin mucus secretions. ➡ Dyspnea decreases energy available for eating - encourage soft, high calorie foods
ARDS is most likely to occur in the patient with
Systemic inflammatory response syndrome (SIRS), sepsis, gastric aspiration, and severe massive trauma
Goals of palliative care
The goal of palliative care is to learn to live fully with an incurable condition ➡ Regard dying as a normal process. ➡ Provide relief from symptoms, including pain. ➡ Support holistic patient care and enhance quality of life. ➡ Offer support to patients to live as actively as possible until death. ➡ Offer support to the family during the patient's illness and in their own bereavement.
The nurse observes a client in the manic phase of bipolar disorder in group therapy. The client has interrupted the counselor's group session multiple times and states "I already know this information about dealing with others when you are down." Which nursing action is appropriate? 1. Ask the client to walk with the nurse to get a snack 2. Ask the group to reflect on the client's behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel about the disruptions 4. Instruct the client to perform jumping jacks to rid of some energy
1. Ask the client to walk with the nurse to get a snack
How does the nurse recognize that atropine has produced a positive outcome for the patient with bradycardia?
The monitor shows an increase in heart rate. An expected outcome after the administration of atropine is an increased heart rate. By definition, the bradycardia has resolved when the heart rate is greater than 60 beats/min. Dizziness and weakness indicate symptoms of decreased cerebral perfusion and intolerance to the bradycardia. Dyspnea indicates intolerance to the bradycardia. A heart rate of 42 beats/min after atropine has been given indicates that bradycardia is unresolved.
Standards of care
These guide nursing care through established standards and legal guidelines, including: ➡ The nurse practice act which varies from state to state ➡ The ANA standards of practice ➡ Health care facility policies and procedures ➡ Accrediting bodies ➡ Quality assurance programs ➡ National Patient safety goals
Clinical manifestations of left-sided heart failure
➡ Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea ➡ Fatigue ➡ Displaced apical pulse (hypertrophy) ➡ S3 heart sound (gallop) ➡ Pulmonary congestion (dyspnea, cough, bibasilar crackles) ➡ Frothy sputum (can be blood-tinged) ➡ Altered mental status ➡ Symptoms of organ failure, such as oliguria (decrease in urine output)
Teaching for sickle cell crisis
➡ Early signs and symptoms of crisis ➡ Importance of routine vaccination - pneumococcal Haemophilus influenzae type B, and meningococcal vaccines (because of the susceptibility to infection from functional asplenia)
Exercise discharge teaching for the client newly diagnosed with chronic obstructive pulmonary disease (COPD)
➡ Exercise conditioning includes improving pulmonary status by strengthening the condition of the lungs through exercise. ➡ Determine client's physical limitations ➡ Structure activity to include periods of rest ➡ Encourage client to use oxygen during activity if prescribed.
Fidelity
➡ Fidelity - the concept of keeping a commitment and is based upon the virtue of caring. ➡ Example: A patient asks the nurse not to reveal the fact that she is dying or give her diagnosis to his family. The nurse asks why she does not want her family advised. The patient explains that her family is very emotional and has stated they would do everything to keep her alive, even if it required long-term mechanical ventilation. The patient has explained multiple times that she does not want mechanical ventilation. The nurse recognizes that keeping of this information in confidence, while supporting the family.
Complications of epoetin alfa therapy
➡ Hypertension ➡ Risk for thrombotic event ➡ Deep-vein thrombosis ➡ Headache and body aches
Patient presenting with increased risk for suicide
➡ If a client is crying or not speaking to anyone due to a difficult diagnosis, they may be at risk for depression and suicide. ➡ The nurse should ask the client directly if they plan to kill themselves, as this can provide relief and convey concern. ➡ The nurse should also establish a therapeutic relationship with the patient, demonstrating empathy, active listening, and a non-judgmental attitude.
Complications of sickle cell crisis
➡ Increasing anemia ➡ Decreased perfusion ➡ Shock
Role of the nurse in obtaining informed consent
➡ Informed consent is a legal process by which a client has given written permission for a procedure or treatment. Consent is informed when a provider explains and the client understands ➡ Nurse's Role with Informed Consent: The nurse's role in the informed consent process is to witness the client's signature on the informed consent form and to ensure that the provider obtained informed consent appropriately
Clinical manifestations of right sided heart failure
➡ Jugular vein distention ➡ Ascending dependent edema (legs, ankles, sacrum) ➡ Abdominal distention, ascites ➡ Fatigue, weakness ➡ Nausea and anorexia ➡ Polyuria at rest (nocturnal) ➡ Liver enlargement (hepatomegaly) and tenderness ➡ Weight gain
Clinical manifestations of right-sided heart failure
➡ Jugular vein distention ➡ Dependent edema ➡ Ascites ➡ Weakness/fatigue ➡ Anorexia ➡ Nausea ➡ Hepatomegaly ➡ Weight gain * Pulmonary clinical manifestations are associated with left-sided failure - Left: Lungs
Advance directives: living will vs durable power of attorney
➡ Living Will: legal document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. Types of treatments that are often addressed in a living will are those that have the capacity to prolong life. (Ex: CPR, mechanical ventilation, & feeding by artificial means) ➡ Living wills are legal in all states. State statutes and individual health care facility policies may vary. Nurses need to be familiar with their state statute and facility policies. Most state laws include provisions that health care providers who follow the health care directive in a living will are protected from liability. ➡ Durable Power of Attorney: A written document that authorizes someone to make healthcare decisions for you at all times you can't make your own health care decisions, including times of temporary limited capacity. It lasts only as long as you are incapable of making decisions for yourself. You can set out specific provisions in the POA telling your agent how you would like them to act in regards to deathbed issues.
Discharge teaching for patient with multiple sclerosis
➡ Medication management ➡ Home safety ➡ Coping mechanisms ➡ Bladder management ➡ Exercise ➡ Energy conservation and rest periods ➡ Avoiding infections ➡ Communication methods if the client has dysarthria
Adverse effects to monitor for in a client with diabetes taking metoprolol
➡ Metoprolol can mask tachycardia (tachycardia is an early manifestation of low blood glucose) ➡ Teach clients to monitor blood glucose to detect hypoglycemia ➡ Use metoprolol cautiously in clients who have diabetes mellitus
Actions to prevent refeeding syndrome
➡ Monitor baseline & daily electrolyte lab values ➡ Place patient on a cardiac monitor ➡ Monitor I's & O's and vital signs ➡ Initiate low calorie feedings slowly ➡ Gradually increase calories ➡ After a period of starvation, carb rich nutrition (glucose) stimulates insulin production with a shift of electrolytes from the blood into the tissue cells for anabolism. ➡ Other findings include sodium retention, hyperglycemia, and thiamine deficiency
Epoetin alfa - laboratory values to monitor
➡ Monitor for an increase in blood pressure. ➡ Hgb & Hct (2x/week) ➡ Monitor for a cardiovascular event if Hgb increases too rapidly (greater than 1 g/dL in 2 weeks)
Guidelines for informed consent
➡ Must be signed by a competent adult (person who signs the form must be capable of understanding the information provided; person must be able to fully communicate in return with the health care professional) ➡ Emancipated minors (minors who are independent from their parents, such as a married minor) may provide informed consent for themselves
Maintenance Medications for recovery from Chronic Alcohol Use
➡ Naltrexone - to reduce or eliminate cravings ➡ Acamprosate - to reduce anxiety, dysphoria, tension ➡ Disulfiram - look obvious & hidden alcohol use - Alcohol-Disulfiram reaction causes LIFE THREATENING PHYSICAL EFFECTS: severe n/v, respiratory depression, cardiac changes, MI, acute CHF
Interventions for sickle cell crisis
➡ Oxygen ➡ Maintain adequate hydration and blood flow - oral fluids & IV normal saline as prescribed ➡ Blood transfusions as prescribed to increase tissue perfusion ➡ Analgesics ➡ Positioning - assist child to assume a comfortable position so that the child keeps the extremities extended (promotes venous return), elevate the head of the bed no more than 30 degrees, avoid putting strain on painful joints and do not raise the knee gatch of the bed ➡ Encourage high-calorie, high-protein diet with folic acid supplementation ➡ Prophylactic antibiotics
Refeeding Syndrome - Basics
➡ Patient needs to be on a cardiac monitor ➡ Daily labs (you will see HYPOKALEMIA, HYPOMAGNESEMIA, HYPOPHOSPHATEMIA) ➡ Strict I's & O's ➡ Commonly associated with anorexia nervosa, but can occur with any long term deficit of food intake ➡ This is a medical problem - you do not need a psychiatrist for refeeding syndrome (only for the anorexia nervosa diagnosis)
Referrals for patient with multiple sclerosis
➡ Physical therapy ➡ Occupational therapy ➡ Speech therapy ➡ Respite services for family ➡ Visiting nurses and home health aides
Clinical manifestations of opiate toxicity / overdose
➡ Pinpoint pupils ➡ Respiratory depression ➡ Coma / Unresponsive ➡ Cardiac arrest ➡ Shock ➡ Seizure ➡ Death
Duchenne's muscular dystrophy
➡ Primary goal: maintain function in unaffected muscles as long as possible, prevention of contractures ➡ Management: steroids, physical therapy, orthotics, keeping child as active as possible, performing range of motion, bracing, performance of activities of daily living, surgical release of contractures
Defamation
False communication or communication with careless disregard for the truth with the intent to injure an individual's reputation. Includes libel and slander
Stages of alcohol withdrawal
1. Acute: 12-48 hrs after last drink; Tremors, sweating, hyperreflexia, seizures ("rum fits"), anxiety, insomnia, nausea and abdominal pain 2. Alcoholic hallucinosis: 24-72 hrs, high blood pressure, increased temp, unusual heart rate + confusion 3. DT: 2-7d, hallucinations, fever, seizures, agitation, illusions, confusion, poor sleep, autonomic lability. Can be fatal.
Hypomagnesemia occurs in
30% to 80% of alcoholics.
What should the nurse recognize as an indication for the use of dobutamine in the care of a patient with heart failure
A nurse might recognize severe refractory heart failure as an indication for using dobutamine when cardiac output is critically low. Dobutamine is an inotropic agent that strengthens the heart muscle to treat heart failure, which occurs when the heart doesn't pump well. Inotropic agents can support circulation for a short period of time, but they can also increase the risk of cardiac arrhythmias
What should a HCP do when the person giving the informed consent is unable to communicate due to a language barrier or hearing impairment
A trained medical interpreter must be provided
Hospice care
Hospice care is comprehensive care delivered in a variety of settings, and can be implemented when a client is not expected to live longer than 6 months. Further medical care aimed toward a cure is stopped, and the focus becomes enhancing quality of life and supporting the client toward a peaceful and dignified death.
Interdisciplinary team for palliative care
An interprofessional team of physicians, nurses, social workers, physical therapists, massage therapists, occupational therapists, music/art therapists, touch/energy therapists, and spiritual support staff provide palliative care.
When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? (Select all that apply.) 1. Projection 2. Suppression 3. Sublimation 4. Identification 5. Rationalization 6. Denial
Answer: 1. Projection 5. Rationalization 6. Denial RATIONALE: Projection is the unconscious denial of unacceptable feelings and emotions in one's self while attributing them to others. This defense mechanism commonly is used by clients with alcoholism because it helps make reality more acceptable. Rationalization is making acceptable excuses for behavior; this defense is used by people with alcoholism because it makes reality more acceptable. Denial is refusing to acknowledge reality. Clients with excessive alcohol consumption may deny they have a drinking problem, pointing out how well they function in their job or relationships. Suppression keeps uncomfortable thoughts, feelings, and wishes in the subconscious; suppression is used rarely by people with alcoholism. Sublimation (the rechanneling of anxiety into constructive activities) is rarely used by these clients. Identification is the unconscious wish to be like another person; it is not commonly used by clients with an alcohol problem.
The parents of a child with cerebral palsy (CP) ask if there are any medications available to help control the child's symptoms. Which type of medication should the nurse discuss with the parents? (Select all that apply.) 1.Baclofen 2.Antidepressants 3.Muscle relaxants 4.Botulinum toxin 5.Benzodiazepines
Answer: 1.Baclofen 3.Muscle relaxants 4.Botulinum toxin 5.Benzodiazepines RATIONALE: Medications that are used to control seizures and spasms include skeletal muscle relaxants, baclofen, benzodiazepines, and botulinum toxin. Antidepressants are not used to manage the symptoms of CP. The nurse should instruct the client not to take antihistamines while taking baclofen. Antihistamines will intensity the depressant effects of baclofen.
A client with schizophrenia is admitted to the facility. When collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia? Select all that apply: 1. Delusions 2. Hallucinations 3. Apathy 4. Blunted affect 5. Lack of motivation
Answer: 3. Apathy 4. Blunted affect 5. Lack of motivation RATIONALE: Negative symptoms of schizophrenia reflect the absence of normal characteristics. They include apathy, lack of motivation, blunted affect, poverty of speech, anhedonia (diminished capacity to experience pleasure), and antisocial behavior. Negative symptoms are thinks that are taken from the patient, including flat affect, asocial/social withdrawal, self neglect. *Remember the 6 A's: anhedonia (no pleasure), flat affect (lack of expression), apathy (lack of interest), anergia (lack of energy), alogia (lack of speech), avolition (lack of motivation)
A female client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering the medication? 1. Calcium 2. Sodium 3. Chloride 4. Potassium
Answer: 2. Sodium RATIONALE: Lithium is chemically similar to sodium. If sodium levels are reduced (such as from sweating or diuresis) lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. ➡ Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions but sodium is most important to the absorption of lithium.
A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehab via oral and enteral feedings. Which of the following findings would indicate that the patient is developing refeeding syndrome? 1. Phosphorus 0.65, Potassium 2.9, Magnesium 0.5 2. Phosphorus 5.0, Potassium 3.5, Magnesium 2.0 3. Random blood glucose 3.3, Sodium 120, Calcium 1.75 4. Random blood glucose 5.6, Sodium 140, Calcium 2.50
Answer: 1. Rationale: Refeeding syndrome is a potentially deadly complication of nutritional replenishment (via oral, enteral, parenteral feedings) in extremely malnourished patients. ➡ Refeeding syndrome is marked by decline in phosphorus, potassium, and magnesium (PPM). ➡ Patients can also develop fluid overload. ➡ Low-calorie feedings and gradual increases in calories can prevent refeeding syndrome.
When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? 1. "I will need to isolate any tissues I use so as not to infect my family." 2. "I will notify all of my sexual partners so they can get tested for HIV." 3. "Unprotected sexual contact is the most common mode of transmission." 4. "I do not need to worry about spreading this virus to others by sweating at the gym."
Answer: 1. "I will need to isolate any tissues I use so as not to infect my family." RATIONALE: HIV is not spread casually. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, or attending school with an HIV-infected person.
A patient has been admitted to the emergency department because of an overdose of an oral benzodiazepine. He is very drowsy but still responsive. The nurse will prepare for which immediate intervention? 1. Hemodialysis to remove the medication 2. Administration of flumazenil 3. Administration of naloxone 4. Intubation and mechanical ventilation
Answer: 2. Administration of flumazenil RATIONALE: Flumazenil is an antidote for benzodiazepines
A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? 1. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) 2. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) 3. About 0200 on hospital day 3 (72 hours after drinking stopped) 4. About 0200 on hospital day 4 (96 hours after drinking stopped)
Answer: 2. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) RATIONALE: Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake and peaks between 24 and 48 hours, then resolves or progresses to delirium.
A client has active TB. Which of the following symptoms will he exhibit? 1. Chest and lower back pain 2. Chills, fever, night sweats, and hemoptysis 3. Fever of more than 104 & and nausea 4. Headache and photophobia
Answer: 2. Chills, fever, night sweats, and hemoptysis RATIONALE: Typical signs and symptoms of tuberculosis are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isn't a cardinal symptom. Clients with TB typically have low-grade fevers, not higher than 102*F. Nausea, headache, and photophobia aren't usual TB symptoms.
A man is prescribed with lithium to manage bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings? 1. Manic episodes a week ago 2. Having diarrhea every day 3. Client has rash & pruritus on his arms and legs D. The client presents as severely depressed
Answer: 2. Having diarrhea every day RATIONALE: Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. Rashy pruritus is not a symptoms of lithium toxicity. Having a depressive or manic episodes is not an indication of lithium toxicity—these findings indicates that the lithium is not effective or is not at a therapeutic level.
What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? 1. Acute anxiety 2. Hypotension and tachycardia 3. Peripheral edema and weight gain 4. Paroxysmal nocturnal dyspnea (PND)
Answer: 2. Hypotension and tachycardia RATIONALE: Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.
A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for a hallucinating client is to: 1. Take an as-needed dose of psychotropic medication whenever he hears voices. 2. Practice saying "Go away" or "Stop" when he hears voices. 3. Sing loudly to drown out the voices and provide a distraction. 4. Go to his room until the voices go away.
Answer: 2. Practice saying "Go away" or "Stop" when he hears voices. RATIONALE: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as-needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.
The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? 1. Taking a hot bath at least once daily 2. Resting in an air-conditioned room whenever possible 3. Increasing the dose of muscle relaxants 4. Avoiding naps during the day
Answer: 2. Resting in an air-conditioned room whenever possible RATIONALE: Fatigue is a common symptom of patients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; [extreme cold should be avoided]. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the patient with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue.
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, Snakes are crawling on my bed. Ive got to get out of here. What is the most accurate assessment of the situation? The patient: 1. Is attempting to obtain attention by manipulating staff. 2. May have sustained a head injury before admission. 3. Has symptoms of alcohol withdrawal delirium. 4. Is having a recurrence of an acute psychosis.
Answer: 3. The patient has symptoms of alcohol withdrawal delirium. RATIONALE: Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.
Which is part of the nursing management for ARDS? 1. Aggressive use of intravenous (IV) fluids 2. Administration of a β-blocker 3. Use of positive end-expiratory pressure (PEEP) 4. Use of the lateral recumbent position
Answer: 3. Use of positive end-expiratory pressure (PEEP) RATIONALE: Use of positive end-expiratory pressure (PEEP) is an expected part of the management of ARDS (higher levels of PEEP may be used) It increases the functional residual capacity (FRC) and opens collapsed alveoli. The issues in ARDS treatment are respiratory related, not fluid deficit. β-Blockers are part of myocardial infarction management, not ARDS. Some ARDS patients do better when placed in a prone position instead of a supine position. In the supine position, the heart places pressure on the pleural cavity. Changing the patient to a prone position allows air-filled, non-atelectatic alveoli in the ventral portion of the lung to become dependent.
While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? 1. Complete an incident report. 2. Request the risk manager obtain consent for HIV testing from the client. 3. Wash the site of injury with soap and water. 4. Consent to postexposure treatment with antiretroviral medications.
Answer: 3. Wash the site of injury with soap and water. RATIONALE: The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission. The nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility to be tested, and receive follow up testing in 6-8 weeks. Persons exposed to the blood of HIV-infected patients should receive 4 weeks of antiretroviral therapy. Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Additionally, the nurse should initiate the emergency reporting system.
A client is hospitalized following a suicide attempt after breaking up with her boyfriend. She says to the nurse, "When I get out of here, I'm going to try this again, and next time I'll choose a no-fail method." Which is the best response by the nurse? 1. You are safe here. We will make sure nothing happens to you. 2. You're just lucky your roommate came home when she did. 3. What exactly do you plan to do? 4. I don't understand. You have so much to live for.
Answer: 3. What exactly do you plan to do? RATIONALE: During the assessment phase it is important to assess how serious the intent was, if the person has a plan, if they do have a plan if they have a means of carrying out said plan, how lethal those means are, and if the individual has attempted suicide before. The client already has attempted suicide so it is vital to ask the other questions about her suicidal plan.
The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What would the nurse expect to note in the client? 1. Warm, pink skin 2. Low arterial Pao2 3. Elevated arterial Pao2 4. Decreased respiratory rate
Answer: Low arterial Pao2 Rationale: The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a Pao2 lower than 60 mm Hg. The patient may also experience hyperglycemia, decreased LOC, pallor to cyanosis, AKI (secondary to hypoxemia, hypercarbia, and acidemia - thus, increased Cre),
Medications Prescribed for Secondary Stroke Prevention
Antihypertensives Used to reduce blood pressure to prevent long-term damage from excessive shear stress and reduce the chance for complications of hypertension, such as intracerebral hemorrhage Lipid-Lowering Medications Used to reduce the production of cholesterol or the reabsorption of cholesterol, which leads to deposition in blood vessels and eventual blood vessel occlusion Platelet Inhibitors Used to prevent platelet aggregation, reducing the risk of blood clot formation, which could cause cerebral blood vessel occlusion Anticoagulants Used to prevent clotting in patients with disorders such as atrial fibrillation
A client with schizophrenia states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic? 1. "I don't hear the voice, but I know you hear what sounds like a voice." 2. "You shouldn't focus on that voice." 3. "Don't worry about the voice as long as it doesn't belong to anyone real." 4. "King Tut has been dead for years."
Correct Answer: 1. "I don't hear the voice, but I know you hear what sounds like a voice." RATIONALE: This response states reality about the client's hallucination. The other options aren't therapeutic.
Mandatory reporting
Health care providers have a legal obligation to report certain situations and findings in accordance with state law; this includes abuse and communicable diseases
ALCOHOL WITHDRAWAL TIMELINE
EARLY SIGNS ➡ 4-6 HOURS PEAK ➡ 24-72 HOURS TONIC-CLONIC SEIZURE ➡ Most likely at 7 TO 48 HOURS DELIRIUM ➡ Most likely to start about 3 days after last drink WITHDRAWAL CONTINUES FOR ➡ About a week ALCOHOL WITHDRAWAL SYMPTOMS ➡ Starts hours after last drink; peaks in 1-3 days; rapidly & dramatically disappears or develops into delirium; irritability & shaking; hypertension; tachycardia; sweating; tonic-clonic seizures likely 7-48 hours after cessation ALCOHOL WITHDRAWAL DELIRIUM ➡ Most likely to occur around 3 days after reduction/cessation of alcohol intake; severe autonomic hyperactivity; psychotic symptoms; delirium; fluctuating loss of consciousness; agitation; tremor; diaphoresis; this is a medical emergency that may result in death
After providing AM care to a client receiving mechanical ventilation via an endotracheal tube, the nurse notes a sudden decrease in the pulse oximetry reading. How will the nurse assess endotracheal tube placement?
Endotracheal tube placement can be confirmed by: ➡ End-tidal carbon dioxide levels ➡ Auscultating bilateral lung sounds ➡ Observing symmetrical chest movement ➡ Chest x-ray results
Priority lab for HIV patient
CD4-T-cell count
Assault
Conduct of one person that makes another person fearful and apprehensive
The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate ? 1. Approach the client and touch him to get his attention. 2. Encourage the client to go to his room where he'll experience fewer distractions. 3. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. 4. Ask the client to describe what the voices are saying.
Correct Answer: 3. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. RATIONALE: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination. (Follow up: what about assessing for command hallucinations?)
Credé's method (maneuver)
Credé's method (maneuver) - A technique for manual expression of urine from the bladder used in bladder training for paralyzed patients ➡ The hands are held flat against the abdomen, just below the umbilicus. ➡ A firm downward stroke toward the bladder is repeated six or seven times ➡ Followed by pressure from both hands placed directly over the bladder to manually remove all urine.
Most common form of muscular dystrophy
Duchenne muscular dystrophy (DMD)
For each potential nursing or collaborative intervention, specify whether the intervention is indicated or not indicated to include in the plan of care. Interventions Provide oxygen via nasal cannula Administer intranasal naloxone Administer PO charcoal Administer intranasal flumazenil Apply a cardiorespiratory monitor Obtain a neurological assessment Start chest compressions
Interventions Provide oxygen via nasal cannula - indicated Administer intranasal naloxone - indicated Administer PO charcoal - not indicated Administer intranasal flumazenil - not indicated Apply a cardiorespiratory monitor - indicated Obtain a neurological assessment - indicated Start chest compressions- not indicated Rationale: The oxygen via nasal cannula would support the client's respiratory status and naloxone would be given to reverse the respiratory depression. Oral charcoal would only be given if the team suspected that the client had ingested poison. Intranasal flumazenil would be given for a benzodiazepine overdose. Continuous vital signs would be done to monitor respiratory status for further respiratory depression. A neurological assessment is indicated as the client had hypoxia for an unknown amount of time. Chest compressions are not needed because the client has a pulse.
Interventions for palliative care
Interventions focus on: ➡ The relief of physical manifestations (pain) ➡ Addressing spiritual, emotional, and psychosocial aspects of the client's life Palliative care interventions are primarily used when caring for clients who are terminal and family members who are grieving but can be used for any client who has a chronic or curable illness, regardless of the stage of the disease process. Assessment of the client's family is very important as well.
Anorexia Nervosa patient will have a ____ BMI
Low
A-fib commonly occurs in HF.
Multiple areas in the atria initiate rapid, irregular electrical stimuli, which results in the inability to see clear P waves on the ECG recording. Some, but not all, of these electrical impulses travel through the AV node, causing an irregular ventricular response.
Considerations for delegation
Prior to delegating client care, consider the following: ➡ Predictability of outcome: Will the completion of the task have a predictable outcome? ➡ Is it a routine treatment? ➡ Is it a new treatment? ➡ Potential for harm: Is there a chance that something negative can happen to the client (risk for bleeding, risk for aspiration)? ➡ Is the client unstable? ➡ Complexity of care: Are complex tasks required as a part of the client's care? ➡ Is the delegatee legally able to perform the task and do they have the skills necessary? ➡ Need for problem solving and innovation: Is nursing judgment required while performing the task? ➡ Does it require nursing assessment skills? ➡ Level of interaction with the client: Is there a need to provide psychosocial support or education during the performance of the task?
A client who has Chronic Kidney Disease should restrict which nutrients
Protein A client who has CKD should restrict protein intake to prevent uremia that can develop as a result of the kidneys' inability to remove the waste products of protein. Calories A client who has CKD requires adequate calories to meet metabolic needs. Phosphorous A client who has CKD is at risk for hyperphosphatemia due to a reduction in excretion of phosphorous by the kidneys Sodium A client who has CKD is at risk for hypernatremia, edema, and hypertension due to sodium retention.
The client is most likely experiencing [myocardial infarction, opioid overdose, sepsis] ___________________________. The priority is to treat the __________________________________ [blood pressure, infection, respiratory effort.]
The client is most likely experiencing opioid overdose. The priority is to treat the respiratory effort. Rationale: This client has more signs of respiratory depression related to opioid overdose than any other conditions. The client may have a severe enough infection in their arm to cause sepsis, however early signs of sepsis include rapid respirations, tachycardia, and fever. Severe hypotension is late sign. A myocardial infarction (MI) is a major cause of cardiogenic shock. If the client was having an MI, it would be expected that the client reported other symptoms such as shortness of breath, chest pain, or left arm pain. The client does have low blood pressure and infection; however, the immediate concern is respiratory depression supported by the clinical findings.
Goals for Subaracnoid hemorrhage
The goal for SAH - is to prevent complications such as cerebral vasospasm, rebleeding, hyponatremia (salt-wasting syndrome), and ARDS. The nurse should monitor for hyponatremia, provide feeding access (as the client is intubated so a swallow study cannot be performed), and perform neurological assessments every 1-2 hours. Davis Chapter 39 pages 885-891
Cirrhosis 101
o Early signs and symptoms: fatigue, significant change in weight, GI symptoms, and comfort. Many patients at this stage may not even know they have a problem until the liver function tests come back. o Late stage tends to make patients seek treatment: GI bleeding, jaundice, ascites, and spontaneous bruising indicate poor liver function o Look for: jaundice, dry skin, rashes, petechia/ecchymosis, red/warm palms, spider angiomas, ascites, peripheral dependent edema, and a vitamin deficiency o Ascites and hepatomegaly seen in the abdomen o Observe for blood in vomit and stool, fetor hepaticus, amenorrhea, gynecomastia, petechiae, bruising, asterixis (tremor) and changes in mental status (secondary to increased ammonia levels)
0930. Client being treated for cellulitis presented with a complaint of right arm pain not controlled by prescription narcotics. The client is alert and oriented but agitated, rating pain 10/10 pain. Denies shortness of breath or chest pain. Informed client of wait times, placed wristband on client, and had him return to the waiting room to be triaged. 1055. Notified by a family in the waiting room that the client was slouched in chair and "seemed dead." Client was found to be unresponsive with constricted pupils, clammy skin, bradypnea, and circumoral cyanosis. Rt arm is red and swollen with blistered areas. 1100. Emergency response team activated. Vital signs obtained. Vital Signs Time 1100 T 97.1F /36.1C P 48 RR 6 B/P 90/50 Pulse oximeter 86% Oxygen RA Pain Unable to report
Ø For each finding click to indicate if the finding is consistent with opioid overdose, sepsis, or myocardial infarction. Each finding may support more than one condition. Findings : Constricted pupils - opioid overdose Depressed respiratory rate- opioid overdose Cyanosis- opioid overdose; sepsis; MI Change in level of consciousness- opioid overdose; sepsis; MI Rt arm pain Clammy skin- opioid overdose; sepsis; MI Rationale: Constricted pupils, respiratory depression, cyanosis and change in the level of consciousness are all signs of opioid overdose. Sepsis and myocardial infarction (MI) can cause cyanosis and a change in the level of consciousness. Right arm pain is not specific to any of the listed conditions. Clammy skin is consistent with sepsis, MI, and opioid overdose.
Epoetin Alfa
➡ A hematopoietic growth factor used to increase production of RBCs. ➡ Used for patients with chronic kidney disease
What protocol should be utilized in the event of a disaster that necessitates determining client discharge from the hospital?
➡ Ambulatory clients requiring minimal care should be discharged or relocated first. ➡ Clients requiring assistance should be the next to be discharged or relocated, and arrangements should be made for continuation of their care ➡ Clients who are unstable and require continued nursing care should not be discharged or relocated unless they are in imminent danger.
Cultural Considerations
➡ Buddhism - may refuse care on holy days, clients may fast on holy days chanting is common ➡ Christianity - Baptize infants at birth, may fast during Lent, some give last rites ➡ Hinduism - Do not prolong life, Lie on floor while dying, a thread is placed around the neck/wrist ➡ Islam - Must pray 5 times a day facing Mecca, Client may fast during Ramadan ➡ Jehovah's Witnesses - Clients avoid foods having or prepared with blood, do not accept blood products ➡ Judaism - On the eight day after birth, males are circumcised, kosher diet ➡ Mormonism - Children are baptized at age 8 by immersion
Clinical manifestations of an acute hemolytic transfusion reaction
➡ Can be mild or life threatening, resulting in disseminated intravascular coagulation (DIC) or circulatory collapse. ➡ Manifestations: chills, fever, lower back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom.
TBI / Head injury - priority findings that would indicate a need to contact the provider immediately.
➡ Change in oxygen saturation/respiratory status - the brain is dependent upon oxygen to maintain function; untreated hypoxia leads to brain injury or death in as little as 3 minutes ➡ Change in level of consciousness ➡ Symptoms of increased intracranial pressure ➡ Change in cranial nerve function ➡ Change in pupil size / reaction
Categories of triage in a mass casualty situation
➡ Class 1 (Red tag)- Emergent or Immediate; Highest priority is given to clients who have life threatening injuries but also have a high possibility of survival once they are stabilized. ➡ Class 2 (Yellow tag)- Urgent or Delayed Second-highest priority is given to clients who have major injuries that are not yet life threatening and usually require treatment in 30 min to 2 hr. ➡ Class 3 (Green tag)- Non-urgent or Minimal. The next highest priority is given to clients who have minor injuries that are not life-threatening and can wait hours to days for treatment. ➡ Class 4 (Black tag) Expectant. The lowest priority is given to clients who are not expected to survive and will be allowed to die naturally. Comfort measures can be provided, but restorative care will not.
A nurse is caring for a client with acquired immune deficiency syndrome (AIDS). The nurse notes the serum albumin level is 2.9 g/dL. What does this serum level tell the nurse about the client's status? What measures should the nurse anticipate the provider will take to address this low serum albumin level?
➡ Client is malnourished AEB the serum albumin level (Normal range for this serum albumin is 3.4 - 5.4 g/dL) ➡ Nurse should notify the provider of this finding ➡ It is likely the provider will prescribe a high protein diet or total parenteral nutrition (TPN) to address the nutritional state of the client
False imprisonment
➡ Confining or restraining a person against their will ➡ Example: using restraints on a competent client to prevent his leaving the health care facility
Clinical manifestations of opiate intoxication
➡ Constricted pupils ➡ Slurred speech ➡ Drowsiness ➡ Slow movement ➡ Impaired concentration / memory / judgement ➡ Euphoria ➡ Respiratory depression
Positive symptoms of schizophrenia
➡ Delusions ➡ Hallucinations ➡ Disorganized speech ➡ Disorganized behavior
Symptoms of lithium toxicity review
➡ Diarrhea, vomiting, drowsiness, muscular weakness, lack of coordination / ataxia, giddiness, blurred vision, tinnitus, and a large output of dilute urine may be seen. ➡ Lithium toxicity is prevented by regularly monitoring serum lithium levels to maintain a therapeutic range between 0.8 to 1.2 mEq/L. ➡ Diuretics increase the excretion of lithium from the kidneys; therefore, the nurse would question administering lithium to this client ➡ If a patient is exhibiting signs & symptoms of a manic episode (impulsivity, insomnia, anorexia) - obtain a lithium level
Causes of autonomic dysreflexia in a spinal cord injury patient
➡ Distended bladder (most common) - kinked or blocked urinary catheter, urinary retention, or urinary calculi ➡ Fecal impaction ➡ Cold stress or drafts on lower part of the body ➡ Tight clothing ➡ Undiagnosed injury or illness - kidney infection or stone, lower extremity fracture
Discharge teaching for the child who has a resolving sickle cell crisis
➡ Provide emotional support, and refer to social services if appropriate. ➡ Instruct in signs and symptoms of crisis and infection. ➡ Advise the family of the importance of promoting rest and adequate nutrition for the child. ➡ Encourage the child and family to maintain good hand hygiene and avoid individuals who are sick. ➡ Give specific directions regarding fluid intake requirements, such as how many bottles or glasses of fluid should be consumed daily. ➡ Provide information about genetic counseling. ➡ Encourage maintenance of up-to-date immunizations. ➡ Advise the child to wear a medical identification wristband or medical identification tags.
Nursing interventions for a child who has sickle cell disease
➡ Provide oxygen ➡ Provide hydration ➡ Administer analgesics ➡ Provide parental support
Nursing Interventions for a Manic Episode: Patients too busy to eat - use the following interventions to maintain patient's body weight
➡ Provide patients with foods that can be eaten on the run (finger foods) because some patients can't sit long enough to eat ➡ Provide high-protein, high-calorie snacks for patients. ➡ A vitamin supplement might be indicated ➡ Weigh patients regularly (sometimes weighing daily is needed)
What is the concern with the concurrent use of rifampin & warfarin
➡ Rifampin accelerates metabolism of warfarin. It is discouraged to take these two medications concurrently ➡ It is imperative to monitor PT and INR. Rifampin, also known as rifampicin, belongs to the antimicrobial class of drugs. This medication is used to manage and treat diverse mycobacterial infections and gram-positive bacterial infections
Bulimia
➡ Self-induced elimination ➡ Cycles of bingeing & purging (may be vomiting or through the use of laxatives) ➡ BMI: normal to slightly elevated ➡ Bulimia patients will display feelings of shame & guilt ➡ You may see swollen parotid gland, Russel's sign (calluses on knuckles)
Nursing Interventions for an acute hemolytic transfusion reaction
➡ Stop the transfusion. ➡ Remove the blood tubing from the IV access. ➡ Avoid infusing further blood products into the circulatory system. ➡ Initiate an infusion of 0.9% sodium chloride using new tubing. ➡ Monitor vital signs and fluid status. ➡ Send the blood bag and administration set to the lab for testing
Discharge teaching for the patient with stroke
➡ Stroke diagnosis ➡ Activation of EMS ➡ Warning signs & symptoms of a stroke ➡ Patient specific signs and symptoms of a stroke ➡ Smoking cessation ➡ Medications for stroke prevention
A nurse is planning care for the below assigned clients. Which client will the nurse check on first? 1.) A postoperative client recently returned from surgery with a drain. 2.) A client admitted with confusion that is now oriented to person and place. 3.) A client who required daily dressing changes. 4.) A DNR client who has Cheyne-Stokes respirations.
➡ The nurse will first check in on the newly returned client from surgery with a drain to assess status. The strategy that the nurse would use is acute vs. chronic. All other clients are stable.
Pharmacology for the management of alcohol withdrawal symptoms
➡ Thiamine = Vitamin B1 - to prevent Wernicke's ➡ Benzodiazepine - for alcohol withdrawal Administration of Benzodiazepines (valium) to reduce with tremor, anxiety and confusion Vitamins may be given to restore nutrients (Magnesium sulfate, thiamine, folic acid, multivitamin) Antipsychotics may help with hallucinations -agitation Beta blockers - assist people with coronary artery disease Phenytoin may be given to people with a history of seizure disorder (does not treat withdrawal seizures) LORAZEPAM = Assess for liver problems CHLORDIAZEPOXIDE = No liver alterations, brings VS WNL, decreases symptoms of withdrawal SUBSTITUTE FOR ALCOHOL IN WITHDRAWAL CLONIDINE, ATENOLOL, HYDROXYZINE
Management of homonymous hemianopsia
➡ Turning the head from side to side in the direction of the unaffected side to the affected side to gain a full view of both visual fields.
Discharge teaching for halo traction device
➡ Used to stabilize cervical spine injury ➡ Pin care ➡ Clothing might need to be altered to cover the device ➡ If activity is restricted, perform deep breathing and leg exercises and other techniques to prevent complications of immobilization (pneumonia or thrombus formation).
Questions that may be asked to assess alcohol use
➡ When was your last drink ➡ How much do you drink ➡ How often do you drink ➡When did you start drinking ➡ How does drinking affect you and your life
Clinical manifestations of Lithium toxicity
➡ With lithium levels between 1.5 and 2 mEq/L the client will experience coarse tremor, polyuria, nausea, vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. ➡ With Lithium levels of 2 -2.5 mEq/L the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea / vomiting. ➡ With Lithium levels of 2.5 to 3 mEq/L or higher, urinary & fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death.
The nurse cares for a 21-year-old male in the emergency department with cellulitis and uncontrolled pain. Ø Which of the underlined findings require immediate follow-up? 0930. Client being treated for cellulitis presented with a complaint of right arm pain not controlled by prescription narcotics. The client is alert and oriented but agitated, rating pain 10/10 pain. Denies shortness of breath or chest pain. Informed client of wait times, placed wristband on client, and had him return to the waiting room to be triaged. 1055. Notified by a family in the waiting room that the client was slouched in chair and "seemed dead." Client was found to be unresponsive with constricted pupils, clammy skin, bradypnea, and circumoral cyanosis. Rt arm is red and swollen with blistered areas.
➡ unresponsive ➡ constricted pupils ➡ bradypnea ➡ circumoral cyanosis Rationale: The client reports narcotic use and may be suffering from an opioid overdose as evidenced by the respiratory depression, constricted pupils, change in the level of consciousness, and color changes. This client shows evidence of hypoxia with circumoral cyanosis and bradypnea. Respiratory depression should be the priority assessment. Clammy skin can have multiple causes including pain and anxiety. The redness, swelling and blistered skin are expected findings with cellulitis. These findings can be addressed at a later time.
