CM2 Finals

Absence seizures

Absence seizures present with automatisms, and the client is unaware of his or her environment.

Explain how a 24-hour urine specimen is collected.

Ask pt to void, then discard and note the time. Collect all urine of the next 24 hours. 24 hours after initiation, ask pt to empty bladder and add that urine to container.

An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate? Cerumen = ear wax

Assess for cerumen buildup.

A T-score from a bone density scan at or lower than -2.5 indicates osteoporosis. What medication should the nurse teach the patient about. Side effects?

Bisphosphonates. Side effects: bone, joint or muscle pain. · Side effects of the oral tablets may include nausea, difficulty swallowing, heartburn, irritation of the esophagus and gastric ulcer.

For which electrolyte imbalance would the nurse assess for a patient with excessive production of thyrocalcitonin (calcitonin)?

Calcium

The nurse has given a community group a presentation on eye health. List items that should be covered.

Clients should be taught to protect their eyes from ultraviolet (UV) exposure by consistently wearing sunglasses when outdoors, when tanning in tanning salons, or when working with UV light.

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client?

Corneal staining

Explain the confidentiality requirements for individuals having genetic testing. A nurse cares for an adult client who has received genetic testing. The clients mother asks to receive the results of her daughters genetic tests. Which action should the nurse take?

Direct the mother to speak with the client and support the clients decision to share or not share the results

Corticosteroids reduce immune function, so patients taking these medications must avoid being exposed to illness. List other side effects of corticosteroids.

Edema, increased ocular pressure, HTN

A patient is receiving plasmapheresis. What action by the nurse best prevents infection in this patient?

Hand washing

A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer. The client states that he does not want any family to know about this result. How should the nurse respond?

It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them

Which prescribed medication would the nurse prepare to administer for a client who is experiencing status epilepticus?

Lorazepam (Ativan)

A patient is going on a cruise but has had motion sickness in the past. What medication does the nurse suggest to this patient?

Meclizine (Antivert) Anti vertigo

The first priority for a patient with a spinal cord injury is assessment of respiratory status and airway patency.

Patients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation.

Atonic seizures

Presents as a sudden loss of muscle tone followed by postictal confusion.

A patient is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority?

Respiratory system

Genetic testing can be a stressful experience:

Seeing a genetic counselor can provide support and education throughout the process.

Tonic-clonic seizures

Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities

Beta-blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. The patient states she doesn't need to medication b/c she has no symptoms. How does the nurse respond?

Tell me the reason why you are not taking the meds Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.

After witnessing a client beginning to experience a tonic-clonic seizure what action would the nurse take first?

Turn the client's head to the side

Validation therapy with clients who have Alzheimer's disease involves acknowledgment of the client's feelings and concerns. Describe how this therapy can be implemented.

Use of validation therapy with clients who have Alzheimer's disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation

What places a patient at greatest risk for the development of carcinoma of the liver?

chronic alcohol consumption, hepatitis B, hepatitis C and non-alcoholic fatty liver disease

Damage to the sacral spinal nerves may be assess by a ______

distended bladder.

List how Hepatitis A may be contracted?

poor sanitation, homeless, living/sleeping with infected person, drug users, international traveling.

Clients with Alzheimer's disease have a tendency to wander, especially at night. List safety interventions for this condition.

- Engage the client in structured activities -Another is to take the client for frequent walks. - If possible, alarms should be installed on all outside doors to alert family members if the client leaves. - At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. - The client should be allowed to exercise within his or her limits. - Throw rugs are a slip and fall hazard and should be removed. - The client should eat a well-balanced diet.

A client who has Parkinson disease has problems chewing food. List interventions to help this patient eat.

-Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs, Bite sized portions of food -Keep the head of the bed 30 degrees or higher

Myoclonic seizures

A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups.