Health Care Concepts 2
venous insufficiency symptoms
Edema worsening when feet are dependent venous stasis ulcers (open sores in skin)
Nurse caring for client that has pneumonia. Which action should the nurse take to promote thinning of secretions?
Encourage client to increase fluid intake
Nurse caring for 6 mos old baby post op. Which pain scale?
FLACC
a nurse is assessing a client who has hyperthyroidism. THe nurse should expect the client to report which of the following manifestations?
Frequent mood changes
Laboring mother. Reports feeling light headed. What is priority action?
GIve oxygen via mask 10L
Hypercalcemia
Greater than 11 decreased neuromuscular activity diminished reflexes decreased LOC
Hypermagnesemia
Greater than 2.5 Decreased neuromuscular activity diminished reflexes decreased LOC
A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?
Grilled chicken breast with white rice.
The nurse is reviewing lab values for a femal client suspected of having a fluid imbalance. Which lab value evaluated by the nurse supports the diagnosis of dehydration
Hematocrit 53%
a nurse is caring for a client hwo has Addison's disease and is at risk for Addisonian crisis. What action should the nurse take?
Weigh the client daily
Hypernatremia
greater than 145 Impaired cerebral function, decreased LOC thirst TREAT WITH HYPOTONIC
signs of preeclampsia
hypertension and protein in the urine
Introjection
incorporation and outside factors into oneself
SIADH
increased amount of ADH resulting in retention of water
Desensitization
involves exposing the client to increasingly intense situations that the client fears. WITH NO HARM
Hypomagnesemia
less than 1.5 increased neuromuscular excitability muscle cramps twitching hyperactive reflexes seizures
Hyponatremia
less than 132 Symptoms N/V decreased LOC, impaired cerebral function seizures TREAT WITH HYPERTONIC
Hypocalcemia
less than 9 increased neuromuscular excitability, muscle cramps, twitching hyperactive reflexes seizures positive Chvosteck's and Trosseau's signs
mitral stenosis
low pitched rumbling murmer and week pulse
CLient in ED after passing out. Fasting with ketones in urine
metabolic acidosis
Repression
unconsciously forgetting a stressor
Hyperglycemia symptoms
warm skin, rapid respirations nausea lethargy
FOur older adult clients. Who to administer vaccine to
Client that takes medicine for peptic ulcers
Which of these for patients is at risk for urinary stones?
QUadripelegic bc of immobility
Enteral feeding indications
dysphagia, long term intubation, damage/surgery to esophagus
nurse caring for client with urolithiasis which is an associated risk
family hx
A nurse is caring for a client who has a history of alcohol abuse disorder. The nurse comes into the room and finds the client shouting "get these bugs off me." Which is the appropriate response?
"I don't see any bugs, but you seem very anxious."
A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which statement indicates a further need fo rteaching
"I will reducae my exercise to 3 times a week"
A nurse is caring for a client who was involved in heavy combat and observed war casualties. THe nurse would suspect that the client is suffering from PTSD because?
"In my dreams all I can see are the wounded reaching out and trying to grab me."
Small bowel obstruction symptoms
Abdominal distention high pitched HYPO active bowel sounds Water stools leaking around the obstruction
Antivirals
Acyclovir (varicella) Ribavirin (RSV) Antiretroviral therapy (HIV and AID
Which infant should receive a higher neonatal abstinence score?
An infant with a high pitched cry and a respiratory rate greater than 60 with retractions. And tremors of the arms
Early withdrawl symptoms of alcohol
Anxiety, diaphoresis, irratibility, mood swings, tremors, dilated pupils, tachycardia, hypertension, anorexia, and insomnia
Nurse caring for client one day post op. Reporting incisional pain. Which action should nurse take?
Ask the patient to rate the pain
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following lab values is the priority for the nurse to assess?
Aspartate aminotransferase. (AST)
A nurse is caring for a clinet who has cushing's syndrome. Which of the following interventions should the nurse expect to perform?
Assess for jugular venous distention
Indications of toxicity with Magnesium sulfate
Bradychardia, urine output of less than 30 ml an hour, resp rate less than 12/min diminished deep tendon reflexes.
Deep vein thrombosis symptoms
Calf pain Redness Swelling (Confirmed via Venous doppler studies)
Side effects of ACE inhibitors
Dry cough
A nurse is teaching a client who has a history of hemophilia A about manifestations of the disorder. THe nurse should include which element of the teaching.
Disabling joint pain.
Ventricular septal defect
Hole in the wall that seperates the heart's lower chamber
Priority in early detox of alcohol withdrawl
Hydration. Safety. Rest.
Nurse providing infor for pain control. Gastric re-suction. Whih indicates understaind fo information
I will call for pain medicine before the previous dose wears off.
Nurse teaching students about kidney infections. Which statement should be included:
Increases chances of pregnant women's preterm labor
Planning care for cystitits what should be included?
Instruct client to stay away from carbonated beverages
Nurse reviewing lab values for respiratory acidosis. What should they expect?
Low pH paC02 high HC03 normal or high depending on how long
Treatment for preeclampsia
Magnesium sulfate
Nurse receives pt ED that is comatose. Breathing deeply and rapidly. BGS pH7.25 PCO2 25 HCO3 18
Metabolic acidosis with partial respiratory compensation
Signs of cardiac valve malfunctions
Mitral valve prolapse Aortic regurgitation Mitral stenosis Aortic stenosis
Nurse is discharging a child with sickle cell after crisis episode. What should be included in teaching parents?
Offer fluids to child multiple times a day
Antibiotics used to treat otitis metia. What means it's fixed?
Pain has subsided
Which medications are FDA approved for the management of PTSD
Paroxetine (paxil) and sertraline (Zoloft)
A child with hemophilia is seen for a check up. Which lab value would the nurse expect to be abnormal for the child?
Partial thromplastin time.
A nurse is discussing obsessive compulsive disorder with a newly licensed nurse. Which statement by the newly licensed nurse indicates an understanding of the reason clients with OCD perform ritualistc behaviors
Perfom ritualistic behaviors to provde temporary relief. q
Tetralogy of Fallot
Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
nurse caring for client post op. respirations are shallow at 9 permin.
Respiratory acidosis
Victim of sexual assault with respiratory rate of 32-36. what should you expect?
Respiratory alkalosis
Nurse in ED providing care for mild ankle sprain
Rest, Ice, Compression, Elevate
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?
Review the clients electroytes
Which is the most effective treatment for separation anxiety in an 8 year old child?
Selective serotonin reuptake inhibitors and cognitive behavioral therapy
Increase for diabetes insipidus
Specific gravity
a nurse is caring for a client who has chrohn's disease. which of the following food choices would follow the recommended diet for clients who have chron's.
Toast with jelly
CNS symptoms of NAS
Tremors, irritability, wakefulness, high muscle tone, hyperactive deep tendon reflexes, seizures, frequent yawning and sneezing
ELements for normal sinus rhythm
Uniform regular P-waves PR interval 0.12-.2 secs A narrow QRS complex associated with P wave Rate of 60-100 6-10 per 6 sec strip
Signs of improvement of CHF
Urine output greater than 30 ml/hr Decrease in adventitiuous lung sounds Decreased use of supplemental oxygen
Mitral valve prolapse
Valves don't close smoothly and bulge upwards. Chest pains, palpitations, exercise intolerance and a systolic click
Treatment of diabetes insipidus
Vasopressin ADH Increased fluid intake to prevent dehydration
ALcohol intolerance is
a decreased response requiring more alcohol to achieve the desired effects.
Hypnosis
a viable treatment option for phobias
right ventricular hypertrophy
abnormal enlargement of cardiac muscle
Which nursing intervention should be implemented for somebody with respiratory acidosis COPD>
administer bronchodialators
Aortic regurgitation
bounding arterial pulses and widened pulse pressure
Side effects of beta blcokers
bradychardia lethargy and drowsiness bronchospasms and wheezing N/V and diarrhea
Arterial insufficiency symptoms
cap refill >3 secs extremities pale and cool weak pedal pulses dependent rubor lack of hair on extremeties leg cramps with activity
Nurse caring for metabolic alkalosis. WHat should the nurse monitor for?
circumoral paresthesia
Acute abdominal pain. Reports pain has subsided
contact provider
Desired effect of Vasopressin
decreased urine output
Pulmonic stenosis
opening to pulmonary valve is too narrow
ABGS provder suspects Acidosis. What should the nurse see?
pH below 7.35
Nurse assessment experiencing N/V for four days. WHat values would you expect to have
pH high PaC02 normal or elevated HC03 elevated
Nurse admitting client with acute pancreatitis what should the nurse anticipate
pantoprazole proton pump inhibitor.
Nurse caring for pt with actue COPD. ph 7.30 pCo2 58 Hco3 32
partially compensated respiratory acidosis
overriding aorta
positioned over VSD
Illness anxiety disorder
preoccupation with various illnesess
Paronoia
refusal of medications related to fear of poisoning
Bolus feeding
residual should be checked and reinstilled. IF GREATER THAN HALF THE VOLUME FROM PREVIOUS FEEDING HOLD FEEDING AND CONTACT PROVIDER
Regression
reverting to childlike behaviors
aortic stenosis
rough systolic crescendo-decrescendo murmur
Hypoglycemia symptoms
sweating tachycardia tremors palpitations hunger, anxiety
Dissociation
the ability to compartmentalize the source of anxiety
Phobias
the fear my seem irrational, but is very real to the client
Conversion disorder
the involuntary loss of sensory function
Diabetes insipidus
the loss of large amounts of urine and extreme thirst
