N150B Final
57. Open-ended questions
"How could I modify this proposal to meet more of your requirements?" "What kind of information do you need in order to go forward?" "How are you feeling about all of this?"
14. Cholesterol - patient whose thyroid produces an insufficient amount of thyroid hormone - response of nurse A patient whose thyroid gland produces an insufficient amount of thyroid hormone tells the nurse, "I watch what I eat but my cholesterol continues to go up." An appropriate response for the nurse to make to this patient is which of the following? 1. "The thyroid gland malfunction can affect your cholesterol level." 2. "Maybe you don't realize how much fat is in the foods that you eat." 3. "Elevated cholesterol is a normal part of aging." 4. "Describe your typical bedtime snack."
"The thyroid gland malfunction can affect your cholesterol level." deficient TH elevates serum cholesterol and triglyceride levels→ increased risk for atherosclerosis and cardiac disorders
85. The nurse is assessing the musculoskeletal status of a 70-year-old patient. What finding should the nurse consider as expected age-related changes in this body system? (select all that apply)
#1,2,4 and 5: Decreased muscle mass, reduced muscle strength, reduced range of motion of shoulders and hips, loss of ½ inch in height from previous assessment -decrease speed and power of skeletal muscle contractions -slower reaction time -loss of ht: atrophy to intervertebral disk, -increased flexion at hips and knee -loss of bone mass and muscle -joint stiffness -impaired balance -greater difficulty in complex learning and abstraction: fewer cells in cerebral cortex
12. Nursing diagnosis for herpes zoster (shingles)- highest priority (Pg. 403 Med-Surge)
*Acute Pain related to the presence of lesions and pruritus --Risk for infection related to open oozing areas --Deficient knowledge of the cause of the skin disorder and recommended tx --Anxiety related to need to work in areas of pesticide application --Ineffective health maintenance related to limited access to healthcare --limit exposure to others to prevent spread of infection
42. Select all that apply - Mayeroffs philosophy of caring
*knowing *alternating rhythms *patience *honesty *trust *humility *hope *courage
9. Select all that apply - What patient would be at risk for osteoporosis Pg. 1268
--Insufficient intake of dietary calcium, Vitamin D deficient --In women after menopause being female, especially Caucasian and Asians --Individuals immobilized or physically inactive (sedentary lifestyle) --Endocrine disorders and malabsorption disorders --DM, Cushing Syndrome -High alcohol, low estrogen, smoking, sedentary lifestyles, corticosteroids -older age --family hx of osteoporosis & hx of fx in first degree relative --Being thin and or having a small frame --Low testosterone levels in men --Medication use; corticosteroids, some anticonvulsants
7. Interventions to prevent injuries on a pt with osteoporosis, history of falls and dementia
--provide info about risk factors of osteoporosis --adequate intake of calcium and vitamin D --keeping meds and poison out of reach --knobs off kitchen stoves to prevent burns and fires --special locks on doors for persons who tend to wander
70. Select all that apply - nurse completed back massage for pt, what would nurse document (Pg 1238 Fundamentals)
-Back massage performed -Client's response -Unusual findings
69. Gave med for mild pain, getting worse, what should you do
-Give opioids for moderate pain -WEAK opioids according to the WHO ladder (codeine, tramadol, or combos such as oxycodone with acetaminophen or hydrocodone with ibuprofen)
95. Pt teaching regarding meds to treat diabetes
-Medication to treat diabetes depends on the type. -Type 1 needs a lifelong exogenous source of insulin to control and not to cure it. -insulin lispro (Humalog), rapid acting - regular (Humulin), short acting -intermediate ( NPH) - Lantus, long acting -Combinations 50/50, 70/30
67. Select all that apply - Pt having difficulty sleeping due to pain, what diagnosis
-Sleep pattern disturbance, insomnia -Pain (acute/chronic) -Fatigue
3. A nurse is teaching a diabetic education class when one of the patients asks, "What can I do to prevent going blind due to my diabetes?" What is the best response by the nurse? 1. "The risk of developing blindness is related to how long you've had diabetes, and how well your blood sugar and hypertension are controlled." 2. "It is due to the small blood vessels in the eye becoming hardened and clogged and not being able to transport oxygen and nutrients to the retina." 3. "This is only a problem with type 2 diabetes so you won't have this problem." 4. "Laser photocoagulation surgery will treat any problems that develop and stop the progression of diabetic retinopathy."
1 -- The risk of developing diabetic retinopathy is related to the duration of the diabetes and the degree of glycemic control. Hypertension is also a risk factor. Option 2 is correct as the retinal capillaries become sclerotic and lose their ability to transport sufficient oxygen and nutrients to the retina, but this statement does not answer the patient's question. Diabetic retinopathy is seen in both type 1 and type 2 diabetes. Laser photocoagulation is used to treat both forms of diabetic retinopathy, however it does not cure the disease.
16. A nurse should recognize that a patient with untreated hypothyroidism is at risk for developing which of the following? Standard Text: Select all that apply. 1. elevated serum cholesterol 2. anemia 3. hyperglycemia 4. hypernatremia 5. decreased serum LDL
1, 2 -increased Triglycerides -risk for atherosclerosis and cardiac disorders. -decreased renal blood flow and GFR- HYPOnatremia -sleep apnea myxedema coma- lifethreatning
18. The nurse is teaching a patient who has a diagnosis of hypothyroidism about the importance of dietary fiber. The nurse realizes the patient understands teaching when the patient states which of the following? Select all that apply. Standard Text: Select all that apply. 1. "I will drink a full glass of water with my fiber pill each morning." 2. "I will snack on popcorn rather than potato chips." 3. "I will take an over-the-counter fiber pill each morning with my levothyroxine." 4. "I will increase my intake of protein sources such as meat and eggs." 5. "I will read the nutrition labels and choose foods with high carbohydrate content."
1,2 -- A full glass of water should be taken with fiber tablets to decrease the risk of intestinal blockage. Popcorn is a high-fiber food and an appropriate choice for a patient who needs a high-fiber diet. The patient should not ingest a high-fiber source at the same time that thyroid replacement medications are taken, as the fiber will interfere with absorption of the thyroid replacement medication. Meat and eggs are not good sources of fiber. This patient should look for fiber content on labels rather than carbohydrate content.
32. The patient asks the nurse about metabolic syndrome. Which is the most accurate answer for the nurse to provide? 1. "Metabolic syndrome is caused by obesity, physical inactivity, and genetic factors." 2. "This syndrome is not a concern for females unless they smoke." 3. "This problem affects only older adults over the age of 65." 4. "It can be avoided by taking vitamins daily and drinking 64 fluid ounces of water a day."
1. "Metabolic syndrome is caused by obesity, physical inactivity, and genetic factors."
5. Which nursing diagnosis is a priority for a patient with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting? 1. Disturbed Sensory Perception 2. Imbalanced Nutrition: Less than Body Requirements 3. Risk for Trauma 4. Disturbed Sleep Patterns
1. Disturbed Sensory Perception
26. A patient who is being treated for a deep vein thrombosis (DVT) complains of chest pain and shortness of breath. Which of the following should the nurse do first? 1. Elevate the head of the bed and begin oxygen therapy. 2. Obtain a 12-lead EKG and notify the physician. 3. Measure the patient's blood pressure. 4. Assess the extremity with the thrombosis and heart sounds. 5. Assess the pulses on the extremity with the thrombosis and check the PT/INR level .
1. Elevate the head of the bed and begin oxygen therapy.
13. The patient with herpes zoster has pruritus and reports difficulty resting at night. Which of the following interventions will best aid the patient? 1. Encourage the patient to take prescribed antipruritic agents approximately one hour before bedtime. 2. Massage the irritated skin areas with lotion. 3. Apply powder to the lesions. 4. Use heavy bed linens to avoid chilling at night.
1. Encourage the patient to take prescribed antipruritic agents approximately one hour before bedtime.
55. Know working phase
1. Exploring and understanding thoughts and feelings Empathetic listening & responding: Nonverbal behaviors indicating empathy include moderate head nodding, a steady gaze, moderate gesturing, and little activity or body movement. Empathetic listening focuses on a kind of "being with" clients to develop an understanding of them and their world. *Respect: show respect for the client's willingness to be available, desire to work with the client, and a manner that conveys the idea of taking the client's point of view seriously. *Genuineness: Personal statements can be helpful in solidifying the rapport between the nurse and the client. These statements must be used with discretion. *Concreteness: When the client says, "I'm stupid and clumsy," the nurse narrows the topic to the specific by pointing out, "You tripped on the rug." *Confrontation: The nurse points out discrepancies between thoughts, feelings, and actions that inhibit the client's self-understanding or exploration of specific areas. 2. Facilitating and taking action- the client must make decisions & take action, however, the nurse collaborates in these decisions, provides support, and can offer options or information.
31. A nurse is conducting teaching about risk factor management for cardiovascular disease (CVD) at a senior center. What is the most important info for the nurse to include? 1. Stop smoking. 2. Eat in moderation. 3. Exercise when able. 4. Reduce saturated fats in the diet.
1. Stop smoking.
58. The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format, this statement would be documented under which category?
1. Subjective data s- subjective: pt's complaints, date started, what relieved the complaint, previous medical treatment, family history, etc o- objective: vital signs and physical examination findings. Results of diagnostic/laboratory testing a- assessment: physician's analysis of the problem based on the pt's complaints and physical examination p-plan: treatment plan including follow up
30. The nurse, caring for a pt admitted w/ chest pain, realizes that which factor places the pt at the highest risk for heart disease? 1. overweight & carries the weight around the waist 2. mother died at age 70 of an acute myocardial infarction 3. a single mother of four young children with a low income 4. has a desk job & works long hours
1. overweight & carries the weight around the waist
90. Diabetes - number of people that get it per year incidence
1.9 million in the US
10. A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.
2. Assess for a full bladder.
38. In which situation can the nurse apply restraints to a client? 1. Client wanders around the care area 2. Client is picking at the access site for intravenous infusion of chemotherapy 3. Client needed to use the bathroom and waited for help but didn't want to soil the bed and fell while attempting to walk to the bathroom 4. Client does not want to stay in bed but wants to sit in the lounge with others.
2. Client is picking at the access site for intravenous infusion of chemotherapy
40. A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this client's documentation? 1. Who assisted the client back to bed. 2. Location of the seizure. 3. Duration of the seizure. 4. Status of airway and use of oxygen. 5. Who discovered the client.
2. Location of the seizure. 3. Duration of the seizure. 4. Status of airway and use of oxygen.
37. What should the nurse do for a client who experiences a seizure? 1. Insert a tongue blade into the client's mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position if possible
2. Loosen any clothing around the neck and chest.
39. A client is prescribed seizure precautions. What can the nurse delegate to UAP to complete when implementing the precautions?
2. Padding the client's bed.
24. A pt is seen for increasing edema in his left lower extremity, erythema, & pain in the limb w/ ambulation. Which of the following disorders do these symptoms suggest? 1. arterial occlusion 2. deep vein thrombosis 3. superficial vein thrombosis (SVT) 4. varicose veins
2. deep vein thrombosis
25.A patient with a deep vein thrombosis (DVT) is going to be weaned from intravenous heparin. The nurse anticipates that oral warfarin sodium should be prescribed 1. the same day the heparin is discontinued. 2. the day before the heparin is discontinued. 3. four to five days before the heparin is discontinued. 4. the day the patient is discharged.
3-- Oral anticoagulation with warfarin may be initiated concurrently with heparin therapy. Overlapping heparin and warfarin therapy for four to five days is important because the full anticoagulant effect of warfarin is delayed, and it may actually promote clotting during the first few days of therapy.
36. Which intervention will prevent falls in a health care agency? 1. Display the phone number to the nurses' station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions.
3. Keep the environment tidy.
87. Pt has diabetes and toenails that are thick and ingrown, what would the nurse tell them 1. Soak feet in Epsom salts daily. 2. Use a clean sharp razor blade to trim nails. 3. Make an appointment with a podiatrist. 4. Cut toenails immediately prior to bathing.
3. Make an appointment with a podiatrist.
The nurse suspects that a pt is experiencing the effects of peripheral atherosclerosis. Which of the following did the nurse most likely assess in this pt? 1. rubor w/ extremity elevation 2. normal hair distribution bilaterally over lower extremities 3. peripheral pulses present bilaterally 4. complaints of leg pain upon rest
4 Rationale 4: Manifestations of peripheral atherosclerosis include intermittent claudication; pain at rest; paresthesias; diminished or absent peripheral pulses; pallor w/ extremity elevation; rubor w/ extremities in dependent position; thin, shiny, hairless skin; thickened toenails; & areas of skin discoloration or skin breakdown.
27. The nurse is teaching a community education class on hypertension and risk factors for this disorder. Of the following risk factors, which is the primary one leading to the higher incidence of hypertension in older adults? 1. being a black adult 2. being a white male 3. having a family history of hypertension 4. age-related increase in the systolic blood pressure
4 -- An age-related increase in the systolic blood pressure is the primary factor leading to the high incidence of hypertension in older adults. Systolic blood pressure continues to rise with aging, unlike the diastolic blood pressure which tends to rise until age 50 and then levels off. The other options are also risk factors for hypertension in older adults.
35. The nursing care goal for a client who is at risk for injury is: 1. Assess the client's mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury.
4. Remain free from injury.
48. Healthy lifestyle, best example
A healthy lifestyle will involve balance and moderation healthy lifestyle - ie: nutrition, activity and exercise, recreation mind-body therapies - ie: guided imagery, meditation, yoga *unique and lifelong process. Responding to one's own needs
89.The nurse is assessing a diaphoretic pt who has a HR of 112 BPM. The pt. states "I feel nervous and shaky," Which of the following should you do: A.) Provide the pt. with a snack of milk and crackers B.) Administer insulin utilizing the prescribed sliding scale dosages C.) Contact the lab and order a serum glucose level D.) Obtain a capillary serum glucose level reading with a glucose meter
A.) Provide the pt. with a snack of milk and crackers
52. What to do if pt is crying
Acknowledge their tears. + "sometimes it's difficult to share the things to someone you are concerned about with someone you do not know well. I'd like to be able to help"
1. A patient with COPD is being treated for glaucoma. The medication that will most likely be prescribed for this patient is which of the following? 1. an adrenergic agonist 2. a beta-blocker 3. a calcium channel blocker 4. an antibiotic
An adrenergic agonist may be prescribed along with a beta-blocker or if beta-blockers are contraindicated, as for patients with heart failure, asthma, or COPD.
34. A 52-year-old obese male pt who is admitted with elevated triglycerides & a history of smoking two packs of cigarettes a day for 20 years asks about his risk for coronary artery disease. What info should the nurse provide? 1. He is at risk for coronary artery disease. 2. He is not at risk for coronary artery disease. 3. He possesses all nonmodifiable risk factors for coronary artery disease that cannot be overcome. 4. He possesses all modifiable risk factors for coronary artery disease that can be overcome.
Answer: 1 Rationale 1,2,3,4: Age is a nonmodifiable risk factor & obesity, elevated triglycerides & smoking are modifiable risk factors. Together the risk factors place the pt at higher risk to develop coronary artery disease.
33. What info does the nurse consider when administering medication to treat hyperlipidemia? 1. Such meds include the statins, which act by lowering LDL levels. 2. These meds act by increasing the LDL levels & decreasing the HDL levels. 3. These meds do not include angiotensin-converting enzyme (ACE) inhibitors. 4. Such meds include bile acid sequestrants as first-line drugs to lower cholesterol levels.
Answer: 1 Rationale 1: The statin drugs specifically lower LDL. Rationale 2: Hyperlipidemia drugs are meant to lower LDL & raise HDL, not the opposite. Rationale 3: Angiotensin-converting enzyme (ACE) inhibitors are appropriate to add to drug treatment for high-risk pts. Rationale 4: Bile acid sequestrant drugs are not first-line drugs but may be added to statins when combination treatment is needed.
22. Ineffective peripheral tissue perfusion - interventions MEdsug 990
Assess: peripheral pulses, pain, color, temperature, cap refill q4h prn. Doppler may be needed, mark pulses, establish baseline Position with extremities dependentà gravity for blood flow Avoid smoking: nicotineà vasodilator (use gum/patches[less nicotine] to reduce cravings Discuss benefits of exercise (promotes development of collateral circulation to ischemic tissues and slows atherosclerosis) Use foot cradle and lightweight blankets, socks, and slippers to keep extremities warm. Avoid electric heating pads or hot water (warm= conserves heat, prevents spasms promotes arterial blood flow. Heating devicesàpossible burning. Foot cradleàavoid compression) Encourage frequent position changes, don't cross legs or use pillow under knees (promotes blood flow and prevents ulcers, crossing legs/pillow under knees compresses partially obstructed arteries further and impairs distal tissue blood flow)
4. Pt responds incorrectly to questions during basic conversation, what should the nurse assess for
Confused "LOC"
11. A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? 1. "I will stop taking this medicine if I notice any bruising." 2. "I will not eat spinach while I'm taking this medicine." 3. "It will be OK for me to eat anything, as long as it is low fat." 4. "I'll check my blood pressure frequently while taking this medication."
Correct Answer: 2 Rationale: Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless by prescriber order. Low-fat foods do not interfere with warfarin therapy, which is not prescribed to affect the blood pressure.
78. Not able to hold urine, what should nurse say (p. 778 med surge #9 NCLEX) 9. A patient has difficulty getting to the bathroom in time to prevent urine leaks once the need to void occurs. What should the nurse teach this patient?
Could recommend pelvic floor muscle (kegel) exercises. Answer 3. Limit intake of caffeine containing beverages particularly in the evening. Rationale: Caffeine and artificial sweeteners are bladder irritants causing instability of the detrusor muscle and aggravating manifestations.
83. Risk of developing dementia and delirium
Dementia is a progressive loss of cognitive function and delirium is acute and reversible. Delirium causes are infection, medications, and dehydration. The most common is Alzheimer's of which the cause is unknown The characteristics for dementia are cognitive dysfunctions, including decline in memory, learning, attention, judgement, orientation and language skills.. (hand out paper) Risk for dementia, Alzheimer's: over 65 genetics-4 genes Herpes simplex type I Down syndrome Head injury- may have happened years before Risk for Delirium: Elderly Terminally ill Fever Surgery Night time lack of sleep New or change in environment New medication
88. Know blood glucose levels
Diabetic Levels HgA1c > 6.5 Fasting plasma glucose ≥ 126 Glucose tolerance test ≥ 200 Random glucose (plasma) test ≥ 200
60. After making a documentation error, which action should the nurse take?
Draw a line through the mistake and write mistaken entry with initials above it
45. Student asks instructor different types of knowledge are important in clinical area, best response by instructor
Empirical Personal Ethical Aesthetic
72. 8 month old infant, what would you use for pain indication
FLACC scale
65. Pt is using an ice pack to reduce intensity of back pain, the nurse knows this as
Gate Control Theory
49. How to restore peace and balance between mind and body
Help restore peace and balance to thoughts and emotions ex. imagery, meditation, storytelling, music therapy, and yoga
94. Nursing diagnosis for pt with no history of diabetes with a new level of hemoglobin A1c (p.530) (p.506)
HgA1C: > or equal to 6.5% FPG > or equal to 126mg/dL (7.0mmol/L), no caloric intake for 8 hours b4 Two hour PG greater than or equal to 200mg/dL (11.1mmol/L) Random plasma glucose greater than or equal to 200mg/dL (11.1mmol/L) Nursing dx: - Ineffective self health management r/t control of blood glucose aeb by recent episode by recent -powerlessness r/t to a perceived lack of control of DM due to present demands on time -Deficient knowledge r/t self management of DM -Risk for ineffective role performance r/t uncertainty about capacity to achieve desired role as registered nurse HgA1C : between 5.7%-6.5% is prediabetes
21. A patient is diagnosed with peripheral atherosclerosis. What should the nurse expect to assess in this patient?
Impaired sensation in the affected extremity
93. Plan of care for pt who has type 1 to help reduce complications (p,530)
Implement exercise, check labs Hgb A1c, implement low fat, low cholesterol diet, Mutually establish specific and individualized short term and long term goals for self management of blood glucose. Provide pt with opportunities to express feelings about illness,. Explore perceptions of the patient's own ability to control illness and future and clarify these perceptions by providing info about resources and support groups. Facilitate decision making abilities in the patient for self managing prescribed treatment regimen. Provide positive reinforcement for increasing involvement in self care activities. Provide relevant learning activities about insulin administration dietary management, exercise, self monitoring of blood glucose, and healthy lifestyle.
41. What behaviors would a student interpret as caring by the nurse
Informing the pt/answering questions about details regarding a surgical procedure Caring Nursing is focused attention. Following 3 things between nurse and patient: -Connection -Mutual recognition -Involvement *Helping one to grow and actualize Caring - influenced by diversity of human response. Caring pattern includes knowing the client, nursing presence, empowering the client and compassion & competence.
53. Zone of proximity for catheter
Intimate: touching to 1.5 feet
59. What should student review before going in to take care of the pt
Labs, pain levels, medical history, OTC drugs, med hx/reconciliation, age, race, vital signs, MAR, patient history (surgeries, xrays),
46. Compassion, best example of compassionate nursing
Learning the pt's spiritual needs / addressing the pt's individual spirituality and helping the pt meet those needs [if possible w/in hospital regulations] / advocating for their spiritual needs COMPASSION- Awareness of one's relationship to others, sharing their joys, sorrows, pain, and accomplishments. Participation in the experience of another.
71. Pt is in a long leg cast complaining of knee discomfort, what non pharmacologic can you do
Mind body interventions including: Distraction,relaxation techniques, imagery, meditation, biofeedback, hypnosis, cognitive reframing, emotional counseling (Pg. 1236 and 1239 fund)
92. Know what is related to development of type 2 diabetes, risk factors
Modifiable: obesity (BMI 25-29.9), low physical activity, high sedentary behavior, socioeconomic status Non-modifiable: Ethnicity (Pima indian, hispanic, asian and african american), family history of type 2 dm, puberty, previous gestational diabetes, females.
96. Select all that apply - pt demographic group that are at an increased risk for receiving insulin
Non-hispanic African Am. (14.7%) Hispanics (9.5 %) Am. Indians and Native Am. (16.5%) Asian Americans (7.5%) Non-hispanic Whites (9.8%)
99. Diabetes demonstrates albuminuria, hypertension and edema, what nursing diagnosis
Nursing Diagnosis for Preeclampsia Ineffective Cerebral Tissue Perfusion related to decreased cardiac output secondary to vascular vasopasme. Impaired Gas Exchange related to accumulation of fluid in the lungs: pulmonary edema. Decreased Cardiac Output related to decreased venous return, cardiac trouble. Excess Fluid Volume related to glomerular function impairment secondary to the decrease of cardiac output. Activity Intolerance related to weakness. Impaired Urinary Elimination related to impaired glomerular filtration: anuria and oliguria. Imbalanced Nutrition Less Than Body Requirements related to inadequate intake. Knowledge Deficit: the management of therapy and treatment related to misinterpretation of information.
64. Select all that apply - conducting pain assessment what are you assessing for
Onset Location Duration Characteristics Aggravating factors Radiating Time Note: PQRST
75. Elderly women who come to community center for exercise class, what will it help with
Osteoporosis and decrease muscle atrophy; slow bone-density loss
66. Hip surgery reluctant to ambulate due to pain - what can nurse due to help with pain control
Plan administration of pain meds prior to ambulation so as to anticipate pt's pain
84. Why is it Difficult to recognize disease process in some geriatric pts
Polypharmacy, multiple disorders and multiple drugs, missed diagnoses, underreporting symptoms
15. Select all that apply - How do you diagnosis primary hypothyroidism (labs) (Pg. 479 & 483 MEd-Surge) Hypothyroidism Normal ↑in 1° Decreased, <5 mcg/dl Decreased, <80ng/dl Decreased, <25% No change
Primary- most common, occurring from congenital defects in gland, loss of thyroid tissue following treatments for hyperthyroidism with surgery or radiation, anti thyroid meds, Test: serum TA (normal) serum TSH(increased) serum T4 (decreased) serum T3 (decreased) T3 uptake (T3RU) (decreased) thyroid suppression (no change) Decrease in TH, especially T4 TSH concentration increased Elevated serum LDL cholesterol, triglycerides and lipoproteins Anemia, hypoglycemia and hyponatremia, lactic acidosis, hypothermia also common
2. Sensorineural - type of hearing loss - what type of patient would be at risk for this (med surge p. 1526) risk factors
Results from damage to the hair cells of the organ of corti due to: loud impulse noise (an explosion) loud continuous noise ( machinery) exposure to a high level of noise (standing close to the stage or speaker at a concert) on intermittent or continuing basis ototoxic; when combined with high noise level AND ototoxic drugs- aspirin, furosemide, aminoglycosides, streptomycin, vancomycin, antimalarial drugs, and chemotherapy drugs(cisplatin) ....(greater damage and results in more profound hearing loss when combined) Prenatal exposure to rubella viral infections, meningitis, trauma, menieres disease, aging tumors such as vestibular schwannomas, vascular disorders, demyelinating or degenerative diseases, infections ( bacterial meningitis)
47. Caring, chose which situation shows the best whole idea of caring
Roach defines these attributes as the six Cs of caring: compassion, competence, confidence, conscience, commitment, and comportment. BOX 25-1 The Six Cs of Caring in Nursing
44. During a midterm evaluation, the nurse educator tells the students they need to work on improving their aesthetic knowledge. A good way for the students to accomplish this is to:
Spend time in the clinical area with seasoned nurses.
23. Instructions for a pt going home on oral anticoagulants for an arterial thrombus - know how they present and what oral anticoagulants due and interventions (teaching a pt what to look for)
Take precautions to prevent injury and bleeding, use soft toothbrush. Notify all healthcare providers, including dentists and podiatrists of therapy. Teaching: a. Keep Vitamin-K available to reverse effects of warfarin in the event of excessive bleeding b. Do not take prescribed dose if bleeding occurs (hematemesis, red or black, tarry feces, hematuria, bleeding gums, excessive bruising) c. Take warfarin at the same time everyday; do not change brands as their effects may differ d. Menstrual bleeding may be slightly increased e. Take precautions to prevent injury and bleeding (Use a soft toothbrush, electric razor, wear shoes, use a night light, and avoid participating in contact sports) f. Do not smoke, drink alcohol, or take OTC drugs (unless recommended by healthcare provider) Manifestations (medsurg 995) ischemic tissues: painful, pale, cool/cold distal pulses absent paresthesias (numbness/tingling) in extremities cyanosis and mottling (of skin) paralysis and muscle spasms may develop in affected extremity (dependent on which artery is blocked) line of demarcation between normal and ischemic tissue may be seen (embolism divides it) pulselessness distal to blockage (other) oral medications (medsurg 1001) [neither requires monitoring, but no reversal agent] dabigatran (pradaxa): direct thrombin inhibitor (stops from forming) rivaroxaban (Xarelto): selective X factor inhibitor, inactivates cascade of coagulation
79. Erikson's' theory of task development, what should they be able to do at the elderly age (p. 358 Fundamentals) Integrity vs. Despair
Task met: Acceptance of worth and uniqueness of ones own life and acceptance of death Task not met: Sense of loss, contempt for others
80. Nurse is helping home health, pt acquires supplies he'll need when discharged, what should nurse consider when looking at supplies (p. 43 med surge)
The nurse must be resourceful and cost conscious with equipment, supplies, and services in the home. She also must make sure that the supplies will be safe, needle disposal boxes, disposal of toxic medications especially if children are present.
56. Promoting communication with someone who is nonverbal
The nurse should convey encouragement to the client and provide nonverbal insurance, perhaps by touch if appropriate. Ways to help communication include keeping words simple and concrete. Begin to establish signals yes/no to direct physical cue (eye blinking, hand squeezing). Communicate effectively by: using sign language, using word board or picture board, using a computer
54. Nurse ask pt about level of pain, pt is grimacing saying it's fine, what factor of communication is pt struggling with?
The pt is is struggling to verbally communicate. r/t language deficits, sensory deficits, cognitive impairments, structural deficits ( deficits in the oral and nasal cavities & respiratory system) & paralysis.
91. Diabetes - which pt is at risk for developing DKA
Type I (Med-Surg) Diabetic Ketoacidosis - insufficient insulin Not enough glucose getting in the cells Fat stores breakdown to provide energy At risk: -surgery -trauma -illness -omitted insulin -stress Elevated blood glucose level and low plasma bicarbonate level.
63. CRAMPING -type of pain
Visceral Note: Somatic pain is associated with cramping.
43. Nurse theorist- concept of caring in clinical setting
Watson- philosophy and caring model
28. How to describe pedal pulses and document During the assessment, a pt's pedal pulses are increased. The nurse should document this finding as which of the following? 1. +1 2. +2 3. +3 4. +4
Where the dorsalis pedis artery passes over the bones of the foot, on an imaginary line drawn from the middle of the ankle to the space between the big and second toes Assess rate, rhythm and volume Correct answer:3 Rationale: The correct documentation for this finding is +3. Pulses should be described as increased, normal, diminished, or absent. Scales that range from 0 to 4+ are sometimes used as follows: 0 = absent; 1+ = diminished; 2+ = normal; 3+ = increased; 4+ = bounding.
86. Statement about prescription and over the counter drugs by adults, which one would be true
Which of the following statements is accurate when discussing self-treatment options with a patient? "Over-the-counter medications can, at times, be used in place of prescription drugs. It is important to discuss the use of these with your health care provider."
Coronary heart disease (CHD) is a major problem in the United States. Pts with which history may require closer evaluation for CHD? Select all that apply. 1. diabetes 2. hyperlipidemia 3. positive family history 4. a premenopausal woman 5. hypotension
answer: 1,2,3 Rationale 1: Diabetes is a disease condition that contributes to coronary heart disease (CHD). Rationale 2: Hyperlipidemia is a disease condition that contributes to CHD. Rationale 3: Positive family history in some cases is considered a nonmodifiable risk factor for CHD. Rationale 4: Women experiencing premature menopause (not premenopausal women) is also a condition to be evaluated. Rationale 5: Hypotension is not associated with development of CHD.
61. First action for nurse to do for a pt comes to emergency room that complains of severe abdominal pain
ask if patient is N/V to assess if its associated with current presence.
6. Select all that apply - Nursing interventions for a diagnosis of impaired verbal communication related to hearing deficit. Pg 1530 The nurse is caring for a patient who has a hearing deficit. Which of the following techniques should be implemented by the nurse to improve communication? (Select all that apply.) a. Keep the patient's face in full light. b. Use a low voice pitch with normal loudness. c. Speak at a slower rate than usual. d. Use short sentences.
b. Use a low voice pitch with normal loudness. d. Use short sentences. -- wave your hand or tap their shoulder before beginning to talk to them --when speaking, face patient and keep your hands away from your face --keep your face in full light --reduce background noise before speaking --use short sentences and pause at the end. --use a low pitch with normal loudness, don't over articulate --use facial expressions and gestures --provide a magic slate to write on --make sure hearing aid is properly placed, turned on, and has fresh batteries --No IVs in dominant hand --Rephrase statements if they can't understand, and repeat important info
97. Statement by a pt new to diabetes that require immediate nursing intervention The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following? a. "I can have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I can choose any foods, as long as I use enough insulin to cover the calories." d. "I will eat something at meal times to prevent hypoglycemia, even if I am not hungry."
c. "I can choose any foods, as long as I use enough insulin to cover the calories
76. What should nurse recommend to address sensory loss that accompanies aging process
hearing and visual aids, lighting, diet. routine eye exams, wearing sunglasses, use ear protection, check for impacted earwax, assistive hearing devices, dating and labeling food (decreased smell and taste), decreased skin receptors- pain, touch, temperature (set water heater to 110)
19. Adverse effects of digoxin in a pt that has hyperparathyroidism
hypercalcemia
77. group of nursing students are doing their first rotation in a long term care facility the nurse educator, in meeting the needs of this particular client group reminds a student to
independence, respect. the student should encourage them to do as much as possible for themselves, provided that safety is maintained, do not take over for them
20.Abdominal assessment - order of assessment
inspection, auscultation, percussion palpation
8. Select all that apply - Modifiable and nonmodifiable risk factors for hyperlipidemia
modifiable- smoking, obesity, poor diet, physical activity/exercise (sedentary lifestyle) non modifiable- age, gender, family history
68. Pain reported as being a 2 on scale of 1-10, which meds
nonopiods/NSAIDs
82. a nurse who works in a long term care facility has notices that one of the residents has been showing signs of impaired cognitive and self care abilities over the last two weeks. the nurse should
normal age related changes vs physiologic related changes. cognitive impairment that interferes with normal life is not a normal part of aging. a decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnomal
81. Elderly pt has a stroke, what can you do to support pts independence p. 1376 med surge)
nurse needs to acknowledge their ability to think, reason and make decisions. the nurse can support a decision by an older adult even if eventually the decision is reversed because of failing health
73. Recovering from an BKA (below the knee amputation) and experiencing foot pain
phantom limb
51. Bowel prep before going into any GD - how would you explain
simple language
17.Select all that apply - data likely associated with diagnosis of hypothyroidism
thin/brittle hair a. TH production decreases=thyroid gland enlarges as an attempt to produce more hormones b. Characteristics: i. Goiter, fluid retention (edema), decreased appetite, weight gain, constipation, dry skin, dyspnea, pallor, hoarseness, and muscle stiffness ii. Decreased sense of smell, menstrual disorders, anemias, and cardiac enlargement, pulse is typically slow iii. Deficient amount of TH cause abnormalities in lipid metabolism with elevated serum cholesterol and triglyceride levels (as a result pt is at risk for atherosclerosis and cardiac disorders) iv. Decreased renal blood flow and glomerular filtration rate reduce the kidney's ability to excrete water, which may cause hyponatremia v. Sleep apnea is more common in pt with hypothyroidism
