quizlet- wrong questions

neuro: A health care provider makes the tentative diagnosis of herniated intervertebral disk for a client experiencing lower back pain. What should the nurse ask when assessing this client's back pain?

"Is there any tenderness in the calf of your leg?" "Have you had any burning sensation on urination?" "Does the pain begin in your flank then radiate around to the groin?" "Do you have any increase in pain when bearing down during a bowel movement?"

s/sx of TB

1. fever- infection 2. night sweats 3. blood tingled sputum d/t damage of alveolar membrane 4. productive cough--> purulent indcating infection

A nurse is planning to transfer a client who is experiencing pain when transferring from the bed to a chair. Place the following steps in the order in which they should be implemented.

1. verify the prescription 2. identify factors that may impact the ability to transfer 3. explain the steps 4. lock wheels 4. position the bed

On the second day after surgery, a client reports pain in the right calf. What should the nurse do first?

Apply a warm soak. Document the symptom. Elevate the leg above the heart. Notify the health care provider. Calf pain may be a sign of thrombophlebitis, which can lead to pulmonary embolism. A postoperative client with pain in the calf should be confined to bed immediately and the health care provider notified. A prescription for application of heat may be given after a diagnosis is made; application of heat is a dependent nursing function. Documentation is not the priority; this is a potentially serious complication. The leg should not be elevated above heart level without a prescription; gravity may dislodge a thrombus, creating an embolism.

While making rounds, the nurse finds a client lying on the floor next to a wheelchair. The client states, "I was trying to get back to bed and slipped." What should be the nurse's initial action?

Call the nurse manager to alert administration Arrange for the client to be examined by the in-house health care provider Complete an incident report to ensure documentation of the event Provide information about the incident to the client's primary health care provider

A client is admitted to the hospital for a total hip replacement. The nurse is planning preoperative teaching about the nursing care to be delivered during the immediate postoperative period. Which is the most important factor that the nurse should focus on regarding immediate postoperative care?

Flexing the operative hip Abducting the operative hip Turning onto the operative side Maintaining the contour position After surgery, abduction is maintained to reduce the chance of dislocation of the femoral head. Flexing the operative hip can lead to dislocation of the femoral head. Turning onto the operative side causes hip adduction, which can lead to dislocation of the femoral head. The contour position flexes the hip and can lead to dislocation of the femoral head.

A client with multiple injuries from a motor vehicle accident now is permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse:

Fold the client's arms across the chest Place the sling so that the top is below the client's scapulae Call the primary health care provider to secure a prescription to use a mechanical lift Raise the lift so that the sling is at least 12 inches above the mattres

The nurse considers that sensory restriction in a client who is blind can:

Increase the use of daydreaming and fantasy Heighten the client's ability to make decisions Decrease the client's restlessness and lethargy Lead to the use of permanent neurotic behaviors Internal self-stimulation increases as external stimuli decrease. Blindness is an added stress that can increase anxiety, which impairs decision-making; lack of visual stimuli limits data for decision-making. Lack of visual stimuli can increase restlessness, lethargy, and apathy. Blindness will not precipitate neurotic behavior unless other emotional factors are present.

A client with pulmonary tuberculosis is being treated at home. To help control the spread of the disease, the nurse instructs the client to:

Have visitors sit across the room from the client Keep personal articles away from the rest of the family Open the windows frequently to allow air to circulate throughout the house Avoid putting used dishes in the dishwasher with the rest of the family's dishes Fresh airflow through the house exchanges the air and lowers the concentration of microorganisms. Having visitors sit across the room from the client is not necessary. Only articles contaminated with infected sputum, such as used tissues, should be contained. It is permissible to put used dishes in the dishwasher because the extreme heat used to clean the dishes will kill the mycobacteria.

A client who has passed the acute phase of rheumatoid arthritis now is permitted to be out of bed as tolerated. After assisting the client out of bed, the nurse should place the client in a:

Low, soft lounge chair Straight-back armchair Wheelchair with footrests Recliner chair with both legs elevated

The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, the nurse should:

Place a pillow under the thighs Elevate the knee gatch of the bed Encourage active range of motion Maintain the feet at right angles to the legs :Maintaining the feet at right angles to the legs produces dorsiflexion of the feet and prevents the tendons from shortening, preventing footdrop. Placing a pillow under the thighs and elevating the knee gatch of the bed will not prevent plantar flexion; it can promote hip and knee flexion contractures. The client will not have the ability or strength to perform range-of-motion exercises unassisted at this time.

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states that it is important to:

Plan activities for later in the day Eat meals in a semi-recumbent position Avoid people with respiratory infections Take muscle relaxants when under stress Respiratory infections place people with myasthenia gravis at high risk because they do not cough effectively and may develop pneumonia or airway obstruction. Activity should be conducted earlier in the day before the energy reserve is depleted; periods of activity should be alternated with periods of rest. The client should eat sitting in a chair to prevent aspiration. Taking muscle relaxants when under stress is contraindicated; these potentiate weakness because of their effect on the myoneural junction.

A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises?

Spend more time inhaling than exhaling to blow off carbon dioxide Perform diaphragmatic exercises to improve contraction of the diaphragm Perform sit-ups to strengthen abdominal muscles to improve breathing Use abdominal exercises to limit the use of accessory muscles of respiration. With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable. Longer expiration, not inhalation, facilitates removal of carbon dioxide. Sit-ups are too strenuous for clients with emphysema. The abdominal muscles are accessory muscles of respiration, and their contraction and relaxation are enhanced in diaphragmatic breathing.

Which nursing action is important when suctioning the secretions of a client with a tracheostomy?

Use a new sterile catheter with each insertion. Initiate suction as the catheter is being withdrawn. Insert the catheter until the cough reflex is stimulated. Remove the inner cannula before inserting the suction catheter During suctioning of a client's secretions , negative pressure (suction) should not be applied until the catheter is ready to be drawn out because, in addition to the removal of secretions, oxygen is being depleted. The sterility of the catheter can be maintained during one suctioning session; a new sterile catheter should be used for each new session of suctioning. A cough reflex may be absent or diminished in some clients; the catheter should be inserted approximately 12 cm (4 to 5 inches) or just past the end of the tracheostomy tube. The inner cannula is not removed during suctioning; it may be removed during tracheostomy care.

The nurse concludes that a client with glaucoma needs education when the client states "It is dangerous for me to:

Use sedatives." Lift heavy objects." Become constipated." Take atropine in any form." Sedatives have no effect on intraocular pressure. Additional teaching is not necessary; lifting heavy objects, becoming constipated, and taking atropine in any form should be avoided because it will increase intraocular pressure.

Haldol--> usually dose is 2-5 mg q-24 hours

antidepresants: takes 2-3 weeks for it to be effective

what does protective isolation mean?

neutropenic precuations

accurate measurement of a clients respiratory status

oxygen saturation-> measurement of 02 and hemoglobin -any form of pa02/pac02--> need a venipuncture

quadrepledgia

paralysis of all 4 extremities

Guillain-Barré syndrome

symptoms appear d/t an infection

neuro: A nurse is assessing a client with the diagnosis of osteoporosis. What part of the client's body should the nurse assess to identify osteoporotic changes?

verebtral column-->kyphosis--> able to see through the naked eye