Basic Adult Health Final exam review

Nursing interventions for post cardiac catheterization

1. Assess site for bleeding 2. Assess peripheral pulses (most distal) 3. Watch for dysrhythmias

What is the proper method to ensure you have matched the correct patient with the correct unit of blood for transfusion? SATA

1. Confirm prescription 2. Type and crossmatch 3. Verification of signed consent 4. Double check orders with another nurse 5. Patient identifiers

Age related changes for cardiovascular system

1. Decreased cardiac output 2. Increased blood pressure 3. Heart rate and stroke volume do not increase with maximum demand.

What are the three factors of the Virchow's triad?

1. Endothelial damage 2. Venous stasis 3. Altered coagulation

Hypothalamic-pituitary response

1. Hypothalamus stimulates pituitary gland which then secretes ATCH, which then stimulates the adrenal glands to secrete cortisol. 2. Example: A person with diabetes who is under stress such as an infection, they will need more insulin than normal.

The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures? 1. Insert a gauze wick into the stoma 2. Close the opening temporarily with a cellophane seal 3. Suction the stoma before changing the appliance 4. Avoid oral fluids for several hours before changing the appliance

1. Insert a gauze wick into the stoma

The nurse is participating at a health fair at the local mall giving influenza vaccinations to senior citizens. What level of prevention is the nurse practicing? 1. Primary Prevention 2. Secondary Prevention 3. Tertiary Prevention 4. Quaternary Prevention

1. Primary prevention

What are the clothing requirements in each of the three zones of the operating suite?

1. Unrestricted zone-- Street clothes allowed 2. Semi-restricted zone-- Scrubs & caps 3. Restricted zone-- Scrubs, caps, masks, and shoe covers.

To prevent recurrence of cystitis, the nurse should plan to encourage the female client to include which of the following measures in her daily routine? 1. Wearing cotton underpants. 2. Increasing citrus juice intake. 3. Douching regularly with 0.25% acetic acid. 4. Using vaginal sprays.

1. Wearing cotton underpants

The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and that there are several throw rugs throughout the home and a low footstool in the living room. She suggests that the rugs and the footstool be removed and improving the lighting in the home. The nurse is addressing which need according to Maslow? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-actualization

2. Safety and security

The client with an ileal conduit will be using a reusable appliance at home. The nurse should teach the client to clean the appliance routinely with which product? 1. Baking soda 2. Soap 3. Hydrogen peroxide 4. Alcohol

2. Soap

A client has an ileal conduit. Which of the following solutions will be useful to help control odor in the urine collecting bag after it has been cleaned? 1. Salt water 2. Vinegar 3. Ammonia 4. Bleach

2. Vinegar

When should a woman perform a Breast Self Examination (BSE)?

1 week after period

A nurse is assessing a client with Cushing syndrome. Which signs should the nurse expect the client to exhibit? (Select all that apply.) 1. Hirsutism 2. Round face 3. Pitting edema 4. Buffalo hump 5. Hypoglycemia

1. Hirsutism 2. Round face 4. Buffalo hump

What are essential components of a pre-operative assessment? SATA

1. Most recent labs 2. Signed consent 3. Vital signs 4. Medications and allergies

Discuss the management of hypoglycemia

15g of carbs= 2-3 glucose tablets 1 tube glucose gel 0.5 cup juice

Would you expect afterload to be increased by venous or arterial vasoconstriction?

Arterial vasoconstriction

Nursing management for patient experiencing anaphylaxis?

Assess Oxygen Rapid response Epinephrine Antihistamines

What is a similarity between Crohn's disease and Ulcerative colitis?

Both inflammatory

What are clinical manifestations of cushing syndrome?

Buffalo hump Moon face Excessive hair growth (Hirsutism)

Patient teaching for a patient newly prescribed sildenafil (Viagra)?

Do not take nitroglycerin

Teaching plan for ileal conduit?

Same as Ostomy care

For the patient receiving periodic morphine via intravenous push, which of the following findings would be of utmost concern to the nurse? a. Increased temperature b. Decreased bowel sounds c. Respiratory depression d. Increased red blood cell count

c. Respiratory depression

Moral problem

competing moral claim or principle; one claim or principle is clearly dominant

Clinical manifestations of hypervolemia

peripheral edema JVD bounding pulse polyuria dyspnea, crackles, rales pulmonary edema weight gain

Moral distress

the anguish experienced when a person feels unable to act according to closely held core values

Clinical manifestations of hypoglycemia?

*Cold and clammy give some candy* Release of epinephrine - shakiness, tremors, palpitations - nervousness, diaphoresis, anxiety, pallor Insufficient glucose to the brain - Faintness, dizziness, headache - Unsteady gait, slurred speech, difficulty speaking - *stupor, confusion, seizures, coma* Other clinical manifestations - *Numbness of fingers, toes, and mouth*

Clinical manifestations of hypocalcemia

-Increased neuromuscular excitability (Paresthesias, muscle twitching/cramping, tetany, hyperactive reflexes, trousseau/chvostek signs) -Cardiac arrhythmias

Clinical manifestations of hypovolemia

-Thirst -Dry mucous membranes -Decreased skin turgor/delay return/tenting -Hypotension, tachycardia -Weight loss -Decreased urine output, concentrated urine -Restless, drowsy, confused, dizzy, weak

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood teaching? Select all that apply 1. "If I limit my fluid intake, I will not have to empty my ostomy pouch as often" 2. "I can place an aspirin tablet in my pouch to decrease odor" 3. "I can usually keep my ostomy pouch on for 3-7 days before changing it" 4. "I must use a skin barrier to protect my skin form urine" 5. "I should empty my ostomy pouch of urine when it is full"

3. "I can usually keep my ostomy pouch on for 3-7 days before changing it" 4. "I must use a skin barrier to protect my skin form urine"

The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. The nurse should tell the client to drink: 1. Twice as much fluid as usual. 2. At least 1 quart more than usual. 3. A lot of water, juice, and other fluids throughout the day. 4. At least 3,000 mL of fluids daily.

4. At least 3,000 mL of fluids daily.

How is hypertension defined by the American Society of Hypertension and the International Society of Hypertension?

A BP of 140/90 or above on average of two or more accurate BP measurements taken 1-4 weeks apart.

Clinical manifestations of hypokalemia

ARRHYTHMIAS, weak irregular pulse, weakness, confusion, muscle cramps, paralysis

What is the priority intervention for someone having an acute asthma exacerbation?

Administer albuterol

Clinical manifestations for COPD? SATA

Chronic cough Barrel chest Low skin turgor Edema

What is an indication of Crohn's disease?

Cobblestone appearance

What teaching would you provide your patient prior to an exercise or pharmacologic stress test?

DO NOT TAKE METOPROLOL PRIOR TO TESTING Refrain from caffeine

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

Dehydration

What is the most common and most serious complication from diarrhea?

Dehydration

Adverse effects of xenical (Orlistat)?

Diarrhea Flatus (gas) Oily stools Fecal incontinence

What psychosocial diagnosis would be considered for a patient undergoing a mastectomy?

Disturbed body image Determine their readiness to learn

What diagnostic test can be used to diagnose a DVT?

Doppler study

Patient teaching to prevent UTI

Drink plenty of fluids Wear cotton underpants Cranberry juice is preventative, but not curable.

If a patient is making a rattling noise, what phase of the trajectory model is the patient in?

Dying phase

What is the first thing you would do if a client came into the ED complaining of chest pain

EKG

What postoperative care is most appropriate for a patient who has undergone modified radical mastectomy in the right breast?

Elevate HOB to 30 degrees.

A nurse is planning care for a client who has urolithiasis (kidney stone). Which of the following actions should the nurse take?

Encourage intake of at least 3 L of fluids per day.

Nursing intervention for patient undergoing a bone scan?

Ensure patient fully empties bladder

What is the most common symptom of anemia?

Fatigue

Adverse effects of NSAIDs

GI symptoms, risk for bleeding

What is the best method of infection prevention?

Hand Hygiene

Secondary prevention

Health maintenance, early detection, prompt intervention to prevent or minimize loss of function and independence, health screenings and health risk appraisals. Example: Breast self exam

A nurse is caring for a client with a diagnosis of Cushing syndrome. What is the most common cause of Cushing syndrome that the nurse should consider before assessing this client for physiological responses?

Hyperplasia of the adrenal cortex

Which immune globulins are typically involved in allergic reactions?

IgE

How is AML treated?

Induction therapy

What are patients being treated for AML most at risk for?

Infection

What process would you suspect if neutrophil levels were elevated?

Infection

What are the chances of inheriting cystic fibrosis

It is an autosomal recessive disorder so you have a 25% chance of inheriting.

Patient teaching for patient with urolithiasis?

Limit sodium intake Drink plenty of fluids Contact provider at the first sign of UTI

Most common adverse effect of Tylenol

Liver damage

Post-operative teaching for patient undergoing surgery for testicular cancer?

Maintain regular follow up appointments to detect other types of malignancies. *Frequent screening*

Tertiary prevention

Minimize deterioration, improve quality of life, rehabilitation, physical therapy.

What does MONA stand for?

Morphine Oxygen Nitroglycerin Aspirin

What is the priority assessment for a patient in a cast, splint, or brace?

Neurovascular assessment-- 6 P's

What is an indication of a stage 1 pressure injury?

Non-blanchable redness

What is the most common risk factor for sleep apnea

Obesity

Clinical manifestation for a patient with HIV/AIDS?

Oral candidiasis

How do you assess neurovascular function?

Pain Pallor Poikilothermia Paresthesias Pulselessness Paralysis

Difference between palliative and hospice care

Palliative care-- Can begin at the time of diagnosis Hospice care-- Begins when patient has 6 months or less to live.

What diagnostic test would be used to detect elevated levels of IgE?

RAST

What teaching would a nurse give to a patient with halix valgus (bunion)

RICE

Significance of Mcburney's point

RLQ for appendicitis (Hotspot question)

What is the pathophysiology of Guillain Barre Syndrome?

Rapid demyelination with ascending paralysis

What are the 5 cardinal signs of inflammation? SATA

Redness (erythema) Warmth Swelling (Edema) Pain Loss of function

Primary prevention

Reducing the risk of disease through health promotion and risk reduction strategies. Examples: COVID vaccine, dietary modifications

Nursing intervention for patient undergoing a DEXA scan?

Remove any jewelry or metal objects from person.

What is the purpose of surgical drains?

So fluid does not accumulate inside the wound and to prevent infection.

What is the difference between a stage 3 and stage 4 pressure injury

Stage 3= full thickness tissue loss with fat visible Stage 4= Exposed tendon, bone and muscle visible

What is the purpose of specific gravity, creatinine, and BUN tests?

To assess kidney function

Clinical manifestations of acoustic neuroma?

Vertigo

Moral dilemma

a conflict in which you have to choose between two or more actions and have moral reasons for choosing each action

What is an acoustic neuroma?

a tumor of the 8th cranial nerve (Vestibulocochlear) that compresses the 8th cranial nerve and the brainstem

A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed aqueous vasopressin. Which of the following outcomes indicates that treatment has been effective? a. Blood pressure of 90/50 mm Hg b. Fluid intake of 2,400mL in 24 hours c. Urine output of 200mL per hour d. Pulse rate of 126 beats/minute

b. Fluid intake of 2,400mL in 24 hours