Exam 4 Review

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. What is a correct response from the nurse make?

"Please ring for assistance when you wish to get out of bed" SAFETY! Tinnitus, one-sided hearing loss, and vertigo are all manifestations of Ménière's disease that can increase the clients risk of falls when ambulating.

When caring for a client with cirrhosis, which symptom(s) should the nurse report immediatley?

A change in mental status Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, diarrhea, or constipation with accompanying weight loss are regular symptoms of cirrhosis

A nurse is creating a teaching plan for a client with glaucoma. What instructions should the nurse include in the plan of care?

Eye medications will need to be administered for life Administration of eye drops is a critical component of the treatment plan for the client with glaucoma

A nurse is reviewing the laboratory date of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?

Amylase An enzyme that changes complex sugar into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released in the mouth, stomach, and instances to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2-3 days

Which is useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or waist?

Arthrography Useful in identifying tears

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?

Avoid heavy lifting anything heavier then 4.5kg for 1 week The nurse instructs the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10lb) for week following surgery

A nurse is planning to discharge instruction for a patient following an acute onset of Gout, what should the nurse include?

Avoid purine rich foods, red meats, red wine, limit alcohol Clients should be encouraged to increase fluid intake to help prevent formation of uric stones

A nurse is caring for a patient with Ménière's disease is experiencing severe vertigo, what instruction should the nurse give to control the vertigo?

Avoid sudden head movements

A client is starting Celebrex to treat Osteoarthritis, the nurse should instruct the client to monitor and report what adverse effect?

Black, tarry stools Can cause GI bleeding or ulcers The nurse should also monitor for abdominal pain, coffee ground emesis Educate the patient to take Celebrex with food to decrease gastric irritation

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should the initial nursing action be?

Call the provider Severe pain or pain accompanied by nausea following a cataract extraction is an indicator of increased intraocular pressure and should be reported to the provider immediately

Which terms refers to a grating or crackling sound or sensation?

Crepitus May occur with movement of the ends of a broken bone or irregular joint surface

What is the black color triage tag used in disaster's labeled and what does it mean?

Deceased or Expectant The individual's injuries incompatible with life or without spontaneous respiration

A nurse is teaching a class about preventative care for clients who are at risk for acquiring viral hepatitis, what information should the nurse include?

Depending on geographical location, prepare food with purified water

a nurse is teaching self management to a client who has Hep B, what kind of instruction should the nurse include in the teaching?

Frequent rest and limited activity to reduce metabolic demands of the liver and to decrease energy needs

A nurse is providing teaching to a client who has Hepatitis A, what should the nurse include in the teaching?

Hand washing along with immunizations are the most effective strategies to prevent the spread of Hep A

What Hepatitis does not have an immunization?

Hepatitis C

What is the red color triage noted for?

Immediate Patient has severe injuries but high potential for survival with treatment

A client has undergone a liver biopsy. Which post procedure position is appropriate?

Laying on the right side

A nurse is reviewing risk factors with a client who has cholecystitis The nurse should identify that ______ is a risk factor for cholecystitis?

Obesity

What is the term that describes the passage of a hollow instrument into a cavity to withdraw fluid?

Paracentesis

A nurse is planning care for a patient who has end stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the clients ammonia level?

Reduce the patients intake of protein Ammonia is formed in the GI tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary proteins is not recommended.

A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. What instruction should the nurse include related to their diet?

Resume diet of choice

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?

Semi-Fowler's The nurse should expect a prescription to place the client in semi-fower's position following a traditional cholecystectomy to facilitate lung expansion as well as coughing and deep breathing. This position will place minimal stress on the abdomen and increase comfort

What lab study indicates the rate of bone turnover?

Serum Osteocalcin Serum Osteocalcin (bone GLA protein) indicates the rate of bone turnover

What does START Triage stand for?

Simple Triage And Rapid Treatment

Most cases of osteomyelitis are caused by which microorganism?

Staphylococcus aureus 70-80% of infections are caused by staph

In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation?

Surgical debridement In chronic osteomyelitis, antibiotics are an added therapy to surgical debridement before and after

What is a cholecystectomy?

Surgical removal of the gallbladder

Inflation of anthrax mimics which disease process?

The Flu Usually, treatment is sought only when the second stage of severe respiratory distress occurs

A client is diagnosed with a disorder involving the inner ear. What is the most common client complaint associated with a disorder involving this part of the ear?

Tinnitus or Inner Ear Pressure Most common complaint of clients with ontological disorders. Symptoms range from mild ringing in the ear, to loud roaring in the ear

What term is defined as an agent that can cause injury to the body?

Toxicity The medical lethal dose is amount of the chemical that will cause death in 50% of the who are exposed