final
Nursing Care for Cataracts
- Increase the light in the room - Large print - Magnifying lens
A nurse is completing discharge teaching with a patient who has irritable bowel syndrome (IBS). Which of the following should the nurse include in the teaching?
Avoid foods that trigger exacerbation
When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing?
0.9% Sodium Chloride
Cardiovascular disease
A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?
Which of the following is anatomy of the lower airway?
Bronchi Lungs Alveoli
D.
Nursing Diagnoses for the patient in shock may include: A. Ineffective peripheral tissue perfusion with risk for decreased cardiac tissue perfusion B. Ineffective cerebral tissue perfusion C. Ineffective renal perfusion D. All of the above
D.
Nursing Diagnoses for the transplant patient include which of the following: A. Risk for infection B. Risk for injury (rejection) C. Knowledge deficit related to new life-long immunosuppression medication D. All of the above
The nurse and UAP are caring for a patient diagnosed with an acute exacerbation of MS who is receiving soli-medrol, a glucocorticosteriod, intravenous push (IVP) every 6 hours. Which nursing intervention should the nurse delegate to the UAP?
Obtain a bedside glucose test before meals
What nutrition category should a patient consume if they have a pressure ulcer?
Protein
A nurse is caring for a patient who has a blood guclose of 52mg/dL. The patient is lethargic but arousable. Which of the following actions should the nurse perform FIRST?
Provide 4 oz of orange juice
Which four defects comprise tetrology of fallout?
Pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy
Pulmonic stenosis
Pulmonary valve doesn't completely open, narrowed
In assessing the patient, which abnormal finding should the nurse relate to thrombocytopenia?
Purpura
Which assessment data would warrant immediate interventions by the nurse:
The client diagnosed with DVT who complains of pain on inspiration
The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse?
The client has 450 mL of bright-red drainage in the chest tube.
What vertebrae injury location signifies Neurogenic Shock?
T6 or higher
Which of the following defects results in increased pulmonary blood flow?
VSD
treatemnt of sensory neuropathy
contorl blood sugar medications- topical creams (capsaicin), tricyclic antidepressants (anitriptyline (elavil)), SSNRI (duloxetime(cymbalta)), antiseizure medications (gabapentin(neurontin), pregabalin (lyrica))
how to help reduce recurrence of headaches
daily exercise, relaxation periods, socializing, yoga, self-hypnosis, learn to cope more appropriately, learning food triggers, avoid smoking
cluster headache drug therapy
not as useful, inhalation of 100% O2 at 6-8 l a min for 10-20 min, sumatriptin can be affective prophylactic- may include verapamil, lithium, ergotamine, divalproew, melatonin, or anitserizure med, nerve blocks or ablative surgery
examination of the findings
objective data (gait, posture, muscle site and srength, ROM)
assessment for gout
pain swelling redness of affected joint
clinical management primary
protect eyes and ears, silver nitrate GTT newbron, oral care, chronic condition management DM and heart disease
cluster headaches
rare form, repeated headache for weeks or months, most severe pain
Cluster headaches
rare, occur weeks/months followed by periods of remission, severe; sharp stabbing, intense pain lasting a few minutes to 3 hours; around eye radiating to temple, forehead, cheek, nose, or gums
complications for infection
recurrence, callulitis, chronic infection, osteomyelitis
migraine
recurring headaches than are... unilateral or bilateral throbbing, a triggering even or factor, manifestations associated with neuroligc and autonomic system dysfunction
Osgood-schlatter disease
inflammation of the patellar ligament at the tibial tuberosity. It is characterized by a painful bump just below the knee that is worse with activity and better with rest
etiology and pathophysiology of RA stage four
inflammatory process subsides loss of joint function formation of subcutaneous nodules
what spinal injury needs mechanical ventilation
injury above c3- round the clock caregiver, resp hygiene, trach care
Trigeminal neuralgia
intermittent intense pain in face, triggered by touch, cold, talking, chewing, brushing teeth, entrapped trigeminal nerve, compression, or tumor
how will headache pain arise
intracranial and extracranial
diagnositc studies RA
lab- rheumatiod facotr (RF), ESR and CRP, antinuclear antibody, antibodies to citrullinated peptide (Anti-ccp) synovial fluid analysis x-rays of involved joints bone scan
Hypopituitary
lack of pituitary hormones, dwarfism and premature aging adults
What vital signs characterize Neurogenic Shock?
- Bradycardia - Hypotension
Vital Signs with Injury above T5
- Bradycardia - Hypotension
genetic etiology of pagets disease
40% of people with pagets have a family member with it
risk factors for glaucoma
5 times more likely in african americans that whites genetic predisopsition hypertension diabetes increasing age tumors infection
ADH
A client has been hospitalized for impaired function of the posterior pituitary gland. The nurse plans to monitor for signs and symptoms of which hormone imbalance?
BP
A client is admitted to the hospital with a diagnosis of pheochromocytoma. The nurse would check which item to detect the primary manifestation of this disorder?
A patient is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed?
Administer corticosteroids as prescribed for inflammation
The emergency room nurse is assessing a patient who is in shock unknown etiology. Which is the priority nursing intervention?
Administer oxygen
A nurse caring for a patient admitted to the ED with DKA. In the acute phase, the PRIORITY nursing action is to prepare to:
Administer regular insulin intravenously
A child with coactation of the aorta would have which of the following symptoms?
Bounding upper extremity pulses and weak lower extremity pulses
Which of the following increases the risk for a urinary tract infection? SATA
Bubble baths Constipation
Injury to the Lumbar and Sacral nerve roots results in what?
Cauda Equine
fifths disease
Caused by parvovirus B19, causes distinctive red rash on face that makes a child appear to have a "slapped cheek"
What is the PRIORITY action for the nurse to take if the patient with type II diabetes complains of blurred vision and irritability?
Check the patients blood glucose level
IBS
Chronic *functional disorder* with intermittent abdominal pain or discomfort and stool pattern irregularities more frequent in women have visceral hypersensitivity which causes abnormally strong response to stimuli (stretching after meal) S/S: abdominal pain, diarrhea/constipation, abdominal distention, excessive flatulence, bloating, urgency, sensation of incomplete evacuation, fatigue, sleep disturbances Risk factors: stress, anxiety, panic disorders, depression, PTSD, abuse history, gastroenteritis (norovirus/rotovirus)
A nurse is caring for a patient who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?
Give the patient extra time to perform activities
Loss of peripheral vision is called what?
Glaucoma
Location of the rash changes with the rash appearing and disappearing on parts of the body - describes which of the following rashes?
Hives
Which of the following is the most important goal of nursing care for a client who is in shock?
Manage inadequate tissue perfusion
Autonomic dysreflexia
Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system; life threatening: HTN, bradycardia, flushed, diaphoretic, h/a
A.
Multiple organ dysfunction syndrome (MODS) is the failing of two or more organ systems in an acutely ill patient such that homeostasis cannot be maintained without intervention. The first body system that is often the first to show signs of dysfunction in MODS is: A. Respiratory B. Gastrointestinal C. Neurological D. Musculoskeletal
treatment pagets
NSAIDS, heat, massage therapy, firm matress, brace, physical therapy to increase muscle strentgh, nutrition- calcium, protein, vitamin D for bone formation
Neuropathy is defined as:
Nerve damage that occurs because of metabolic derangements associated with diabetes
The most specific systems for the nurse to assess related to headaches is:
Neurological assessment
Which of the following history and physical exam finding is/are typical in a patient with slipped capital femoral epiphysis? SATA
Obesity Pain with range of motion Vague history of trauma
B.
One of the collaborative goals of shock is to prevent gastrointestinal bleeding. How could the nurse evaluate if the H2 blocker medication is effective? A. No stomach pain B. Stools for occult blood are negative C. Patient is gaining weight D. Tolerating diet well
The client with burns may be developing DIC. Which symptoms would support the diagnosis of DIC?
Oozing blood from the IV catheter site
Herberden's and Bouchard's Nodes are evident in what disease?
Osteoarthritis
Noninflammatory Synovial Joints are present in what?
Osteoarthritis
Stiffness in the morning lasting 30 mins in indicative of what disorder?
Osteoarthritis
The autoimmune disease in which the body attacks its own tissues is referred to as what?
Systemic Lupus
Injury to what vertebrae would cause paralysis only below the chest?
T6
Which of the following is a cynatoic heart defect?
Transposition of the Great Arteries
Cluster headaches occur at the same time of day for 4 to 12 weeks True or False?
True
Loss of vision with Glaucoma is permanent True or False?
True
Persons with altered taste problems should try experimenting with spices and other seasonings to help mask taste alterations
True
True or false, Addison's disease education includes information about lifelong hormone therapy.
True
True or false, a patient with a spinal cord injury is prone to developing a gastrointestinal stress ulcer
True
True or false. Conductive hearing loss can usually be corrected
True
True or false. Nursing management for headaches may include daily exercise, yoga, and relaxation periods
True
long term management gout
allopurinol (zyloprim) Cholchichine (colcrys)
neurogenic bladder
areflexic (flaccid), hyperreflexic (spastic), or dyssynergia common pronlmes- urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into kidneys
surgical option OA
arthroscopic procedure- for patient with loss of function, unmanaged pain, decreased independence common for patients with knee OA may provide no additional benefit over PT and medical treatment
nursing management SLE
assess for symptoms monitor for seizures skin, musculoskeletal assessments teach patient to manage stress teach patient to avoid infection emotional support
nursing actions stapedectomy
assess for vertigo, N/V
During the progressive stages of shock, lactic acidosis occurs, resulting in: a. Arterial pooling in the periphery b. Constriction of the microvasculature c. Increased capillary permeability d. Movement of fluid into the capillaries
c.
medical management scleroderma
calcium channel blockers- raynauds topical analgesitcs- joint pain beta blockers for hypertensiosn w/ renal involvement immunosuppressive drugs- cyclophosphamide proton pump inhibitors and histmaine blockers- esophageal involvement avoid foods that stim gastic secretions
SLE and pregnancy
can affect women of childbaring age, pregnancy is disocuraged
Pheochromocytoma is a tumor of the adrenal medulla that can increase:
catecholamines
rheumatiod arthitis
chronic, systemic autoimmune disease inflammation of connective tissue in diarthrodial (synovial) joints periods of remission and exacerbation extraarticular manifestations
surgical interventions- hearing loss and deafness
cochlear implant stapedectomy labyrinthectomy
Subluxation of radial head
common childhood injury that is characterized by the partial dislocation of the elbow due to the radius, a bone in the forearm, being pulled away from its normal position
ASIA scale A
complete- no sensory or motor function is preserved in the sacral segments s4-5
degree of injury
complete- total loss of sensory and motor function below level of injury incomplete (partial)- mixed loss of voluntary motor activity and sensation, some tracts intact
incomplete SCI brown-sequard syndrome
damage to one half of cord typically results from penetrating injury ipsilateral loss of motor function and pressure, position, and binration snese contralaterl loss of light touch, pain, and temperature sensation
elderly
decline in sensory/perceptual functions with aging
pathophysiology glaucoma
decreased outflow of aqueous humor increased production of aqueous humor extra fluid caused increased presure of retina- which is painless decrease outflow+increased production= increased pressure on retina
spinal shock
decreased reflexes loss of sensation absent thermoregulation flaccid paralysis below level of injury lasts days to weeks
cataract
dehydration of lens (UV ray exposure), immature to ripe phases; blurry vision, photophobia, sensitivity to glare, vision better in low light, cloudy appearance of lense
grief and depression
depression is common overwhelming sense of loss loss of control adjustment more than acceptance wide fluctuation in emotions allow mourning while encouraging hope
roseola
disease in young children in which fever is followed by a rash, occurring in measles, syphilis, and herpes virus
A patient with state 1 colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that
follow up colonoscopies will be needed to ensure that the cancer does not recur.
stage four sore
full thickness loss than can extend to muslce, bone, or supporting structures- bones, tendon, muscle may be visible tunneling may occur
stage three sore
full thickness skin loss, necorsis or damage to subcutaneous tissue, may extend down to but not through underlying fascia, presents as a deep crater, depth varies by anatomic location
Oral candidiasis (thrush)
fungal infection, result of c. albicans overgrowth
neuropathic pain
gabapentin (neurotinin) or pregabalin (lyrica) teach about pain triggers and relaxation therapy
Pneumatic retinopexy
gas bubble puts pressure on retina to connect to choroid
Salter-Harris
growth plate fracture
client education stepdectomy
hearing is initally worse but will improve as healing occurs
client education labyrinthectomy
hearing loss is expected in the affected ear
how is gout diagnosed
history sympotms increased blood uric acid levels x-ray
post op care after carpal tunel release
hourly circulation checks sensation to fingers after anesthesia wears off elevate hand on pillow to minimize edema hand bandaged from palm to wrist for 5-7 dyas dissolvable sutures gripping and heavy lifting limited for 6 weeks
drugs that can cause SLE type reactions
hydralazone (apresoline) procainamide (pronestyl)
neurogenic shock
hypotension bradycardia loss of SNS innervation- peripheral vasodilation venous pooling decreased cardiac output t6 or higher injury
Paget's
idiopathic disorder, abnormal bone breakdown/formation, transfer of Ca from bone to blood; painful deformities in femur, tibia, lower spine, pelvis, skull, upper humerus
acute care spinal injury
immobilization- maintain neural position stabilize to prevent lateral rotation- hard cervical collar, backboard keep body in correct alignemnt turn as a unit (logrolling) monitor resp, cardiac, urinary, GI functions
clinical manifestation chronic osteomeylitis
infection lasting more than one month or has failed to respond to intial antibiotic treatemet continuous and persistent exacerbations and remissions
Osteomyelitis
infection of bone and surrounding tissue
ewings sarcoma
mimics osteomyelitis, 5-15 years old
how long can a tension headache last
minutes to days subcategorized as- episodic and chronic
if blood loss has occured
monitor hemoglobim and hematocrit, possible blood administration
gastroenteritis and IBS
most common causes of abdominal pain
systemic manifestation of chronic osteomyelitis
reduced
Vitrectomy (diabetic retinopathy)
remove bloody vitreous, replace with NS to maintain shape of eye
leading cuase of death in patient with SLE
renal failure from glomerulonephritis
Perform sterile dressing changes
The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention should the nurse plan to perform?
treatment for chronic osteomyeltis
surgical removal extended use of antibiotics acrylic bead chains containing antibiotics intermittent or constant antibiotic irrigation of bone
tension type drug therapy
symptomatic- mild-moderate treated with aspirin, acetaminophen or an NSAID with sedative, muscle relaxant, or tranquilizer
Autonomic Dysreflexia Irritants
- UTI - Constipation - Distended Bowel
Systemic Lupus S/S
- Butterfly Rash - Photosensitivity - HTN - Alopecia
2 Types of Hearing Loss
- Conductive - Sensorineural
Atrial septal defect.. Cyanotic or Acyanotic?
Acyanotic
Left to right shunt... Cyanotic or Acyanotic?
Acyanotic
Results of a patient's most recent blood work indicates an elevated neutrophil level. The nurse should recognize that this diagnostic finding most likely suggests which problem?
An infection
What medication do you avoid if diagnosed with gout?
Aspirin
What disorder can cause facial paralysis?
Bell's Palsy
Respiratory Difficulties with Injury to C5-T6
Decreased respiratory reserve
Glaucoma
Excess fluid results in increased pressure on the retina
T/F Cerebral palsy is reversible disorder if treatment is started soon after diagnosis
False
An older patient relates that she has increased fatigue and a headache. The nurse identifies pale skin and glossitis on assessment. In response to these findings, which teaching is helpful to the patient if she has microcytic hypochromic anemia?
Take the iron with orange juice one hour before meals
labyrinthectomy
surgical treatment for vertigo that involves the removal or the labyrinthine portion of the inner ear
A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test results will confirm the diagnosis of Hodgkin's disease?
The presence of Reed-Sternberg cells in the lymph nodes
Domes of fluid on the retina is called what?
Wet Macular Degeneration
A primary cause of peripheral artery disease is:
atherosclerosis
migraine without aura
called common migraine, most common type
Tension Headache
- Bilateral - Tightening
ringworm
tinea
A nurse in a clinic is teaching a patient who has ulcerative colitis. Which of the following statements by the patient indicates understanding of the teaching
"I will plan to limit fiber in my diet"
The nurse is reinforcing teaching with a patient newly diagnosed with ALS. Which statement would be appropriate to include in the teaching?
"This is a progressive disease that eventually results in permanent paralysis, though you will not lose any cognitive function."
A nurse is teaching a patient who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?
"This medication may cause your skin to appear yellow in color."
What does the PFO connect?
Right atrium and left atrium
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statements suggest that the family understands the measures to use when caring for the client?
"We need to remind him to turn his head to scan the lost visual field"
Stage 3 Pressure Ulcer
- Full Thickness - Visible Fat
A patient with neurogenic shock following a spinal cord injury is to receive lactated Ringer's solution 500 mL over 30 minutes. When setting the IV pump to deliver the IV fluid, the nurse will set the rate at how many mL/hour?
1000 mL/hr
After starting a blood transfusion, the RN stays in the room for how many minutes?
15 minutes
Which of the following clients are NOT at risk for developing acute respiratory distress syndrome?
A client who has a hemoglobin of 15.1 mg/dL
Aortic aneurysms can be best assessed in which of the following locations?
Abdomen
Which of the following are types of primary headaches? -tension type -migraine -cluster -all of the answers
All of the answers
The nurse writes the problem "impaired skin integrity" for a client with stage IV pressure ulcers. What intervention should be included in patient plan of care?
Ask the dietitian to see the client to help with nutrition
Decreased pulmonary blood flow... Cyanotic or Acyanotic?
Cyanotic
RA
Erosive inflammation of joints; Affects more the metacarpophalangeal (MCP) joints and proximal (PIP) joints; Swan-neck deformities, Boutonniere deformity, ulnar drift; Women>men; Exacerbation and remission; bilateral inflammation, STIFFNESS IN MORNING
Giantism is caused by
Excessive growth hormone
The stroke action plan is
FAST
Which of the following is a risk factor for hypovolemic shock?
Hemorrhage
What is the type of stroke with bleeding?
Hemorrhagic
A patient with type II DM has a blood glucose higher than 500 mg/dL and is complaining of weight loss, weakness, and is disoriented to time and place. A nurse reviews the physicians documentation and would expect to note which of the following diagnoses?
Hyperglycemic hyperosmolar syndrome (HHS)
Which criteria must be met for a diagnosis of metabolic syndrome? (Select all that apply)
Hypertension Elevated triglycerides Elevated serum glucose level Increased waist circumference
The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patients visual system?
Hypertension and Diabetes mellitus
Urethral opening located posterior to glans penis or at any point along the ventral surface describes which of the following?
Hypospadias
IBD
IBS symptoms, inflammation, ulcers, and other damage Includes chron's disease and UC
Which of the following are early signs of dehydration in a child? SATA
Increase heart rate Dry mucous membranes (no spit bubbles)
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority?
Ineffective airway clearance caused by high cervical spinal cord injury
Osteomyelitis
Infection of the bone
Cauda Equine Syndrome
Injury to the lumbosacral nerve roots causing loss of bowel, bladder reflex, causes flaccid lower extremities (develops over time, sx on one side of body)
Trigeminal neuralgia symptoms consist of pain where?
Intense pain in the face
A client splashes a chemical in his eyes. What is the 1st intervention?
Irrigate eyes with normal saline
The client comes to the emergency department after splashing chemicals into the eyes. What intervention should the nurse implement first?
Irrigate the eyes with normal saline solution
Heberdan's nodules and Bouchards nodules
Joint deformities in the hands
OA
Joint destruction and deformity, NOT inflammation, overuse disease, >65 y/o; Affected joints may exhibit crepitus; Occurs in the weight bearing joints primarily (hips and knees), but can affect hands; Joint deformities in the hands are called Heberdan's nodules and Bouchards nodules STIFFNESS AT NIGHT/AFTER USE
Injury to what vertebrae would cause paralysis only below the waist?
L1
Ripe Cataracts
Poor light penetration
Which of the following is true regarding concussions?
Prevention of second impact syndrome is the reason why return to play should be avoided until symptoms resolve
Laboratory studies are performed for a patient suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which results indicates this type of anemia?
Reduced red blood cell count with red blood cells that are microcytic and hypochromic
Which one of the following is NOT TRUE about a bone marrow biopsy?
Requires going to surgury
An upper respiratory infection is treated with which of the following? Check all that apply
Rest Hydration
Loss of night vision in childhood is an early sign of what?
Retinitis Pigmentosa
Which of the following rashes develops after 3-7 days of fever, when the temperature returns to normal?
Roseola
etiology and pathophysicology primary injury
SCI due to cord compression by- bone displacement, interuption of blood supply, traction from pulling on cord penetrating trauma- tearing and transection
C=calcinosis-small white deposits on tissues R=Raynaud's E=esophageal hardening S=Sclerodactyly (localized thickening and tightening of the skin of the fingers or toes) Scleroderma of the digits T=Telangiectasias-capillary dilations that form vascular lesions on the face, lips, fingers
Scleroderma nemonic
Osetomalacia
Softening of the bone
In a child with left to right stunt, which of the following is true?
The child would have increased pulmonary blood flow If the child is hitting developmental milestones and gaining weight, no treatment is needed If the child is not hitting developmental milestones or gaining weight with medical management, treatment would be necessary
Place client in sitting position
The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention?
Avoid activities that may cause pressure near the face.
The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do?
Which of the following rashes is a fungal infection?
Tinea Capitis
What food can cause migraines?
Tyramine (Nuts)
Autonomic Dysreflexia
Uncompensated cardiovascular reaction due to an irritant below the level of injury
Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
Urine output greater than 30ml/hr
D.
What is an example of health promotion education for a client at risk for anaphylatic shock? A. Wear an identification badge/bracelet B. Avoid allergens C. Know how to use epipen D. All of the above
D.
What type of shock would you most likely initially give a vasodialator medication? A. Neurogenic B. Hypovolemic C. Anaphylactic D. Cardiogenic
a. Urine specific gravity 1.001 d. Serum osmolality is 320 f. Urine output has increased from 1000ml in 24 hrs to 4000 in 24 hours
Which findings should raise suspicion to the nurse that a head-injured client may be experiencing diabetes insipidus? Select all that apply. a. Urine specific gravity 1.001 b. Ketones are present in urine c. JVD d. Serum osmolality is 320 e. Blood glucose is greater than 200 f. Urine output has increased from 1000ml in 24 hrs to 4000 in 24 hours
A.
Which of the following is a risk factor for hypovolemic shock? A. Hemorrhage B. Antigen-antibody reaction C. Gram-negative bacteria D. Vasodilation
Boycott
dun
diagnosis of thrush
made on clinical appearance
The nurse is admitting a patient diagnosed with Gullain-Barre syndrome (GBS). Which question should the nurse ask the patient?
"Have you had a viral illness in the last few weeks?"
Which statement by a patient would make the nurse suspect the patient may have type 1 DM
"I have to go to the bathroom and urinate all the time."
The nurse provides home care instructions to a patient with systemic lupus erythematosus (SLE) and tell the patient about methods to manage fatigue. Which statement by the patient indicates a need for further instruction?
"I should continue exercising if I start to feel pain"
The patient diagnosed with MS is crying and tells the nurse, "Why me? I did not do anything to deserve this!" Which is the nurses most therapeutic response?
"This must be difficult for you. Would you like to talk about your feelings?"
A nurse is teaching a patient who has a new diagnosis of rheumatoid arthritis (RA). Which of the following statements should the nurse include in the teaching?
"You can experience morning stiffness when you get out of bed"
Which of the following is a therapeutic response to a child asking "is this going to hurt?"
"it feels like heat"
Treatments for increased ICP may include:
(All of the above!!) or below i guess Elevating HOB Hyperventilate to remove CO2 Give oxygen to maintain cerebral oxygenation
Intermittent catheterization is frequently done with spinal cord injury patients to prevent:
(All of the answers) - Infection - Renal calculi - Autonomic dysreflexia
Health promotion strategies related to spinal cord injuries include:
(All of the answers) - identifying high risk populations for spinal cord injuries -supporting legislation on seat belts, helmets for motorcycles, child safety seats -facilitate wheelchair accessible health care exam rooms
A. Cardiogenic - results from the heart's inability to adequately circulate blood volume. B. Hypovolemic - a decrease in intravascular volume. C. Obstructive - mechanical blockage in the heart or great vessels. D. Distributive - widespread vasodilation and increased capillary permeability. Results from a change in size of the vascular space without an increase in blood volume. Three types: neurogenic, anaphylactic, septic.
**Describe the four types of shock A. Cardiogenic B. Hypovolemic C. Obstructive D. Distributive
Acute rejection occurs in the first 2 weeks after transplantation. Clinical manifestations include fever, malaise, elevated WBC, acute hypertension, graft tenderness and manifestations of deteriorating renal function (elevated creatinine). Chronic rejection occurs gradually, over a period of months to years.
**What are signs of acute kidney transplant rejection? Chronic kidney transplant rejection?
Glaucoma Risk Factors
- African Americans - HTN - Diabetes - Age - Tumors - Infection
Respiratory Difficulties with Injury to C1-3
- Apnea - Inability to cough
Cauda Equine Characteristics
- Asymmetrical distal weakness - Flaccid lower extremity paralysis - Flaccid bladder and bowel
Nursing Care after Post Op Cataracts
- Do not lift more than 5 lbs - Do not rub eye - No aspirin
Autonomic Dysreflexia Nursing Interventions
- Elevate HOB - Notify HCP - Monitor & Treat BP - Assess & Remove Cause
Stage 4 Pressure Ulcer
- Full Thickness - Visible Bone, Tendon or Muscle
Autonomic Dysreflexia Manifestations
- HTN (up to 300 systolic) - Bradycardia - Marked diaphoresis above of injury - Throbbing Headache
A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following clinical manifestations should the nurse expect to find? (SELECT ALL THAT APPLY)
- Herberden's nodes - Enlarged joint size - Limp when walking
Post Op Carpal Tunnel Care
- Hourly circulation checks - Hand on pillow
Cardiac Response to Neurogenic Shock
- Hypotension - Bradycardia
Stage 1 Pressure Ulcer
- Intact Skin - Redness
Osteoarthriris S/S
- Joint Stiffness - Asymmetric - Crepitation - Herberden's and Bouchard's
Precipitating Factors of Systemic Lupus
- Meds - Stress - Sunlight - Pregnancy - Genetics
Nursing Management of Systemic Lupus
- Monitor for seizures - Manage Stress - Avoid Infections
What class of drugs are used to help treat Paget's?
- NSAIDS - Bisphosphonates
Cluster Headache
- Pain in and around one eye - Sharp, stabbing, penetrating
Stage 2 Pressure Ulcer
- Partial Thickness - Skin loss
Respiratory Difficulties with Injury to C4
- Poor Cough - Hypoventilation - Diaphragmatic Breathing
A nurse working in an outpatient clinic is assessing a patient who has rheumatoid arthritis (RA). The patient reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)
- Recent influenza - Decreased range of motion - Pain at rest
Rheumatoid Arthritis S/S
- Symmetric - Stiffness - Limited Movement
Migraine
- Unilateral/Bilateral - Throbbing - Manifestations of neurologic and autonomic dysfunction
Osteomalacia Nursing Interventions
- Vitamin D - Calcium - Protein - Sunlight
A nurse is providing information to a patient who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (SELECT ALL THAT APPLY)
-Apply heat to joints to alleviate pain - Ice inflamed joints following activity - Install an elevated toilet seat -Complete high-energy activities in the morning
how much should you drink during gout attack
2-3L/day
Normal Uric Acid Level
2.5-8
nromal uric acid levels
2.5-8 mg/dL
A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylprednisolone (Solu-Medrol) 160 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How many mL will the nurse administer?
2.56
normal ALP
20-130 units
colon cancer
3rd most common, high in AA men and women
A 32-year-old pregnant patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to a. respect the patient's feelings and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patient's concerns with visitors who arrive at mealtimes.
A
A 37-year-old patient with 2 school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that home life is very stressful. Which response by the nurse is most appropriate? a. "Tell me more about situations that are causing you stress." b. "You need to see a family therapist for some help with stress." c. "Your family should understand the impact of your rheumatoid arthritis." d. "Perhaps it would be helpful for your family to be involved in a support group."
A
A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.
A
A 42-year-old woman with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 30 degrees.
A
A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Experiment with volume and hearing ability in a quiet environment initially. b. Keep the volume low on the hearing aids for the first week while adjusting to them. c. Add a second hearing aid after making the initial adjustment to the first hearing aid. d. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.
A
A hospitalized 31-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the ordered PRN oxygen at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.
A
A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound? a. Red wound b. Yellow wound c. Full-thickness wound d. Stage III pressure ulcer
A
A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The purpose of maintaining the head in a prescribed position b. The use of eye patches to reduce movement of the operative eye c. The need to wear dark glasses to protect the eyes from bright light d. The procedure for dressing changes when the eye dressing is saturated
A
A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will be included in the initial plan of care? a. Immobilization of the left leg b. Positioning the left leg in flexion c. Assisted weight-bearing ambulation d. Quadriceps-setting exercise repetitions
A
Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate several times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.
A
The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding a. relief of joint pain. b. increased urine output. c. elevated serum uric acid. d. increased white blood cells (WBC).
A
The nurse evaluating effectiveness of prescribed calcitonin (Cibacalcin) and ibandronate (Boniva) for a patient with Paget's disease will consider the patient's a. pain level. b. oral intake. c. daily weight. d. grip strength.
A
The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. The patient frequently asks the nurse to repeat information. d. The patient states that the right ear has a feeling of fullness.
A
The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.
A
The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.
A
The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-year-old who has noticed increasing loss of peripheral vision b. 74-year-old who has difficulty seeing well enough to drive at night c. 60-year-old who has difficulty hearing clearly in a noisy environment d. 64-year-old who has decreased hearing and ear "stuffiness" without pain
A
The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.
A
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient takes insulin daily. b. The patient states that the ulcers are very painful. c. The patient has had the heel ulcers for the last 6 months. d. The patient has several old incisions that have formed keloids.
A
Which action will the nurse include in the plan of care for a 62-year-old patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient.
A
Which action will the nurse take when caring for a patient with osteomalacia? a. Teach about the use of vitamin D supplements. b. Educate about the need for weight-bearing exercise. c. Discuss the use of medications such as bisphosphonates. d. Emphasize the importance of sunscreen use when outside.
A
Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision b. Joint tenderness c. Abdominal cramping d. Elevated blood pressure
A
Which finding will the nurse expect when assessing a 58-year-old patient who has osteoarthritis (OA) of the knee? a. Discomfort with joint movement b. Heberden's and Bouchard's nodes c. Redness and swelling of the knee joint d. Stiffness that increases with movement
A
Which information will the nurse include for a patient contemplating a cochlear implant? a. Cochlear implants require training in order to receive the full benefit. b. Cochlear implants are not useful for patients with congenital deafness. c. Cochlear implants are most helpful as an early intervention for presbycusis. d. Cochlear implants improve hearing in patients with conductive hearing loss.
A
Crohn's Disease
A chronic inflammatory disease of the intestines, especially the colon and ileum, associated with ulcers and fistulae. Effects anywhere in GI tract. cobblestone, lesions anywhere in GI tract, disease occurs in patches
Listen to breath sounds
A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action?
ADH excess or deficit
A client has a tumor that is interfering with the function of the hypothalamus. The nurse should monitor for signs and symptoms related to which imbalance?
Truncal obesity
A client has been diagnosed with Cushing's syndrome. The nurse should assess the client for which expected manifestations of this disorder?
Chicken liver
A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food?
HTN
A client has been diagnosed with pheochromocytoma. Which clinical manifestation is most indicative of this condition?
It has incompletely dislocated
A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint?
hypotension
A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would assess for which problem as a manifestation of this disorder?
Cortisol
A client is diagnosed with Cushing's syndrome. When reviewing the recent laboratory results, the nurse should expect an excess of which substance?
tinnitus
A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?
a. Irritability b. Complaints of nausea c. Sodium level of 128 e. BP lying 138/70 and standing 110/58
A client is hospitalized with a diagnosis of adrenal insufficiency. Which findings does the nurse identify as supportive of this diagnosis? Select all that apply a. Irritability b. Complaints of nausea c. Sodium level of 128 d. Potassium level of 3.2 e. BP lying 138/70 and standing 110/58
Autonomic dysreflexia (hyperreflexia)
A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect?
Ringing in ears
A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity?
"Usually these physical changes slowly improve following treatment."
A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client?
a. Hypotension c. Hyperkalemia
A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply. a. Hypotension b. Leukocytosis c. Hyperkalemia d. Hypercalcemia e. Hypernatremia
Altered breathing pattern
A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem?
Acknowledge the client's anger and continue to encourage participation in care
A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action?
Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.
A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information?
b. After meals
A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? a. On arising b. After meals c. On an empty stomach d. 30 minutes before meals
Open trauma to the left leg
A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history?
I will maintain a normal sodium intake in my diet
A nurse has provided dietary instructions to a client with Addison's disease. Which statement made by the client indicates that the client understands instructions?
Graham crackers and warm milk
A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. Which items would be the most appropriate choice for this client to meet nutritional needs?
Taking the clients BP
A nurse is performing an admission assessment on a client with a diagnosis of pheochromocytoma. The nurse should assess for the major sign associated with pheochromocytoma by performing which action?
High urine osmolality, low serum osmolality, hypotonicity of body fluids, continued release of ADH
A nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder?
Polyuria, polydipsia, complaints of excess thirst, specific gravity < 1.005
A nurse is reviewing the assessment findings for a client who was admitted to the hospital with a diagnosis of diabetes insipidus. The nurse understands that which manifestations are associated with this disorder?
Androgens, glucocorticoids, mineralocorticoids
A nursing instructor is teaching the class about Addison's disease. The instructor determines that the class understands the disease process if they indicate which are affected in this disease?
c. Because i have no symptoms, my disease is not progressing
A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? a. When I have pain, I will take ibuprofen b. I should perform low-impact exercises regularly c. Because i have no symptoms, my disease is not progressing d. I must notify my HCP if i experience any hearing loss
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?
A positive Brundizinski's sign
The BEST nutritional therapy plan for a person who is obese is
A well balanced diet using the food pyramid as a guide
In which order will the nurse implement these collaborative interventions prescribed for a patient being admitted who has acute osteomyelitis with a temperature of 101.2° F? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain blood cultures from two sites. b. Send to radiology for computed tomography (CT) scan of right leg. c. Administer gentamicin (Garamycin) 60 mg IV. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.
A, C, D, B
When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Maintain a warm room temperature e. Administration of H2 receptor blocker
A, C, D, E
Paget's
Abnormal bone breakdown and formation
Increase in pulmonary blood flow... Cyanotic or Acyanotic?
Acyanotic
Patent Ductus Ateriosus... Cyanotic or Acyanotic?
Acyanotic
Ventricular Septal Defect... Cyanotic or Acyanotic?
Acyanotic
The bariatric surgical procedure involves creating a gastric pouch that is reversible and no malabsorption occurs. What surgical procedure is this?
Adjustable gastric banding
The nurse is preparing to administer a scheduled dose of insulin Aspart (novolog) to a patient who have type I DM. Which of the following actions should the nurse implement?
Administer insulin when breakfast arrives
Overall goals in working with leukemia patients include which of the following? -Understand and cooperate with the treatment plan -Experience minimal side effects and complications of disease and treatment -Feel hopeful and supported during periods of treatment, relapse, and remission -All of the above
All of the above
Oral candidiasis involves assessment of which of the following structures: -tongue -buccal mucosa -gums -all of the answers
All of the answers
Things that can trigger a migraine headache include which of the following: -head trauma - missed meals - stress - all of the answers
All of the answers
UC
An inflammatory bowel disease (IBD) that causes long-lasting inflammation and ulcers (sores) in your digestive tract. It affects the innermost lining of your large intestine (colon) and rectum. Only effects the LARGE intestine. Treated as autoimmune disease. confined to colon, disease is continuous
Fractures
An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones?
A nurse is completing discharge teaching to a patient who had a wound debridement for osteomyelitis. Which of the following information should the nurse include in the teaching?
Antibiotic therapy should continue for 3 months
Coarctation of the aorta
Aorta narrows// ss: cold extremities
What will caring for a patient with a diagnosis of polycythemia likely require the nurse to do?
Assist with or perform phlebotomy at the bedside
Call the HCP
At 8:00 a.m., A client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98°F (37.2°C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99°F (36.7°C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action?
b. Red skin areas under the jacket
At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? a. Tightening screws b. Red skin areas under the jacket c. Clean and dry the labs wool jacket lining d. Finger-width space between the jacket and skin
Which of the following defines legg-calve-perthese disease?
Avascular necrosis of the head and femur due to a temporary disruption of blood supply
Instructions for a client with severe vertigo related to Meniere's disease include:
Avoid sudden head movements
A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which action by the nurse is best? a. Clarify that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patient's comments. d. Reassure the patient about the competence of the nursing staff.
B
A 50-year-old patient is being discharged after a week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? a. How to apply warm packs to the leg to reduce pain b. How to monitor and care for the long-term IV catheter c. The need for daily aerobic exercise to help maintain muscle strength d. The reason for taking oral antibiotics for 7 to 10 days after discharge
B
A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for an increased dosage of the eye drops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eye drops can be prescribed for you."
B
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.
B
A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is most appropriate? a. Teach the patient about adverse effects of the RA medications. b. Suggest that the patient use over-the-counter (OTC) artificial tears. c. Reassure the patient that dry eyes are a common problem with RA. d. Ask the health care provider about discontinuing methotrexate (Rheumatrex) .
B
After the nurse has finished teaching a 68-year-old patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can take glucosamine to help decrease my knee pain." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."
B
An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.
B
The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.
B
The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.
B
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.
B
The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face.
B
The nurse will assess a 67-year-old patient who is experiencing a cluster headache for a. nuchal rigidity. b. unilateral ptosis. c. projectile vomiting. d. throbbing, bilateral facial pain.
B
The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury.
B
To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.
B
Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene immediately? a. UAP raise the side rails on the bed. b. UAP turn on the patient's television. c. UAP turn the patient to the right side. d. UAP place an emesis basin at the bedside.
B
When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair
B
Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patient's external ear for redness, swelling, or presence of skin lesions.
B
Which action should the nurse take before administering gentamicin (Garamycin) to a patient who has acute osteomyelitis? a. Ask the patient about any nausea. b. Review the patient's creatinine level. c. Obtain the patient's oral temperature. d. Change the prescribed wet-to-dry dressing.
B
Which action should the nurse take when assessing a patient with trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side.
B
Which action will the nurse include in the plan of care for a 33-year-old patient with a new diagnosis of rheumatoid arthritis? a. Instruct the patient to purchase a soft mattress. b. Suggest that the patient take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.
B
Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain? a. Provide information about therapeutic neck exercises. b. Ask about numbness or tingling of the hands and arms. c. Suggest that the patient alternate the use of heat and cold to the neck to treat the pain. d. Teach about the use of nonsteroidal antiinflammatory drugs such as ibuprofen (Advil).
B
Which assessment finding about a patient who has been using naproxen (Naprosyn) for 6 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has gained 3 pounds. b. The patient has dark-colored stools. c. The patient's pain has become more severe. d. The patient is using capsaicin cream (Zostrix).
B
Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Application of cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.
B
Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Application of pneumatic compression devices to legs d. Administration of methylprednisolone (Solu-Medrol) infusion
B
Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep
B
Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse's teaching about the condition? a. "I will exercise even if I am tired." b. "I will use sunscreen when I am outside." c. "I should take birth control pills to keep from getting pregnant." d. "I should avoid aspirin or nonsteroidal antiinflammatory drugs."
B
Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid eye drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery
B
With retinal detachment, areas of detachment appear what color?
Bluish-Gray
What nursing assessment is an expected finding with early stages of cataract formation?
Blurred Vision
A nurse is assessing a patient who has systemic lupus erythematousus (SLE). Which of the following findings should the nurse expect?
Butterfly rash
A 22-year-old patient seen at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.
C
A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options
C
A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The most appropriate action by the nurse at this time is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop because the patient is able to perform activities independently. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and encourage that participation.
C
A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment? a. "I use aspirin when I have a sinus headache." b. "I have had frequent episodes of conjunctivitis." c. "I take metoprolol (Lopressor) daily for angina." d. "I have not had an eye examination for 10 years."
C
A 67-year-old patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse chooses a nursing diagnosis of ineffective health maintenance when the nurse finds that the patient a. is frustrated with the length of treatment required. b. takes and records the oral temperature twice a day. c. is unable to plantar flex the foot on the affected side. d. uses crutches to avoid weight bearing on the affected leg.
C
A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep
C
A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed analgesic. c. Assess the blood pressure (BP). d. Notify the health care provider.
C
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV
C
A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patient's left leg when turning the patient d. Teaching the patient to look at the right leg to verify its position
C
A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to a. administer humidified oxygen by mask. b. suction the patient's mouth and nasopharynx. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day.
C
A patient who has undergone a left tympanoplasty should be instructed to a. remain on bed rest. b. keep the head elevated. c. avoid blowing the nose. d. irrigate the left ear canal.
C
A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.
C
A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.
C
A patient's 4 × 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)
C
The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."
C
The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? a. Hyperactive reflex activity below the level of injury b. Involuntary, spastic movements of the arms and legs c. Hypotension, bradycardia, and warm, pink extremities d. Lack of sensation or movement below the level of injury
C
The nurse is planning care for a patient with hypertension and gout who has a red and painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).
C
The nurse should reposition the patient who has just had a laminectomy and diskectomy by a. instructing the patient to move the legs before turning the rest of the body. b. having the patient turn by grasping the side rails and pulling the shoulders over. c. placing a pillow between the patient's legs and turning the entire body as a unit. d. turning the patient's head and shoulders first, followed by the hips, legs, and feet.
C
The nurse will anticipate the need to teach a 57-year-old patient who has osteoarthritis (OA) about which medication? a. Adalimumab (Humira) b. Prednisone (Deltasone) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)
C
When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will a. assess whether the patient is doing daily facial exercises. b. question whether the patient is using an eye shield at night. c. ask the patient about social activities with family and friends. d. remind the patient to chew on the unaffected side of the mouth.
C
When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."
C
When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is most appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed ringing in your ears?" d. "Are you ever dizzy when you are lying down?"
C
Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching d. Wait until family members have left before initiating teaching.
C
Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes
C
Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider? a. Back pain that increases with coughing b. Depression about the diagnosis of a tumor c. Decreasing sensation and ability to move the legs d. Anxiety about scheduled surgery to remove the tumor
C
Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels
C
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program d. Use quad coughing to strengthen cough efforts.
C
Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? a. A 38-year-old man who plays on a summer softball team b. A 56-year-old man who is a member of a construction crew c. A 56-year-old woman who works on an automotive assembly line d. A 49-year-old woman who is newly diagnosed with diabetes mellitus
C
Injury to what vertebrae requires vent dependency?
C3 and above
Injury to what vertebrae would cause complete paralysis below the neck?
C4
Injury to what vertebrae indicated respiratory insufficiencies?
C4 and below
diagnositic studies
CT scan cervical x-ray MRI comprehensive neurologic examination CT angiogram
Risk factors for peripheral artery disease include all of the following EXCEPT -cigarette smoking -Hypertension -Diabetes Mellitus -Caffeine intake
Caffeine intake
A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurses expect to be at risk?
Client who has AIDS
Which of the following meds is no longer recommended for children in the American Academy of Peds?
Codeine
When administering medications to the patient with chronic gout, the nurse would recognize which of the following as a treatment for this disease?
Colchicine
A patient is being admitted to the hospital from home with a stage IV pressure ulcer over the sacral area. What assessment tool should be completed on admission to the hospital?
Complete the Braden Scale
The nurse is assessing the adaption of a client to changes in function status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting MOST successfully
Consistently uses adaptive equipment in dressing self
A patient with DM demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the patients stress and anxiety?
Convey empathy, trust, and respect towards the patient
Hypoplastic Left Heart Syndrome... Cyanotic or Acyanotic?
Cyanotic
Right to left shunt... Cyanotic or Acyanotic?
Cyanotic
Tetralogy of Fallot... Cyanotic or Acyanotic?
Cyanotic
Transposition of the Great Arteries... Cyanotic or Acyanotic?
Cyanotic
A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.
D
A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will need to use bright lights to read for at least the next week." b. "I will use drops to keep my pupils dilated until my appointment." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."
D
A 75-year-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Explain that there are many ways to compensate for decreases in visual acuity. c. Suggest ways of improving the patient's safety, such as using brighter lighting. d. Ask the patient more about what type of vision problems are being experienced.
D
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.
D
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother? a. Change the patient's bedding frequently. b. Use a hydrocolloid dressing over the ulcer. c. Record the size and appearance of the ulcer weekly. d. Change the patient's position at least every 2 hours.
D
After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member places contaminated dressings in a plastic grocery bag. d. The family member dries the wound using a hair dryer set on a low setting.
D
In reviewing a 55-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity. b. pupil reaction. c. color perception. d. peripheral vision.
D
The home health nurse is doing a follow-up visit to a 41-year-old patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins daily. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.
D
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who has increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer
D
The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient? a. "You may be able to prevent Bell's palsy by doing facial exercises regularly." b. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "Call the doctor if you experience pain or develop herpes lesions near the ear."
D
The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas
D
The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests that they a. stand rather than sit when performing household and yard chores. b. strengthen small hand muscles by wringing sponges or washcloths. c. protect the knee joints by sleeping with a small pillow under the knees. d. avoid activities that require repetitive use of the same muscles and joints.
D
The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
D
When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider? a. "My eyes are dry now." b. "It is hard for me to see at night." c. "My vision is blurry when I read." d. "I can't see as far over to the side."
D
Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" over part of the visual field.
D
Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? a. "I will leave the ear wick in place while administering the drops." b. "I should lie down before and for 5 minutes after administering the drops." c. "I will hold the tip of the dropper above the ear while administering the drops." d. "I should keep the medication refrigerated until I am ready to administer the drops."
D
In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).
D, C, B, A, E
Sensorineural Hearing Loss
Damage to cranial nerve VIII
A sense of a curtain falling across the field of vision is a sign of what?
Detached Retina
What is the leading cause of blindness?
Diabetic Retinopathy
Which health problems are considered results of microvascular complications from long-term or poorly controlled diabetes mellitus?
Diabetic retinopathy and erectile dysfunction.
Alkaline phosphatase
Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the health care provider has prescribed which laboratory study?
Decreased diarrhea
Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication?
The nurse is teaching the husband of a woman diagnosed with Alzheimer disease about home care. Which intervention should the nurse discuss with the patient's husband?
Discuss the importance of providing a consistent environment
Most common precipitating factor of Autonomic Dysreflexia
Distended Bladder or Rectum
Which instruction should the nurse discuss with the client who has conjunctivitis?
Do not share towels or linens
A nurse is completing discharge teaching with a patient who has Crohn's disease. Which of the following instructions should the nurse include in the teaching?
Drink canned protein supplements
Thinning retinal tissue with yellowish spots is called what?
Dry Macular Degeneration
You are educating the parent of a child with diarrhea. Which of the following is correct regarding diet for a child with diarrhea?
Early reintroduction of nutrients is desirable
The nurse is caring for a client diagnosed with a traumatic brain injury and an epidural hematoma. Which nursing intervention should the nurse implement? SATA
Ensure the pulse oximeter reading is higher than 93% Administer stool softners daily Monitor for drainage from nose or ears
A nurse is reviewing the serum laboratory data of a patient who has an acute exacerbation of Crohn's Disease. Which of the following will lab tests should the nurse expect to be elevated? (Select all that apply)
Erythrocyte Sedimentation rate (ESR) WBC
Which of the following are true regarding children? Check all that apply.
Every body system in an infant is immature Children have faster respiratory rates than adults
T/F Non-pharmacological pain management strategies should be used instead of pain meds to avoid overdose and addiction
False
True or false, a nurse should always remove a hard cervical collar from a patient with a cervical spinal cord injury after 24 hours.
False
True or false, diabetes insipidus results from inadequate insulin
False
True or false, headaches always arise from an intracranial source
False
True or false, with syndrome of inappropriate antidiuretic hormone, urine production is increased.
False
You are caring for a 12 month old female who came to the ED and was diagnosed with febrile seizure. You are discharging the patient home. Which of the following would be correct to tell the parents?
Febrile seizures are uncommon after the age of 5 years
The nurse and the UAP are caring for patients on a medical surgical unit. Which task would be the most appropriate to assign to the UAP?
Feed the patient with Parkinson disease who has tremors of the hand
A client has clear fluid leaking from the nose after a basilar skull fracture. Which finding would alert the nurse that cerobrospinal fluid is present?
Fluid separates into concentric rings and tests positive for glucose
A 6-week old infant is admitted to the hospital with a possible diagnosis of pyloric stenosis. The nurse asks the parents about the infants feeding history. Which of the following symptoms is most descriptive of pyloric stenosis in the infant?
Frequently appearing hungry after projectile vomiting
Which manifestations in a patient with T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia?
Headache and rising blood pressure
Absence of ganglion cells in the affected areas of the intestine describes which of the following congenital anomalies?
Hirschsprung Disease
Which of the following is true regarding osgood-schalatter disease? SATA
History of recent physical activity (track, soccer, football) Pain increases with activity and decreases with rest There is point tenderness at the tibial tuberosity
Diabetic retinopathy
LEADING cause of blindness, progressive, microscopic damage to blood vessels of retina
A patient with a diagnosis of DKA is being treated in the ED. Which findings support this diagnosis?
Large amounts of ketone in the urine Deep, rapid breathing Elevated blood glucose levels
Right brain strokes typically have symptoms on:
Left side
Which of the following is a group of malignant disorders affecting the blood and blood forming tissue?
Leukemia
How long will a patient with Glaucoma use eye medication?
Lifetime
Bacterial meningitis is diagnosed by which of the following tests?
Lumbar puncture
Loss of central vision is called what?
Macular Degeneration
Which of the following "concepts" are related to respiratory conditions in children? Check all that apply
Pain, nutrition, and gas exchange
Is Glaucoma painful or painless?
Painless
A nurse is caring for a patient who has systemic lupus erythematousus (SLE) and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?
Pallor of the toes with cold exposure
A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect?
Pallor on elevation of the limbs, and rubor when the limbs are dependent
A nurse is assessing a patient who has been taking prednisone following an exacerbation of inflammatory bowel disease (IBD). The nurse should identify which finding as the priority?
Patient reports having an elevated body tempurature
Signs of heading loss include all of the following except: -patient talking excessively loud -patient tilting head when listening -TV/radio too loud -Patient understanding all conversation without need for clarification
Patient understanding all conversation without need for clarification
Which of the following is true regarding cystic fibrosis?
People with CF are at a greater risk of lung infection bc of thick, sticky music that builds up in their lungs
A nurse is teaching foot care to a patient who has DM. Which of the following information should the nurse include in the teaching.
Perform nail care after bathing Trim toenails straight across Wear closed-toe shoes
A nurse is assessing a patient for manifestations of Parkinson's disease. Which of the following are expected findings? SATA
Pill-rolling tremors of the fingers Shuffling gait Drooling Lack of facial expression
Which of the following is included in the care plan of a patient with a halo brace:
Pin site care
Which nursing intervention is the most important when turning a patient following a spinal cord injury?
Placing a pillow between the patient's legs and turning the body as a unit
The partial to complete collapse of the lung due to accumulation of the air in the pleural space is called:
Pneumothorax
Which of the following is/are true regarding caring for children and their families?
Prevention is always best Care should be individualized to the needs of the child and family Care should be as altruistic as possible Approach to the child should be based on the child's developmental level
Conductive Hearing Loss
Problem conducting sound waves through the ear
gout
Protein metabolism is altered so that uric acid crystals deposits in joints and other body tissues, particularly the big toe, can be ankle or other parts of the foot; PAIN; decrease purine (organ meats, shellfish, wild game, beef, pork), no alcohol
The renal system has which of the following functions? SATA
Regulates calcium metabolism Regulates blood pressure Regulates acid-base balance Regulates fluid and electrolyte balance Stimulated production of RBC's in bone marrow
A nurse is making a home visit to a patient with who has Alzheimer's disease. The patient's partner states that the patient is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? SATA
Remove floor rugs Provide increased lighting in stairwells Install handrails in the bathroom Place a GPS tracker on the patient's belt
The nurse is reviewing a health care provider's orders for a patient with sickle cell anemia crisis. Which order should the nurse question?
Restrict fluid intake
Systemic effects are present in what form of Arthritis: Rheumatoid or Osteo?
Rheumatoid
DMARDS are used to treat what?
Rheumatoid Arthritis
Inflammatory Synovial Joints are present in what?
Rheumatoid Arthritis
Sjogren's Syndrome is associated with what disease?
Rheumatoid Arthritis
Stiffness in the morning lasting 60 mins in indicative of what disorder?
Rheumatoid Arthritis
Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve (CN VIII)?
Sensorineural hearing loss
Carpal tunnel syndrome involves which of the following: -Sensory/motor changes in thumb, index, middle finger and radial aspect of the ring finger -Chronic autoimmune disorders involving inflammation of tissues - Nodules of the distal phalange joints -Chronic low-back pain that lasts more than three months
Sensory/motor changes in thumb, index, middle finger and radial aspect of the ring finger
Which of the following is true regarding caring for children with rashes, check all that apply
Skin that is kept moisturized will itch less Rashes are usually self-limiting and rarely an emergency
Immature Cataracts
Some light gets through
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following?
Spinal shock syndrome
What stage pressure ulcer is intact skin with non-blanchable redness?
Stage I
Most Common Cause of Osteomyelitis
Staph Aureus
Which of following are symptoms of kawalaski disease?
Strawberry tongue Swelling of the hands and feet
Which of the following defines scarlet fever?
Strep pharyngitis with a rash
Which of the following assessment findings would indicate and upper airway condition?
Stridor
a. The med will cause constipation
Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? a. The med will cause constipation b. I need to take it with meals c. I may have increased sensitivity to sunlight d. This med should be taken as prescribed
The nurse is providing home care instructions to the parents of a 15-year-old child with hemophilia. Which sport activity should the nurse suggest for this child?
Swimming
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
Teach the client and family about the need for hand hygiene.
Provide a clear path for ambulation without obstacles.
The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety?
a. Using a rotorest bed b. Ensuring that weights hang freely d. Assessing the integrity of the weights and pulleys e. Comparing the amount of prescribed traction with the amount in use
The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. a. Using a rotorest bed b. Ensuring that weights hang freely c. Removing the weights to reposition the client d. Assessing the integrity of the weights and pulleys e. Comparing the amount of prescribed traction with the amount in use
Systemic symptoms such as fatigue, anorexia, and weight loss
The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA?
The parents of a newborn with an umbilical hernia ask about treatment options. The nurse's response should be based on which of the following?
The defect usually resolves spontaneously by 3 to 5 years of age.
B.
The emergency room nurse is assessing a patient who is in shock, unknown etiology. What is the priority nursing intervention? A. Check pulse B. Administer oxygen C. Start IV D. Notify family
Leaving the client in an unchilled area of the room (The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.)
The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?
"Is the pain experienced a stabbing type of pain?"
The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder?
a. Encourage the client to ambulate
The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? a. Encourage the client to ambulate b. Position the client on the left side c. Frequently irrigate the NG tube with 30mL saline d. Discourage the use of the PCA machine
b. Antimicrobial c. Corticosteroid d. Aminosalicylate e. Biological therapy f. Immunosuppressant
The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? Select all that apply. a. Antidiarrheal b. Antimicrobial c. Corticosteroid d. Aminosalicylate e. Biological therapy f. Immunosuppressant
b. I will drive only during daytime
The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? a. I will use a straw for drinking b. I will drive only during daytime c. I will be careful because the device alters balance d. I will was the skin daily under the lambs wool liner of the vest
d. I'll try to eat my food either warm or very cold
The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? a. I will wash my face with cotton pads b. I'll have to start chewing on my unaffected side c. I should rinse my mouth if toothbrushing is painful d. I'll try to eat my food either warm or very cold
B.
The nurse in the preoperative holding area keeps a client with gastric bleeding in a dimly lit environment with one family member present. What is the primary rationale for these nursing interventions? A. To stabilize fluid and electrolyte balance B. To minimize oxygen consumption C. To increase client and family comfort D. To prevent infection
Epinephrine
The nurse is admitting a client diagnosed with pheochromocytoma. The client is complaining of a pounding headache and palpitations and the blood pressure is 170/90 mm Hg. The nurse is aware that which substance is responsible for these clinical manifestations?
a. Initiate an infusion of 3% Nacl c. Restrict fluids to 800 mL over 24 hours e. Administer a vasopressin antagonist as prescribed
The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. a. Initiate an infusion of 3% Nacl b. Administer intravenous furosemide c. Restrict fluids to 800 mL over 24 hours d. Elevate the HOB to high Fowler's e. Administer a vasopressin antagonist as prescribed
Pronator drift
The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How should the nurse correctly document this finding on the medical record?
Extend tongue
The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform?
Cervical cord injury
The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client?
Bone resorption and regeneration
The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities?
Pyrexia, elevated WBC, elevated erythrocyte sedimentation rate, bone scan impression indicative of an infection
The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis?
Devascularization
The nurse is caring for a client diagnosed with osteomyelitis. Which mechanism of the disease process can result in necrosis of the bone?
"Pain is due to stimulation of the affected nerve by pressure and temperature."
The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse?
c. Oral corticosteroids
The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the health care provider prescribing? a. Enteral feedings b. Fluid restrictions c. Oral corticosteroids d. Activity restrictions
hypotension and fever
The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client?
Placing the client on a bed that provides spinal immobilization
The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action?
elevate the HOB
The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take?
tunnel vision
The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma?
"You need to increase salt in your diet, particularly during stressful situations."
The nurse is caring for a client with Addison's disease. The client asks the nurse about the risks associated with this disease, specifically about addisonian crisis. Regarding prevention of this complication, how should the nurse inform the client?
Severe abdominal pain
The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis?
Moon face, HTN, truncal obesity
The nurse is caring for a client with a diagnosis of Cushing's syndrome. Which expected signs and symptoms should the nurse monitor for?
Uric acid level of 9.0 (2.4-7)
The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?
Joint pain that diminishes after rest, joint pain that intensifies with activity
The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder?
Vital signs
The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority?
Vanilla wafers and room-temperature water
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse should offer which best snack to the client?
Speak at a normal volume
The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?
c. rebound tenderness
The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the health care provider (HCP)? a. Hypotension b. Bloody diarrhea c. Rebound tenderness d. Hbg of 12mg/dL
Hematest-positive nasogastric tube drainage
The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications?
a. Monitor for changes in mentation d. Encourage fluid intake of at least 3000mL/day e. Monitor vital signs, skin turgor, and I/O
The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions should the nurse include in the plan of care? Select all that apply. a. Monitor for changes in mentation b. Encourage an intake of low-protein foods c. Encourage an intake of low-sodium foods d. Encourage fluid intake of at least 3000mL/day e. Monitor vital signs, skin turgor, and I/O
c. Eye medications will need to be administered for life
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? a. Avoid overuse of the eyes b. Decrease the about of salt in diet c. Eye medications will need to be administered for life d. Decrease fluid intake to control the intraocular pressure
Fatigue, morning stiffness
The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA?
c. I need to avoid foods high in potassium
The nurse is instructing a client with Cushing's syndrome on follow-up care. Which of these client statements would indicate a need for further instruction? a. I should avoid contact sports b. I should check my ankles for swelling c. I need to avoid foods high in potassium d. I need to check my blood glucose regularly
b. Leukocytosis d. Urinary output of 800mL/hr e. Clear drainage on nasal dripper pad
The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply. a. Anxiety b. Leukocytosis c. Chvostek's sign d. Urinary output of 800mL/hr e. Clear drainage on nasal dripper pad
A rounded "moonlike" appearance to the face
The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which should the nurse expect to note on assessment of the client?
blurred vision
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?
Bone pain
The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease?
Abnormal
The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings?
Cup the hands over the ears if loud noise is expected suddenly.
The nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation?
gabapentin
The nurse is providing discharge education to a client diagnosed with trigeminal neuralgia. Which medication will likely be prescribed upon discharge for this condition?
a. Do not drink fluids with meals b. Avoid foods high in carbohydrates e. Eat 6 small meals a day that are high in protein
The nurse is providing discharge instructions for a client following a Roux-en-Y gastric bypass surgery 3 days ago. What will the nurse include in the instructions? Select all that apply. a. Do not drink fluids with meals b. Avoid foods high in carbohydrates c. Take an extended-release multivitamin daily d. Maintain a clear liquid diet for about 6 weeks e. Eat 6 small meals a day that are high in protein
I should eat foods that have a lot of potassium in them
The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood?
a. S/S of hypoadrenalism b. S/S of hyperadrenalism c. Instruction to take the medications exactly as prescribed d. Importance of maintaining regular outpatient follow-up care
The nurse is providing home care instructions to the client with a diagnosis of Cushing's syndrome and prepares a list of instructions for the client. Which instructions should be included on the list? Select all that apply. a. S/S of hypoadrenalism b. S/S of hyperadrenalism c. Instruction to take the medications exactly as prescribed d. Importance of maintaining regular outpatient follow-up care e. Reminder to read labels on OTC medications before purchase
a. Eat yogurt b. Take loperamide to treat diarrhea c. Use stress management techniques d. Avoid foods such as cabbage and broccoli
The nurse is providing instructions to a client diagnosed with irritable bowel syndrome (IBS) who is experiencing abdominal distention, flatulence, and diarrhea. What interventions should the nurse include in the instructions? Select all that apply. a. Eat yogurt b. Take loperamide to treat diarrhea c. Use stress management techniques d. Avoid foods such as cabbage and broccoli e. Decrease fiber intake to less than 15 g/day
Potassium level of 3.0
The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client?
Hypertension
The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of pheochromocytoma. The nurse reads the assessment findings and expects to note documentation of which major symptom associated with this condition?
Shift weight every 2 hours while in a wheelchair
The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client?
Withdrawal reflex
The nurse is testing the spinal reflexes of a client during neurological assessment. Which assessment by the nurse would help to determine the adequacy of the spinal reflex?
"It's a sensorineural hearing loss that occurs with the aging process."
The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made?
Which of the following is true about costochondritis?
The pain can be exacerbated by coughing, sneezing, and deep inspiration
The most common client complaint with an inner ear disorder is:
Tinnitus
True or false, counseling and support groups are an important part in helping with the losses associated with a spinal cord injury.
True
True, or false, principles of dialysis include diffusion of solutes from an area of greater concentration to an area of lesser concentration.
True
What finding related to glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report?
Tunnel vision with absence of pain
ongoing monitoring
VS, LOC, O2 sat, cardiac rhythm, urine output keep warm monitor for urinary retention, hypertension anticipate need for intubation if no gag reflex
What medication is used to treat HTN during autonomic dysreflexia?
Vasodilators
B.
Which is the priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? A. Fluid balance B. Anaphylactic reaction C. Pain D. Altered level of consciousness
D.
Which nursing intervention is most important in preventing septic shock? A. Administering IV fluid replacement therapy as ordered B. Obtaining vital signs every 4 hours C. Monitoring red blood cell counts for elevation D. Maintaining asepsis of indwelling urinary catheters
A.
Which of the following findings is the bst indication that fluid replacement for the client in hypovolemic shock is adequate? A. Urine output greater than 30ml/hr B. Systolic blood pressure greater than 110 C. Diastolic blood pressure greateer than 90 D.Respiratory rate of 20/min
C.
Which of the following is the most important goal of nursing care for a client who is in shock? A. Manage fluid overload B. Manage increased cardiac output C. Manage inadequate tissue perfusion D. Manage vasoconstriction of vascular beds
D.
Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss: A. Pulse rate less than 60/min B. Respiratory rate of 4 breaths/min C. Pupils unequally dilated D. Systolic blood pressure less than 90
Serum uric acid level, synovial fluid aspiration, 24-hr urine acid level
Which tests can be used to diagnose gout?
diagnostic test mobility
X_ray, CT, MRI, myelogram (radiographic study of nerve root ans spinal cord using dye), bone scan, BMD (bone density for osteoporosis), arthrogram (radioplaque substance into joint cavity)- evaluate bones, cartiladge, ligaments
Generalized body response with rigidity and thrashing, loud crying, eyes tightly closed and no association between approaching stimulus and subsequent pain describes the pain response for what age group?
Young infant
trigeminal motor and sensory defined
a disorder of the tigeminal nerve (V)
pressure ulcer defined
a localized injury to the skin and or underlying tissue due to pressure with or without shear/friction
urticaria
a rash of round, red welts on the skin that itch intensely, sometimes with dangerous swelling, caused by an allergic reaction, typically to specific foods.
A client has been in a motor vehicle accident and sustained significant injuries. The client is in shock and is semi conscious, but is restless and moaning. The family is concerned the client is in pain and demands the nurse give the ordered morphine. The priority action by the nurse is to a. Check the client's O2 sat b. Give morphine as ordered, slowly c. Politely decline their request d. Reposition the patient
a.
A patient in hypovolemic shock has a low PCWP. This should indicate to the nurse that a. Fluid replacement is needed b. Pulmonary edema may be developing c. Resuscitative measures (CPR) are inadequate d. The client's left ventricle is failing
a.
A patient is admitted to ER with chest pain that is being ruled out as MI. Vitals at 11AM are pulse 92, resp rate 24, B/P 140/88.Vitals at 11:20 are pulse 96, resp rate 26, B/P 128/82Vitals at 11:35 are pulse118, resp rate 32, B/P 88/58These changes are most consistent with: a. Cardiogenic shock b. Cardiac tamponade c. Pulmonary embolism d. Dissecting thoracic aortic aneurysm
a.
A patient with peripheral artery disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is: a. Risk for injury related to decreased sensation. b. Impaired skin integrity related to decreased peripheral circulation. c. Ineffective peripheral tissue perfusion related to decreased arterial blood flow. d. Activity intolerance related to imbalance between oxygen supply and demand.
a.
The nurse assessing acutely ill patients who are at risk for multiple organ dysfunction syndrome would assess for the usual precipitating problem of: a. Bradycardia b.Cerebral anoxia c.High creatinine level d.Hypotension
a.
The nurse caring for a patient in shock who is being mechanically ventilated explains that the rationale for this intervention is to a. Decrease CO2 levels in the blood b. Prevent atelectasis and pneumonia c. Rest the client to decrease metabolism d. Stimulate endorphin production
a.
The nurse caring for a patient newly diagnosed with MODS explains that the method of providing nutrition is likely to be a. Enteral feedings b. Intravenous fluids c. Oral diet d. Parenteral nutrition (TPN)
a.
The nurse would assess the individual in the most serious stage of shock as a a. 22 year old man with a falling B/P b. 35 year old woman with a pulse pressure of 40 c. 50 year old woman with a MAP of 90 d. 60 year old man with a pulse rate of 100
a.
When caring for a patient at risk for MODS, the nurse should place the highest priority on: a. Assisting with incentive spirometry hourly b. Hourly checks of urine output c. Maintaining adequate oral intake d. Performing rang-of-motion exercises
a.
vertigo
accompanied by N/V, nystagmus, salivation, sweating, hypotension dizzines is the lack of balance lightheadedness, movement within head
assessment of pagets
aching bone pain skeletal deformity bowing deformities fractures- pathologic nerve compression vertigo hearing loss alkaline phosphatase elevated
Costochondritis
acute and often temporary inflammation of the costal cartilage, the structure that connects each rib to the sternum at the costosternal joint; common cause of chest pain
Addison's disease results from destruction or dysfunction of the:
adrenal cortex
risk factors for pressure sores
advanced age anemia contractures DM elevated body temp immobile impared circulation low diastolic BP (<60 mmHg) metal deterioration neurologic disorders obestiy pain prolonged surgery vascular disease (PAD)
menieres disease
affects both vestibular and auditory function excess endolymph n labrynth (pale transparent fluid within the labyrinth of the ear) hearing loss fluctuates in ealy stage, but becomes permanent vertigo is severe- spinning in nature, increases with movement dietary restriction such as salt and fluid reduces the amount of endolymphatic fluid
sensory neuropathy
affects the hands and feet loss of sensation, abnormal sesnations, pain (burning, cramping, crushing or tearing), parasthesia (tingling, buning, itching) loss of sensation of touch and temp can casue atrophy of small muscles of the hands and feet causing deformity and limiting fine movement
risk facotrs for osteoarthitis
age decreased estrogen at menopause obesity anterior cruicate ligament injury frequent kneeling and stooping regular exercise can help prevent
hearing
age related hearing loss (presbycusis) typically related to sensorineural (changes in nerve pathways from inner ear to brain) a decrease in the ability to process sound
macular degeneration
age-related degeneration of macula central vision loss "dry"- atrophy of outer retina and underlying tissues "wet" serous fluid from choroid leaks into retina and macula no known cure dietary supplements show some promise dry- thinning of retinal tissue woth yellowish spots of debris from cell breakdown- scar tissue wet- domes of fluid appear on retina causing virual change of distorted lines, with dark, blurry while out in center of vision supplements- vit c and vit e and beta-carotene and zinc with egg yolds no effective treatment or cure
Macular degeneration
age-related degeneration of macula, central vision loss (helps read, drive, see fine details), wet or dry, NO EFFECTIVE TREATMENT/CURE (Supplements help reduce risk: Vit C, E, Veta-carotene, zinc, egg yolk)
care acute osteomyelitis
aggressive, prolonged IV antibiotic therapy cultures or bone biopsy surgical debridement and decompression
what biophosphanates are used for pagets
alendronate (fosamax) ibandronate (boniva) pamidronate (aredia) risedronate (actonel) zolerdronic acid (zometa, reclast)
cancer info
alkaline phosphatase (ALP) will rise as a result of primary or secondary bone tumors- also elevated with liver and biliary disease treat with chemo and radiation to shrink growth narcotics round the colck anti-inflammatories help this pain anti-depressants
risk factors for mobility issues
all individuals are potentially at risk for altered mobility regardless of age, ethnicity, race, and socioeconomic class
influencing factors for pressure sore
amount of pressure, length of time pressure is exerted, ability of tissue to tolerate externally applied pressure
chicken pox
an infectious disease causing a mild fever and a rash of itchy inflamed blisters, caused by the herpes zoster virus and mainly affects children, who are afterward usually immune
predisopsing factors for thrush
antibiotic therpay, diabetes, altered immune status, inhaled corticosteroids
drug therapy for neurogenic bladder
anticholinergic, a-Adrenergic blockers, antispasmodics
musculoskeletal nociceptive pain
antiinflammatory drugs, opioids
objective data
anxiety or apprehension, diaphoresis, palloe, unilateral flushing with cheek edema, conjunctivits
Aortic stenosis
aortic valve doesn't completely open/narrowed
nursing intervantions mucositis
assess oral mucosa daily and teach patient to do this encourage nutritional supplements (ensure, carnation instant breakfast) be aware eating, swallowing and talking may be difficult avoid spicy, acidic, irritating food encourage to use artifical saliva dicourage smoking and alcohol apply topical anesthetics offter mouth care before and after meals brush teeht and tongue with soft bristle or sponge provide mouth rinse offer soft foods that are cool and warm
pressure ulcer assessment
assess risk on admission and at periodic intervals
pain management- acute
assess, evaluate, and treat routinely, analgesics, massage and repositioning
Systemic lupus
autoimmune, butterfly rash, SUNLIGHT IS A MAJOR CONTRIBUTOR TO EXACERBATION OF SYMPTOMS, REVIEW THE SIDE EFFECTS OF STEROIDS, Renal failure from glomerulonephritis is the leading cause of morbidity and mortality in the patient
LCPD (Legg-Calves-Perthes disease)
avascular necrosis (AVN) of the proximal femoral head resulting from compromise of the tenuous blood supply to this area; usually occurs in children aged 4-10 years; has insidious onset and may occur after an injury to the hip
vertigo reducing activities
avoid caffeine and alcohol rest in quiet, dark enviroment when severe use assistive devices for safe ambulation maintaine clutter free enviroment take diuretic to recude amount of fluid in the semicircular canals space fluid intake throughout the day decrease salt intake
A patient is admitted to ER with a gunshot wound to the abdomen. The nurse anticipates the initial use of which IV solution? a. Dextran b. Normal saline c. Packed red blood d. Whole blood
b.
Distributive shock is primarily due to: a. A fluid shift from the vascular space b. An increase in the size of the vascular space c. Inadequate circulating blood volume d. Inadequate pumping action of the heart
b.
The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement? a. "I should not use heating pads to warm my feet." b. "I should cut back on my walks if it causes pain in my legs." c. "I will examine my feet every day for any sores or red areas." d. "I can quit smoking if I use nicotine gum and a support group."
b.
joint protection
balance rest and activity rest during acute inflammation- fuctional positioning, do not be immobilized for greater than one week modify activities to decrease joint stress avoid prolonged standing, kneeling, squatting (knee OA) assistive device as needed
diagnostic studies for cluster headache
based on primarily history headache diaries are helpful CT scan, MRI, or MRA to rule out aneursym, tumor, infection
how to deal with hearing loss
be sure you have patient attention speak directly at patient dont turn your back when talking use more than one word-better for context lower tone of voice dont shout use picture board
timoptic (timolo maleate)
beta adrenergic antagonist, miotic- drops: relax iris, reduces aqueous humor usuallly given q12hr antihypertensive, antianginal, migraines- oral adverese effects0 bronchospams, bradycardia, syncope NSAIDS anatgonize hypotensive effects
clinical manifestations tension type
bilateral frontal- occipital discomfort, associated with neck pain, increased tone in cervical and neck mucles may involve sensitivity to light and sound may occur intermittenly for weeks, months, or years
drainage methods
bladder reflex training, indwelling, intermittent, external catherization, urinary diversion surgery
Aura
blindness, bright lights, visual distortions, hearing voices/sounds, strange smells, weakness, paralysis, feeling that limbs are moving.
symptoms of cataracts
blurred vision photophobia sensitivity to glare vision better in low light cloudy appearance of lens
study set
bo
Allusion
boba
diagnostic studies osteomyelitis
bone or soft tissue biopsy blood and/or wound cultures WBC count erythrocyte sedimentation rate (ESR) c reactive protein x-rays/ MRI/ CT scans bone scans
diagnostic studies OA
bone scan, CT, MRI- show early joint changes x-ray- detects joint space narrowing, boney sclerosis, osteophyte formation no specific lab abnormalities synovial fluid analysis
assessment tools
braden scale for skin inspection
Laser photocoagulation
burns edges, prevents further damage
objective data SLE
butterfly rash over nose and cheeks cutaneous vascular lesions hypertension-treat aggressivley due to potential renal complications
A patient is receiving fluid replacement for treatment of shock and the nurse assesses a central venous pressure of 15 cm H2O. The nurse anticipates which of the following interventions? a. Administration of vasoconstrictors b. Administration of vasodilators c. Decreasing fluid infusion d. Increasing fluid infusion
c.
spasicity
can be beneficial and undesirable ashworth and modified ashworth scales treatment- ROM execrises, antispasmodic drugs, botulinum toxin injections
clinical manifestations of migraine
can be preceded by an aura and prodrome can last 4-72 hours- steady htrobbing pain, usually unilateral people hibernate during episode- seek shelter from light, noise, odors, people, and problems not all migraines are disabling, may become progressivley worse
headache other types
can be symptoms of serious illness- subcranial hemorrhage, brain tumor, other intracranial masses, vascular abnormalities, trigeminal neuralgia, diseases of eye, nose, and teeth
taste
cancer cells may release substances that stimulate the bitter taste buds. can expereince alterations in sweet and sour and salty tastes
diagnostic studies tension type
careful history taking EMG may be perfomed may revela sustained contraction of neck, scalp, or facial muscles may not show increased tension even when test is done during headache
different treatments for chronic osteomyelitis
casts or braces negative pressure wound therapy hyperbaric oxygen therapy removal of prosthetic devices muscle flaps, skin grafts, bone grafts amuptation
etiology and pathophysiology of migraine
cause is unkown, evidence suggests vascular, muscular, and biochemical factors are involved
sensorineural hearing loss
cause lies in the vestibularchoclear nerve (cranial nerve VIII), the inner ear or central processing centers of the brain
bells palsy (facial paralysis) defined
caused by a lower motor neuron lesion of cranial nerve VII that may result from and infection, trauma, hemorrhage, menigitis or tumor paralysis of one side of face
secondary headache
caused by naother condition or disorder
tension-type
characterized by bilateral location and pressing/tightening quality mild to moderate intesnity
pilocarpine hydrochloride
choliergic- contraction of cilliary muscle, increasing outflow of aqueous humor, induces miosis applu gentle pressure to nasolacrimal ducto for 1-2 min after instilling to prevent systemic effct given 3-4q day adverse effects-anticholinergic, bronchospasm, tachycarida, dry mouth, urinary retention
what to do for acute gout attack
colchicine (reduces leukocytosis migration) NSAIDs steroids ice bedrest
rehabilitation and homecare
complex goal to function at highest level of wellness retraining focus interprofessional team effort organized around patients goals and needs paient expected- to be involved in therapies, to learn self-care can be very stressful frequent encouragment
aura
complex neurolgic symptoms characterized by visual, sensory, and/or motor phenomena
Barrett's esophagus
complication of GERD, normal tissue of esophagus changes and resembles that of the intestine, endoscopy every 2-3 years
Foramen ovale
connects left aorta to right aorta, bypasses lungs (peds)
Ductus Arteriosus
connects pulmonary artery to aorta, bypasses lungs (peds)
kinetic therapy
continual side to side roatation- prevent pulmonary complications, prevent pressure ulcers
conjunctivitis
covers inner lid and external eye inflammation from bacteria or virus "pink eye" redness and itching, gritty sensation tearing and discharge inflamed preauricular nodes treat with antibiotic drops and pills
stable thoracic or lumbar spine injuries
custom throacolumbar orthosis (TLSO or body jacket) jewett brace
Pruritus in dialysis patients is caused by a. dry skin b. calcium phosphate deposits in the skin c. sensory nephropathy d. all of the above
d.
icomplete SCI anterior cord syndrome
damage to anterior spinal artery- compromised blood flow typically results from flexion injury motor paralysis and loss of pain and temperature sensation below level of injury
incomplete SCI cental cord syndrome
damage to central spinal cord most commonly cervical region more common in older adults motor weakness and sensory loss lower extremitites are not usually affected dysesthetic burning pain in upper extremities
oflactory and gustatory
decrease in the olfactory cells and in the olfactory cillia receptors that send signals to the brain. Taste declines related to decrease in olfactory cells and potential chewing problems and tooth loss, decrease in the number of taste cells
Addison's
deficiency of cortisol, aldosterone, androgens (dysfunction of adrenal cortex), Autoimmune
people at risk for osteomyelitis
diabetes, orthopedic prosthetic devices, vascular insufficiencies
visceral nociceptive pain
diagnostic imaging to evaluate cause
treatment ulcer care
document and describe size, stage, location, exudate, infection, pain, and tissue keep ulcer bed moist, cleanse with nontoxic solutions debride adhesive membrane, ointment, wound dressing, verfiy good nutrition, teach self-care and signs of breakdown, specialty services
interprofessional care RA
drug therapy, disease process, home management strategies physical therapy occupational therapy individualized treatment plan
ambulatory home care
educate patient and care giver in prevention techniques
nursing management with taste
educate to avoid foods that are disliked, experiment with spices and other seasonings,
tests for inner ear
electrostagmography weber rinne glycerol x-ray CT- mastoid, middle ear ossicles
prevention nutrition
elevate caloric intake 30-35 kcal a day 1.25-1.5 g protein a day may need supplemental feedings
nursing interventions autonomic dysreflexia
elevate head, sit upright notifiy HCP assess for and remove cause- immediate catherization, remove stool impaction, remove constrictive clothing/tight shoes monitor and treat BP patient and caregiver teaching
bells palsy interventions
encourage facial execrises to prevent muscle loss promote frequent oral care instruct the client to chew on unaffected side protect the eyes from dryness and prevent injury
acromegaly
enlarged extremities, when ↑ GH occurs in adulthood
intial care
ensure patent airway stabilize cervical spin administer oxygen establish IV acess assess for other injuries control external bleeding obtain imaging prepare for stabilization with tongs and traction
carpal tunnel
entrapment of medial nerve, sensory/motor changes in thumb, index finger, middle finger, and radial aspect of ring finger
carpal tunnel syndrome
entrapment of medial nerve- flexor retinaculum forms tight tunnel with msucles and bones of wrist sensory or motor changes in tumb, index, middle finger, and radial aspect of ring finger associated with gout, pregnancy, hypothyroidism, and repetitive use of hands and wrists
muscositis
epithelial cell are destroyed by chemotherapy or radiation treatment when located in field. iflammation and ulceration occur due to rapid cell destruction
early surgery indicated is
evidence of cord compression progressive neurologic deficit compound fracture bony fragments penetrating wounds laminectomy- removal of the back of one or more vertebrae
cushings's
excess corticosteroid
moisture
excessive
cochlear implant specifics
external microphone placed behind the ear, speech processor and transmitter is implanted under skin that change sounds into electrical impulses, small group of electrodes placed within cochlea to stimulate nerve covers entire range of sound frequencies
treatment for contusion begins at time of injury, apply ice immediately, see physician, and receive thorough eye examination to rule out other eye injuries.
eye injury treatment
signs of hearing loss
failure to respond to verbal communication inappropriate verbal responses excessively loud speech strained facial expressions tilting of head when listening constant need for clarification faulty speech tv radio too loud most hearing loss is gradual and goes unnoticed
T/F If a child's spO2 increases from 85-95 with the addition of supplemental oxygen, you would think the etiology of the condition was of cardiac origin
false
subjective assessment SLE
fever fatigue malaise painful joints photosensitivity hairloss
systemic manifestations osteomyelitis
fever night sweats chills restlessness nausea malaise drainage (late)
surgical therapy SCI
fix instability and decompress toe spinal cord within first 24 hours associated with imporved neuroloigc outcome posteror approach anterior approach fusion
major mechanism of injury are
flexion hyperextension flexion-rotation compression
A patient in hypovolemic shock has a low pulmonary capillary wedge pressure (PCWP). This should indicate to the nurse that:
fluid replacement is needed
etiology and pathophysiology of RA stage three
formation of synovial pannus x-ray: extensive cartilage loss, erosion at joint margins, possible deformity
Chondosarcoma
formation of tumor by cartillage cells, femur, pelvis, ribs, scapula age 30-60
chondosarcoma
formation of tumor by cartillage cells, femur, pelvis, ribs, scapula age 30-60
migraine with aura
formerly called classic migraine, occurs in only 10% of migraine episodes
SCFE (Slipped Capital Femoral Epiphysis)
fracture through the growth plate (physis), which results in slippage of the overlying end of the femur (epiphysis)
etiology and pathophysiology of osteoarthritis
gradual los of articular cartilage formation of osteophytes not normal part of aging process cartilage destruction between ages 20-30 symptoms do not manifest until after 50-60
Scleroderma
hard skin
scleroderma
hard skin affects skin and or organ systems multisystem inflammatory disease, causes skin thickening, excessive quantities of collagen resulting in severe fibrosis
nursing management headaches
health history- seizures, storkes, cancer, trauma, asthma or allergies, mental illness, stress, menstruation, exercise, food, bright lights, noxios stimuli medications surgery and other treatments
assessment of the eye
history external assessment visual fields and eye movement eye position- exopthalmos, enopthalmos eye lids and lashes blink response conjunctivae, sclera light reflex- accommodation v light relfex
paget disease
idipathic disorder characterized by abnormal bone breakdown and abnormal formation. Transfer of calcium from bone to blood painful deformities in the femur, tibis, lower spine, pelvis, skull, upper humerus normal bone is replaced by structurally weaker
acute care for osteomyelitis
immobilize and careful handling of affected limb assess and treat pain dresing care- sterile techique proper positioning/support of extremity
sexuality
important issue regardless of patients age or gender have awareness and an acceptance of personal sexuality have knowledge of human sexual response use medical terminology fertility is not usually effected- preg complications, risk for precipitous delivery female sexual activity- urinary catherization, planning for bowel evacuation prior, incontinence, lubrication
hearing aides
in ear canal behind ear in eyeglasses body worn- box carried in shirt pocket all amplify sound in a controlled manner, but do not change the quality of the sound newer aides can select a perticular range of sounds to amplify
subjective vertigo
in motion in a stable enviroment
gerontologic considerations
increaed incidence increased complications- hospitalized linger, increased mortalitiy rates health promotion and screening rehabilitation lengethened
etiology and pathophysiology of RA stage two
increased joint inflammation gradual destruction in joint catrillage narrowing joint space from loss of cartillage
stress ulcers
increased risk secondary to severe trauma and physiologic stress monitor stool, gastric contents, and hematocrit prophylactic medications
etiology and pathophysiology of osteomyelitis
indirect entry (hematogenous)- young boys, blunt trauma, GU and resp infections: vascular insufficency direct entry- via open wound, foreign body presence
how to manage neurogenic bladder
indwelling urinary catheter- strict aspetic technique, increase fluid intake intermittent catherization- every 4-6 times daily, monitor for signs and symptoms of urinary tract infections patient teaching
clinical manifestations of osteomyelitis
infection lasting more than one month
Measles
infectious viral disease causing fever and red rash on skin, typical in childhood
mucositis
inflammation and ulceration d/t chemo or radiation (rapid cell destruction)
clinicant mainfestations RA joints
insidious fatigue anorexia weight loss generalized stiffness may report precipitating event- infection, stress, exertion, childbirth, surgery, emotional upset specific joint involvement- pain, stiffness, limited motion, and signs of inflammation symtpoms occur symmetrically often small joints larger joints and cervial spine may be involved
stage one sore
intact skin with non-blancable redness indicators- pain, tissue consistency, skin temperature can appear red or blue
trigeminal Neuralgia (tic douloureux)
intermittent episodes of intense pain in lips, gums, nose, or acress cheeks entrapped trigeminal nerve, compression, tumor triggered by touch, cold, talking, chewing, brushing teeth no diagnostic test
IBS Increase fiber intake (20g/day), eliminate gas foods, eliminate fructose and sorbitol, use probiotics
intermittent pain/discomfort and stool irregularities
chemical trauma
irrigate x 10 min immediately visual acuity assessed
headache
is the most common pain expereinced by humans, majority people have functional headaches- migraines and tension
corneal transplant
keratoplasty- use of donor corneas to improve clarity of vision (cadavers) local anesthersia visual return is slow, sutures distort the vision rejection is a problem
diabetic retionpathy
leading cause of blindness progressive disorder causing microscopic damage to the blood vessels of retina microaneurysms of capillaries, dilated and tortuous veins aneurysms rupture and cause small areas of scar tissue progressive retinal ischemia stimulated new vessels to grow- ineffective
nursing care after surgery
leave eye patch on with shield limit activities to sitting, bedrest, limited walking for 24hr do not rub eye do not lift more than 5 pounds do not strain or bend over, avoid reading eye drops as ordered no aspirin notify provider of nausea and severe pain
clinical signs of infection
leukocytosis fever increased ulcer size, orodr, or drainage, necrotic tissue, pain
cataracts
likely after age 70 cumulative exposure to UV reduces O2 uptake by lens dehydration of lens, opacity immature to "ripe"- immature: some light getting through, useful vision ripe= poor vision, poor light penetration bilateral trauma or chemical irritation
what details about the headache do we need
location, type of pain, onset, frequency, duration, time of day, relation to outside event
assessing for ulcers on darker skin
look for areas of darker skin (purple, blue, brown) use natural pr halogen light for accurate assessment assess skin temperature feel the skin (may be itchy, boggy or edematous tissue)
Retinitis pigmentosa
loss of peripheral vision → total blindness, progressive, genetic, d/t production of unstable protein, NO TREATMENT/CURE, genetic counseling
nrusing issues glaucoma
loss of vision is permanent- grieving teach instillation of eye drops issues with diuretics- k loss, dehydration encourage adults 40 and older to have annual eye exam including IOP measurements
Fibrosarcoma
malignant collagen fibers, age 5-80
fibrosarcoma
malignant collagen fibers, age 5-80
angle- closure glaucoma test results
markedly narrow of flat anterior chamber angle, edematous cornea, fixed and moderately dilated pupil, and cilliary injection
autonomic dysreflexia
massive uncompensated cardiovascular reaction mediadted by sympathetic nervous system- SNS respondes to stimulation od sensory receptors- parasympathetic nervous system unable to conteract these responses, hypertnesion and bradycardia
resipratory dysfunction
may be increased in first 48 hours may need intubation for mechanical vent increased risk for pnemonia and atelectasis regular assessment aggressive chest physiotherapy adequate oxygenation proper pain management assisted coughing tracheal suctioning incentive spriometer phrenic nerve stimulator diaphragmatic pacemaker mobile ventilators patient teaching
pain management- chronic pain
may be result of overuse of muscles sleep may be disrupted may refer to pain management specialist
prodrome
may include neurologic, physiclogic, and other manifestations
A patient with extreme obesity has undergone Roux-en Y gastric bypass surgery. In planning postoperative care, the nurse anticipates that the patient...
may only have liquids orally, and in very limited amounts, during the early postoperative period
SCI classification
mechanism of injry level of injury degree of injury
vertigo medications
meclizine (antivert)- has antihistamine and anticholinergic effects and is used to treat the vertigo that accompanies inner ear problems antiemetics- droperidol (inapsine) is one of the several antiemetics used to treat nausea and vomiting associated wth vertigo scopolamine (transderm scop) valium
drug therapy other headaches
medication overuse headache is an analgesic rebound headache- acetaminophen, aspirin, NSAIDS< butalibital, sumatriptan, and opioids
Antidepressants
medication: low dose tricyclic, decrease peripheral nerve sensitivity
Linaclotide (Linzess)
medication: men and women with IBS-constipation
Alosetron (Lotronex)
medication: serotonergic antagonist, severe pain and diarrhea. Last choice for women. Severe side effects: severe constipation and ischemic colitis.
Loperamide (Imodium)
medication: treat diarrhea, synthetic opioid, decrease intestinal transit
Lubiprostone (Amitiza)
medication: women with IBS-constipation
individual risk factors
medications lifestyles medical conditios occupation
treatment of glaucoma
meds are not a cure but can control sx cholinergics (mitotics)- pilocarpine gtts beta-adrenergic blockers- timoptic gtts several systemic meds that decrease production of aqueous humor for closed angle- diuretics to bring intraocular pressure down quickly- mannitol (osmotic diuretic)
what gender is pagets disease more prominent in
men
migraines can be triggered by
menstruation head trauma physical exertion fatigue stress missed meals weather drugs foods- chocolate, cheese, ragnes, tomatoes, onions, monosodium glutamate, aspartame, and alcohol (red wine)
drug therapy RA- DMARDS
methotrexate- monitor for bone marrow suppression sulfasalazine (azulfidine) hydroxychloroquine (plaquenil)- eye exams lefulnomide (arava)-teratogenic tpfactinib (xeljanz)- JAK (janus kinase) inhibitor
profound effects of immobility
meticulous skin care critical fit immobilizers properly
Ewing's Sarcoma
mimic's osteomyelitis, 5-15 years old
migraine headaches are...
more common in females, highest prevalence in low socioecenomic status, most common age is 20-30
Osteosarcoma
most common, distal femur, proximal tibia: age 10-30
osteosarcoma
most common, distal femur, proximal tibia: age 10-30
ASIA scale C
motor incomplete: motor function preserved at the most caudal sacralsegments for volunatry anal contraction
ASIA scale D
motor incomplete: status as defined above, with at least half of key muscle functions below the single neurologic level of injury having a muscle grade >3
systemic lupus erthematosus
multi system inflammatory disorder women 15-40 hormonal and genetic compotnent autoimmune diesease connective tissue and fibrinogen deposits collect in blood vessels on collagen fibers and on organs and lead to- inflammation, vasculopathy and vasculitis
pre-op care for cataract surgery
mydriatic medication pre-operatively to produce mydriasis or dilitation of the eye educate patient on need to have someone available as will have limitation in vision due to eyepatch, cant drive need to frequently instil drops after surgery
angle closure glaucoma
narrow angle, close angle dilation of pupils angle closes completely occurs quickly and the increase in pressure causes damage to retina and permanent blindness happens in darkness, emotional distress avoid mydriatic drugs- atropine, anticholinergics
etiology and pathophysiology of cluster headache
neither cause nor pathophysiologic mechanism known tigeminal nerve is implicated also involves dysfunction of intracarnial blood vessels, the sympathetic nervous system, and pain modulation system
Neuropathy
nerve damage associated with diabetes, lose sensation in lower extremities, pain and paresthesia
neuropathy defined
nerve damage that occurs because of metabolic derangements associated with DM. most common is sensory neuropathy
categories of immobility are based on the cause
neurogenic and musculoskeletal
sensory tactile
neuropathy trigeminal neuralgia bell's palsy carpal tunnel
etiology and pathophysiology of tension headache
neurovascualr factors similar to those onvolved in migraines
penetrating trauma
never remove notify physician immediately visual acuity assessed
planning for pressure sores
no deterioration reduce contributing factors not develop an infection have healing no reccurence
do you take aspirin with gout pain
no it increases the uric acid crystals
treatment of retinal detachment
no medical treatment laser photocoagulation- burns edges and prevents further damage pneumatic retinopexy- instillation of gas bubble that rises to the location of the tear and puts pressure on the retina to connect the choroid scleral buckling- surgical procedure to place retina back in contact with choroid from outside of eye
diagnostic studies SLE
no specific test patient history, physical exam findings, lab findings ANA present in 97% of persosn with disease
clinical manifestations of OA
no systemic symptoms present joint pain- mild discomfort to disability, pain worens with use early stages- rest releives pain late stges- pain with rest and trouble sleeping due to pain
extraarticular menifestations RA
nodules nodular myositis sjogrens syndrome felty syndrome felxion contractures cataracts depression
fundus of the eye
normal orange-red-color darker on darker complexion normal look to blood vessels optic disc where blood vessels converge is yellowish to pale pink macula is responible for central vision
ASIA scale E
normal- if sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E
primary headaches
not caused by another medical condtion or diease
ASIA scale ND
not determined: to document the sensory, motor, and NLI levels, the ASIA impairment scale grade, and/or the zone of partial preservation (ZPP) when they are unable to be determined based on the examination results
medication thrush
nystatin oral suspension swabbed onto mucous membranes, apply after feedings with gloved finger, apply to breast if breast feeding
causes of conductive hearing loss
obstruction- cerumen (ear wax), foreign body, cotton, insects, toys infection-external canal, labrynthitis (infection of inner ear), chronic otitis media otosclerosis- hardening of structures of inner ear tympanic membrane injury CAN BE CORRECTED!!!!!!!
stiffness for OA
occurs after rests of periods or unchanged position morning stiffness resolves in 30 min overactivity leads to mild joint effusion, temporary increase in stiffness crepitation and asymmetrical
open angle glaucoma
occurs over time vision changes are often not noticed loss of peripheral vision difficulty adapting to dark halos around lights pressure increases acuity decreases
etiology and pathophysiology second injury
ongoing, progressive damage that occurs after inital injury several theories exist on what cuases ongoing damag- cellular and molecular: vascular cahnges, free radical formation, lipid peroxidation, release of glutamate, uncontrolled calcium influx apoptosis permanent damage may occur because of edema extend of damage and prognosis for recovery most accureatley determined after 72 hours greatest improvement occurs in the first 3-6 months following injury
glycerol test
osmotic diuretic to pull fluid from inner ear may improve dizzines or hearing loss
bone tumors malignant types
osteosarcome ewings sarcoma fibrosarcoma chondrosarcoma metastatic bone cancers from primary sites have more ominous prognosis and usually cause severe pain
open angle
outflow of aqueous humor impaired but can still get through, occurs over time, loss of peripheral vision
local signs of chronic osteomyelitis
pain swelling warmth grandulation tissue turns into scar tissue to avascular to ideal site for microorganism gorwth whch can not be penetrated with antibiotics
issues with eye infections
pain visual changes risk for spread of infection- wash hands and eye separately
local manifestations osteomyelitis
pain that worsens with activty and unreleaived by rest swelling, tenderness, warmth resitricted movement
retinal detachment
painless detachment from choroid, d/t advanced age/trauma, NO MED treatment, need procedure
glaucoma
painless increased ICP optic nerve atrophy visual field loss common preventable cause of blindness
retinal detachment
painless separation of retina from choroid (vascular layer between sclera and retina)- dense blood vessels-deprived of blood supply more often with advanced age, trauma shadow or black area in vision, floating spots, flashes of light as retia pulls away areas of detachment look blueish-gray
Glaucoma Treatments: NO CURE, control symptoms - Cholinergics (pilocarpine gtts), beta adrenergic blockers (timoptic gtts), diuretics (mannitol) brings intraocular pressure down quick (only closed angle)
painless, ↑intraocular pressure, optic nerve atrophy, preventable; sudden H/A, red conjunctiva, cloudy cornea, N, V
fluid and nutrional maintenance
paralytic ileus may occur, requiring NG tube, monitor fluid and electrolytes, nutrition should be started within 72 hours- individual solutions/addatives, high-protein, high-calorie diet, possible parental nutrition inadequate nutritional intake- assess for cause, contract with patient, general measures: pleasant eating enviroment, adequate time calorie count, dietary supplements increased dietary fiber
stage two sore
partial thickness loss of dermis, shallow open ulcer with red pink wound bed, can be a ruptures or intact serum-filled blister
assessment mobility- history
past health history, meds, surgery/treatments, social history (employment, lifestyle, family, ADL). pain with movement, fatigue, falls, changes in ability to preform ADLS
immediate goals
patent airway adequate ventilation adequate circulationg blood volume prevent extension of cord damage
nursing action labyrinthectomy
patient will have extreme vertigo postoperatively. take appropriate safety precautions and give antiemetics as needed
how do headaches differ from person
personality, life adjustment, enviroment, family situation, neurologic and physical status
treatment for retinopathy
photocoagulation- stop leaking fluid onto retina virectomy- remove bloody vitreous, replace it with normal saline to maintain shape of eye
manifestatins of autonomic dysreflexia
piloerection flushing of skin above level of injury blurred vision or spots in visual field nasal congestion anxiety nausea
Scleral buckling
place retina back in contact with choroid from outside of eye
ripe cataract
poor vision, poor light penetration
causes of sensorineural loss
presbycucis- damage to labrynth in older adults- high pitch hearing loss noise- induced- repeated acoustic trauma tumors of temporal bone acoustic neruoma- unable to interpret stimuli related to position and movement this hearing loss is not usually able to be treated tinnitus- ringing, roaring, chirping in ear
shearing force
pressure exerted on the skin when it adheres to the bed and the skin layes slide in the direction of body movement
pin site care
prevent infection at sites of tongs or halo pins insertion- preventitive care based on hospital protocol, common protocal involves- cleansing with 1/2 strength peroxide and normal saline twice a day, applying antibiotic ointment
neurogenic skin
prevention is essential patient teaching comprehensive daily exam teach to reposition- q2hr in bed, q15-30 min in chair pressure releiving cushion or matress adequate nutrition protect from thermal injury
prevention teaching
prevention is the best treatment identify risk factors and implement prevention strategies
conductive hearing loss
problem with conducting sound waves through outer ear, tympanic membrane, middle ear, (ossicles) and the inner ear (oval window/round window). May occur in conjunction with sensorineural hearing loss
conductive hearing loss
problem with conducting sound waves, CAN be corrected; wax, foreign body, cotton ball, infection, otosclerosis (hardening of structures of inner ear)
stapedectomy
procedure of the middle ear in which stapes is removed and replaced with a prosthesis. bones of the middle ear fuse together
photophobia, irritability, hyperactivity, cravings
prodrome symptoms
retinitis pigmentosa
progressive genetic disease loss of peripheral vision progressing to total blindness caused by production of unstable protein loss of night vision in childhood, early no treatment or cure should have genetic counseling
assess for sings of DVT
prophylactic low-molecular-weight heparin or low-dose heparin sequential compression devices and/or gradient stockings assess thighs and calves every shift range-of-motion exercises and stretching
gout/gouty arthritis
protein metabolism is altered so that uric acid crystals despositis in joints and other body tissues, particuarly the big toe, can be ankle or othr parts of the foot
What does the PDA connect?
pulmonary artery and aorta
Julia comes to the emergency department due to an asthma exacerbation, which of the following medications would you expect to be ordered to treat this exacerbation?
quick relief meds and inhaled steroids
nonpharmacutical treatments
quiet, dim enviroment, heat packs and massage
scope of mobility
ranges on a continuum from complete immobility to partial immobility to full mobility
cluster headaches
rare form with sharp stabbing pain, can occur repeatedly for weeks to months at a time, followed by periods of remission
skeletal traction
realignment of reduction injury- crutchfield, gardner-wells, or halo, rope and pulley with weights traction is maintained at all times if displacement occurs, hold head in neutral position and get help
medical management SLE
reduce inflammation- NSAIDS (watch renal function) steroids in low doses immunosuppressive agents (imuran) and others
surgical therapy RA
relieve severe pain improve function synovectomy total joint replacement (arthroplasty)
skin care prevention
remove excessive mositure avoid massage over boney prominesces turn every 1-2 hours use lift sheets pillows under bney areas specialty beds cleanse skin if incontinence
additional patient teaching
report pain not releived by tylenol report headache, nausea, severe itching eye swelling eye patch should not put pressure on eye tearing is normal unrelieved eye pain and nausea is sign of increase ICP
incomplete SCI cauda equina syndrome
result from damage to cauda equine (lumbar and sacral nerve roots) asymmetrical distal weakness flaccid paralysis of lower extremities complete loss of sensation in saddle area areflexic (flaccid) bladder and bowl severe, radcular, asymmetric pain
incomplete SCI conus medullaris syndrome
result from damage to conus medullaris (lowest portion of spinal cord) motor function in legs may be preserved, weak, or flaccid decrese in loss of sensation in perianal area areflexic bladder and bowel impotence
Hyperpituitary
results from pituitary adenoma
reflexes
return of reflexes may complicate rehabilitation- hyperactive, exaggerated responses, penile erections, spasms patient teaching antispasmodic drugs
cardiovascular instability
risk for bradycardia and cardiac arrest chronic low bp with psotural hypotension increased risk for DVT dysrhythmias may occur assess VS frequently- fluid replacement and vasopressor, anticholinergic drug/pacemaker
closed angle
root of iris occludes trabecular network, occurs quick, needs addressed immediately
most common sites for pressure ulcers
sacrum and heels
clinical management secondary
screening tests- vision and hearing
sensory deprivation
secondary to absent sensations- stimulate patient above level of injury conversation, music, and interesting foods prism glasses to read and watch tv help patient avoid withdrawing from the enviroment
ASIA scale B
sensory incomplete: sensory but no motor function preserved below neurologic level and ext. through sacral segments S4-5
long term and rare osteomyelitits complications
septicemia septic arthritis pathologic fractures amyloidosis
osteomyelitis
severe infection of the bone, bone marrow, and surrounding soft tissue
clinical manifestations cluster headache
sharp stabbing intense pain typically lasting few min to 3 hours pain is usually located around the eye, radiating to the themple, forehead, cheek, nose, or gums swelling around the eye, lacrimation, facial flushing or pallor, rhinitis, constriction of the pupil patient can be agitates and restless, ususally occure at the same time of day, lasts 2-3 weeks than remission for months or years
contributing factors
shearing force, friction, moisture
level of injury
skeletal vs neurologic level can be cervical, throacic, lumbar, sacral tetraplegia paraplegia
operatie repair
skin graft skin flaps musculocutaneous flaps free flaps
open angle glaucoma test results
slit lamp microscopy reveals a normal angle
diagnostic studiea glaucoma
slit lamp microscopy, peripheral and central vission tests, and opthalmoscopy
osteoarthritis
slowly progressive nonimflammatory disorder of the diarthrodial joints 27 million americans affected
treatment of tigeminal neuralgia
small feedings of liquid and soft foods chew on unaffected side antiseizure meds- tegretal antispasmotics- baclofen nerve blocks and periphearl neurectomy can help to alter the perception of the pain
age related changes
smaller pupils lens less elastic lens becomes opaque decreased depth perception, periphearl eyes recessed in socket decreased strength of msucle of the eye movement
immature cataract
some light gets through, useful vision
OA deformities
specific to involved join herberdens nodes (dip joint) and bouchards nodes (pip joint)- red, swollen, and tender, visible deformity, no sig loss of function Knee- bowleg or knock-kneed hip- one leg shorter
objective vertigo
stable in a moving enviroment
microorganism that causes osteomyelitis
staphylococcus aureus (most common can be others)
what will the joints be like in RA
stiff after inactivity morning stiffness 60 min to several hours MCP and PIP joints swollen spindle shaped fingers tender joints, painful, warm pain increases with motion, intensity varies
scarlet fever
strep rash
symptoms of angle closure
sudden H/A, red conjuctive, cloudy cornea, N&V
oral candidiasis
superficial fungal infection of the oral mucous membranes, common in infants, white curdlike plaques on tongue, gums, and buccal mucosa in children
collaborative intervention
surgery, pharmacotherapy, adaptive methods- dogs, braille, sign language
Gastric bypass
surgical reduction of gastric capacity for weight loss
etiology and pathophysiology of RA stage one
synovitis x-ray: soft tissue swelling, possible osteoporosis, no joint destruction
throacic and lumbar vertebrae injuries care
systemic support less intense less respiratory compromise no bradycardia treat symptomatically Once stabilized- obtain history of the accident, thorough assessment: muscle groups, sensory exam, associated brain injury, other injuries logroll continuous monitoring
vision
systemic, primary eye disorders (glaucoma, cataracts, macular degeneration) decresed ability to focus on near objects (presbyopia)
tactile perception
tactile thresholds increase (perceptibility to the sense of touch) potential for injury from heat and cold
sensory- mouth
taste mucositis oral canididasis thrush- infants
primary classifications
tension-type migraine cluster (can have more than one type of headache)
drug therapy migraine
terminating or decreasing symptoms mild to moderate can be treated with NSAID, aspirin, caffeine containing combination analgesics moderate to severe0 triptans, select serotonin receptors, reduce neurogenic inflammation prophylactic- antiseizure drug, botox, antidepressants
normal auditory system
the TM (tympanic membrane) should be pearl gray, white or pink; shiny and translucent the manubrium and umbo or the malleus should be visible should be concave with crisp edges fuzziness may occur with a bulging or retracted TM
sensation
the ability to perceive stimulation through ones sensory organs such as the nose, ears, and eyes. can be internal or external. includes the 5 senses
sensory perception
the abilty to receive sensory input and through various physiological processes in the body, translate the stimulus or data into meaningful information
perception
the process by which we receive, organize and interpret sensation
mobility
the state or quality of being mobile or movable
salir
to leave
nonoperative stabilization
to stabilize and decompress injuried spinal segment traction or realignment eliminate damaging motion prevent secondary damage surgery therapy
Cushing's syndrome is a clinical syndrome that results from:
too much corticosteroid
Acromegaly is caused by:
too much growth hormone
spinal cord injury
trauma or damage to spinal cord 12,500 new SCIs each year 276,000 americans livign with SCI highest in men aged 16-30 increased in older adults decreased mortality long term issues remain- disruption in growth and development, altered family dynamics, economic loss, round the clock care
blunt trauma
treatment beings immediately see physician immediately to determine extent of injury ice visual acuity assessed
Closure of the PDA and PFO is normal after birth. T/F?
true
Defects that shunt right to left cause cyanosis, T/F?
true
T/F Pharyngitis is usually caused by a virus
true
T/F There are two classifications of medications to treat asthma; quick-relief meds and long term control meds
true
T/F A client with atrial fibrillation could develop a thrombotic and/or embolic stroke
true
T/F An elevated BUN and normal Creatinine is indicative of dehyration
true
T/F Salter- Harris Fractures are epiphyseal plate fractures and are classifed as Type I through Type V
true
T/F Subluxation of the radial head can occur when abrupt longitudinal traction is applied to the wrist or hang of the extended forearm
true
T/F The main reason to treat precocious puberty is to prevent short stature.
true
HOB 30-45 degrees for 30-60 min, water irrigation before/after feeding/drugs, check tube positioning before administrations, volume 200-500ml
tube feeding
Pheochromocytoma
tumors of adrenal medulla (benign), ↑ epi and norepi in blood
rinne test
tuning for on the mastoid if sensorineural loss, decreased air conduction
weber test
tuning for on top of the head- if sensorineural loss, lateralize to non-affected, air conduction nirmally greater than bone
friction
two surfaces rubbing against each other
collaborative care headache
type of headache guides therapy, symptomatic and prophylactic therapy, drugs, medications, yoga, biofeedback, cognitive behaviroal therapy, and relaxation training
bells palsy
unilateral paralysis of muscles for expression- cant show teeth, smile, raise eyebrows, puff out cheeks, close eyelids symptoms generally improve in a few weeks
migrane
unknown cause, vascular, muscular, and biochemical factors, family history, associated with: seizures, ischemic stroke, asthma, depression, anxiety, MI, Raynaud's, IBS; triggers: menstruation, head trauma, physical exertion, fatigue, stress, missed meals, weather, drugs, foods (chocolate, aspartame, cheese, oranges, tomatoes, alcohol)
drug therapy RA- bioligoc response modifiers- BRMS
used alone or in combo with DMARDS corticosteroids- intraarticular injections, low-dose oral for limited time NSAIDS and salicylates- antiinflammatory, analgesi, and antipyretic, 2-3 weeks for full effectiveness
diagnostic study migraine
usually based on history neurologic and diagnostic examinations are normal no specific lab or radiologic test to diagnose
drug therapy for ADR
vasopressor agents (dopamine)- maintain mean arterial pressure .90mmhg during neurogenic shock glucocorticoids- decrease edema on spinal cord, (edema can cause spinal cord compression and areas of ischemia) atropine- to treat bradycardia plasma expanders- to treat hypotension muscle relaxants- baclofen and dantroleme- for muscle spasticity cholinergics- bathancechol- decrease spacicity of the bladder so easier to bladder train and fewer accdients analgeics- opioids, nonopioids, and NSAIDs- to help with pain from SCI and muscle spacicity anticoagulants- heparin or lw molecular weight heparins- for DVT prophylaxis stool softeners and bluck florming laxatives- docusate sodium- prevent constipation and keeps stool soft vasodilators- hydrazaline and nitroglycerine- use PRN to treat episodes of hypertension during automatic dysreflexia
risk factors for osteomalacia
vegan lack of sunlight anticonvulsants (phenytoin-dilantin) renal failure very low fat diets
diagnostic tests
vision, hearing- auditory brainstem response (brain activity with sound)
history and physical exam
vision: changes, exam, EOM, snellen interior eye hearing: difficulty hearing, tinnitus, ear pain, exam, hearing test taste: check smell, medications, exam-tongue and oral smell: history, medications, uri/sinus, polyps, inspection nose, breathing touch: neuro related to touch/balance, romberg, monofilament, sharp/dull, location
neurogenic bowel
voluntary control may be lost neurogenic bowel initially bowel program started during acute care- daily rectal stimulation, suppository or small- volume enema, digital stimulation or manual evacuation adequate fluids increased activity and exercise voluntary control may be lost
objective data
warm, dry skin resp dificulties- c1-3 apnea inability to cough, c4 poor cough, diaphragmatic breathing, hypovolemia, c5-t6 decreased respiratory reserve bradycardia, hypotension, postural hypotension, absence of vasomotor tone= injury above t5 decreased or absent bowl sounds= above t5 abdominal distension constipation, incontinence, impaction, urinary retention, flaccid or spastic bladder priapism loss of sexual function paralysis hyperactive deep tendon reflexes muscle atony, contractures
electrostagmography
water in ear canal while monitoring for eye motion normal response- nystagmus. absent nystagmus indicated dysfunction
osteomalacia
widespread decalcification and softening of bones esp in pelvis, spine, and lower extremities related to insufficent vitamin D
clinical manifestations of scleroderma
widespread thickening of skin on face, trunk decreased ROM, joint contractures hyperpignmentation and hypopigmentation mask like faces C= calcinosis small white deposits on tissues R= raynauds E= esophageal hardening S= sclerodactyly scleroderma of digits T= telangiectasis capillary dilations that form vascular lesions on face, lips, and fingers
client information with cochlear impant
wont be turned on immediatley after procedure, infection precaution, avoid MRIs
treatment of carpal tunnel
wrist splint in extension steroid injection to decrease inflammation may need surgery for thenar muscle atrophy- open wrist with endoscope, transverse carpal ligament is divided, tunnel becomes larger and the pressure on nerve is releived