Final Exam Review

B.) The client is using confabulation to protect the ego.

A new admission with Alzheimer's disease states, "Last night I went on a wonderful dinner cruise." Which type of communication is this client expressing, and what is the underlying reason for its use? A.) The client is using confabulation to achieve secondary gains. B.) The client is using confabulation to protect the ego. C.) The client is using perseveration to divert attention. D.) The client is using perseveration to maintain self-esteem.

C." Tell me about what has been happening lately."

A newly admitted psychiatric client was being interviewed by the nurse. Which of the following is an example of a broad opening? A.) "Do you know why you are here?" B.) "Are you feeling depressed or anxious?" C.) "Tell me about what has been happening lately." D.) "Can you name the specific events that have contributed to your admittance?"

C.) Hirsutism

A nurse is assessing a client newly diagnosed with Cushing's disease. Which of the following findings should the nurse expect? A.) Decreased blood pressure B.) Weight loss C.) Hirsutism D.) Increased skin thickness

A.) Decrease anxiety

A nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to: A.) decrease anxiety B.) focus attention on non-threatening things C.) manipulate others D.) Decrease the time available for interaction with people

C.) Decreased auditory hallucinations

A nurse is caring for a client who has a prescription for clozapine. Which of the following is an expected response to the medication? A.) Development of orthostatic hypotenison B.) Control in seizure activity C.) Decreased auditory hallucinations D.) Increased energy level and involvement in activities

C.) Oxygen saturation

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A.) Glasgow Coma Scale B.) Cranial nerve function C.) Oxygen saturation D.) Pupillary response

Keep neck stabilized

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration of his forehead that is bleeding. Which of the following is the priority nursing action at this time?

A.) Substance Abuse

A nurse is discussing cultural concepts in mental health nursing with nursing staff. When discussing Native American clients. the nurse should identify which of the following as an increased risk for this cultural group? A.) Substance Abuse B.) Schizophrenia C.) Personality disorders D.) Eating disorders

D.) End just as agreed, but tell the client he can continue at the next scheduled session.

A nurse is interviewing a client who has personality disorder. The client resists discussion of feelings until 5 min prior to the end of the session. Which of the following is an appropriate intervention? A.) Go over the agreed-upon time, as the client is finally able to discuss important feelings. B.) Arrange for another nurse to continue the interview. C.) Set an extra meeting time to discuss these feelings. D.) End just as agreed, but tell the client he can continue at the next scheduled session.

A.) Administer hydrocortisone succinate (Solu-Cortef)

A nurse is managing the care of a client who is postoperative and is experiencing acute adrenal insufficiency. The nurse should anticipate taking which of the following actions? A.) Administer hydrocortisone succinate (Solu-Cortef) B.) Giving spironolactone (Aldactone) C.) Infusing packed red blood cells D.) Restricting fluids

B.) Atropine

A nurse is planning care for a client prior to electroconvulsive therapy (ECT). Which of the following medications should the nurse plan to administer? A.) Diphenhydramine B.) Atropine C.) Epinephrine D.) Fluoxetine

C.) Remove medication from sealed packages at the client's bedside.

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions is appropriate to include in the plan of care? A.) Rotate staff assignments for this client. B.) Use touch to calm the client during periods of anxiety. C.) Remove medication from sealed packages at the client's bedside. D.) Assign an assistive personnel to feed the client at mealtimes.

B.) Avoid palpating the abdomen.

A nurse is planning care for a preoperative client who has a diagnosis of pheochromocytoma. Which of the following is the priority intervention that the nurse should anticipate in the plan of care? A.) Ensure adequate hydration. B.) Avoid palpating the abdomen. C.) Manage headaches with analgesics D.) Provide a private, darkened room

A.) Oxygen B.) Sterile water C.) Enclosed hemostat clamps E.) Occlusive dressing

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? Select all that apply. A.) Oxygen B.) Sterile water C.) Enclosed hemostat clamps D.) Indwelling urinary catheter E.) Occlusive dressing

B.) Cushing's Disease

A nurse is preparing to provide a client with information concerning Dexamethasone Suppression test. The nurse should explain that the purpose of the test is to assess for which of the following? A.) Addison's Disease B.) Cushing's Disease C.) Pheochromocytoma D.) Hyperthyroidism

D.) Schedule regular weigh-in times.

A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions is appropriate? A.) Complement the client for weight gain. B.) Allow the client to eat at any time. C.) Provide privacy when friends visit. D.) Schedule regular weigh-in times.

C.) Invents words that have no meaning

A nurse is providing care to a client who has schizophrenia. Which of the following behaviors should the nurse anticipate? A.) Periods of elation with unusual talkativeness B.) Preoccupied with folding clothes C.) Invents words that have no meaning D.) Recurrent thoughts of past trauma

A.) "I can drink up to 2 quarts of fluid a day." (Excessive thirst is a manifestation of DI. So, consumption of up to 4-30 liters per day can be expected and fluid intake should not be limited.)

A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the following statements by the client requires further teaching? A.) "I can drink up to 2 quarts of fluid a day." B.) "I should expect to urinate frequently at night." C.) "I may experience headaches." D.) "I may experience dry mouth."

C.) " I notice you seem uncomfortable discussing this."

A client discovered her son's body after he committed suicide. She was subsequently diagnosed with posttraumatic stress disorder and admitted to the inpatient psychiatric unit for evaluation and medication stabilization. An example of the therapeutic technique of "making observations" is: A.) "The day you discovered your son's body, you were arriving home from work. What happened then?" B.) "Tell me about it." C.) "I notice you seem uncomfortable discussing this." D.) "What is it that you would like to see change during your stay here?"

B.) Ineffective airway clearance

A client experiencing sleep apnea may have all of the following nursing diagnoses except: A.) Ineffective breathing pattern B.) Ineffective airway clearance C.) Impaired gas exchange D.) Disturbed sleeping pattern E.) Sleep deprivation

D.) The limbic system is largely responsible for one's emotions.

A client with depression asks, "So what area of my brain causes me to feel depressed?" Which response is most appropriate? A.) The occipital lobe is where negative thoughts and feelings originate. B.) The parietal lobe has been most closely linked to depression. C.) The medulla regulates key biological and psychological activities. D.) The limbic system is largely responsible for one's emotions.

A.) Temporary memory loss is the most common adverse effect.

A nurse is teaching a client about electroconvulsive therapy (ECT). Which of the following should the nurse include in the teaching? A.) Temporary memory loss is the most common adverse effect. B.) Medications will be administered to prevent seizure activity. C.) The greatest risk of ECT is brain damage. D.) ECT is effective in the treatment of substance abuse disorders.

C.) Vomiting and diarrhea

A nurse is teaching a client who has bipolar disorder to recognize the signs and symptoms of lithium toxicity. The nurse evaluates that learning has occurred when the client states that he should report which of the following? A.) Loss of appetite B.) Increased flatulence C.) Vomiting and diarrhea D.) Fine hand tremor

D.) Blood glucose

A nurse is undergoing screening for primary Cushing's disease. The nurse should expect that which of the following laboratory findings will be evaluated? A.) Lymphocyte count B.) Serum potassium C.) Serum calcium D.) Blood glucose

Antibodies - muromonab-CD3 (OKT3) - antithymocyte globulin (Atgam)

"Induction or Rescue" Immunosuppressants

B.) Denial of suicidal ideation and implementing healthy problem-solving skills

A suicidal client is preparing for discharge. Which discharge outcome is most important for the nurse to consider? A.) Knowledge or rehabilitation resources B.) Denial of suicidal ideation and implementing healthy problem-solving skills C.) Verbalization of an understanding of the medication regimen D.) Admittance to somatic complaints and suicidal ideation

B.) Deprivation test

A test used to help diagnose and treat diabetes insipidus is: A.) serum glucose B.) deprivation test C.) serum potassium D.) arterial blood gases

Hemodialysis

A treatment that helps the kidneys to eliminate a poison or toxin from a patient.

C.) Histrionic personality disorder

A woman comes into a psychiatric office in a bright pink satin mini-dress with a low-cut bodice, spiked heels, long red nails, and hair and makeup done theatrically. She speaks in a loud voice and expresses a wide range of emotional states. Which most probable diagnosis does the nurse anticipate? A.) Obsessive-compulsive personality disorder B.) Schizotypal personality disorder C.) Histrionic personality disorder D.) Paranoid personality disorder

B.) preload

Administration of an IV fluid bolus primarily enhances: A.) respiratory function B.) preload C.) afterload D.) stroke volume

Nitroprusside

After IABP, used to reduce afterload in cardiogenic shock

IV Sites

After airway, you need two of these in hypovolemic shock.

C.) Diminished appetite D.) Symptoms diminish as the day progresses. E.) Oriented to time and place with no wandering.

After dementia has been ruled out, a client is diagnosed with pseudodementia (depression). Which of the following symptoms would support this diagnosis? Select all that apply. A.) Slow progression of symptoms B.) Impaired attention and concentration. C.) Diminished appetite D.) Symptoms diminish as the day progresses. E.) Oriented to time and place with no wandering.

B.) may remove air from the visceral pleura and lung

All of the following are true of chest tubes (CT) except: A.) a CT restores negative pressure B.) may remove air from the visceral pleura and lung C.) may remove fluid from the pleura space D.) a CT assists in re-expanding of the lung

N-acetylcysteine

Although it has multiple uses, this medication can be used in cases of Tylenol overdose

Must be taken with meals to promote absorption and effectiveness

Aluminum Hydroxide

True

An AED is used in the treatment of ventricular fibrillation. True / False

C.) Verbalizes a suicidal plan and has the means available in a suitcase

An admitted client tells the nurse, "I'm depressed and would be better off dead." Which client information, if present, would place the client at highest immediate risk for suicide? A.) Plant to take an overdose but has no medication on had to do so. B.) Wants to kill self but doesn't have a definite plan. C.) Verbalizes a suicidal plan and has the means available in a suitcase. D.) Plans to jump off the river bridge after discharge.

A.) Medications used to treat people with ADHD causes decreased appetite.

An adolescent on medication for ADHD has lost 10 pounds in the past 2 months. Which explanation would the nurse anticipate? A.) Medications used to treat people with ADHD causes decreased appetite. B.) Hyperactivity causes excess physical activity, and therefore, increased caloric expenditure. C.) Side effects of the medications used to treat people with ADHD include nausea and vomiting. D.) Excessive stimulation least to decreased appetite.

A.) siblings

An identical match of human leukocyte antigens (HLA) is most likely to occur in: A.) siblings B.) parent and child C.) husband and wife D.) non-related donor and recipient

B.) pre-operative teaching

An important aspect of psychological preparation for the open heart surgery patient is: A.) an operating room tour B.) pre-operative teaching C.) intensive care nurse interview D.) informed consent by surgeon

Not commonly seen in AKI

Anemia

Good sources of Vitamin B12

Animal proteins, eggs, dairy products

Mad as a hatter Dry as a bone Hot as Hades Blind as a bat Red as a beet Examples: antihistamines Treatment: physostigmine

Anticholinergic poem

B.) alcohol abuse

A client is admitted with Laennec's cirrhosis. What data in the client's past history should one inquire about in taking a current history for this client? History of: A.) gallstones B.) alcohol abuse C.) viral hepatitis D.) heart disease

C.) Electrolyte imbalance

An elderly client is experiencing confusion in the emergency department. He is diagnosed with delirium and the family is told his condition is reversible. Which is the likely cause of this disorder? A.) Multiple sclerosis B.) Multiple small brain infarcts C.) Electrolyte imbalance D.) Alzheimer's disease

Spinoaccessory Nerve (CN XI)

Damaged with radical neck dissection

Brush off dry chemicals, irrigate copiously

Decontamination of dermal exposure

Negative (-) Dromotropes

Decrease AV node conduction Ex: calcium channel blockers (verapamil), adenosine

Arterial Vasodilators

Decrease afterload; works on left side of heart Medications: Nitrogylcerin, Morphine, Beta Blockers, ACE inhibitors, ARBs

Negative (-) Chronotropes

Decrease heart rate Ex: beta blockers, Digoxin, calcium channel blockers (diltiazem, verapamil)

Venous Vasodilators

Decrease preload, works on right side of heart Medications: Nitroglycerin, Morphine, ACE inhibitors, ARBs

Ascites and edema

Decreased albumin levels will lead to:

Intra-Aortic Balloon Pump (IABP)

Device used to decrease afterload

EKG, cardiac enzymes, CXR, hemodynamic monitoring, electrolytes, BUN/Cr, liver enzymes, CBC, coagulation tests, ABG, echocardiogram, cardiac catheterization

Diagnostic Tests for Cardiogenic Shock

Usually need Swan-Ganz catheter , all levels are low because they are dry, lack of perfusion = cell death, kidneys also experiencing shock, so creatinine is affected Decreased: HCT, HGB, RBC, Plts, pH, paO2, paCO2, CO, CVP, PAP, PCWP Increased: K, Na, LDH, Cr, BUN, Urine SG, Osmo

Diagnostic Tests for Hypovolemic Shock

Dysuria

Discomfort or pain associated with micturation

Acute Respiratory Distress Syndrome (ARDS)

Disruption of the alveolar-capillary membrane results in edema

Abnormal placement or distribution of vascular volume (massive vasodilation, usual circulating blood volume no longer sufficient, relative hypovolemic shock), sepsis, neurological damage, anaphylaxis

Distributive Shock

Occurs after the oliguric phase in AKI

Diuretic Phase

Immediately stop the transfusion

Do this when you suspect a hemolytic transfusion reaction.

Cardiogenic shock

Dobutamine, Furosemide, and IABP are handy for this condition

B.) fluid is drained out by gravity

During peritoneal dialysis: A.) the dialysate is pumped into the peritoneal kidney B.) fluid is drained out by gravity. C.) the effluent is a sterile fluid D.) the procedure is continuous for about 3-4 hours.

0.04

Each small box on the EKG paper represents _______ seconds.

Potassium, Calcium, Magnesium, Phosphorus

Electrolytes and minerals that influence muscle function.

Hypopnea

Episodes of shallow breathing or abnormally low respiratory rate

Neuroleptic Malignant Syndrome

Fever up to 107 degrees F Encephalopathy Vital Sign changes Enzymes are elevated (CPK) Rigidity

Airway

First line assessment and treatment

A.) Bipolar 1 disorder, single episode B.) Bipolar 1 disorder, most recent episode manic

Flight of ideas, insomnia, delusions of grandeur and intense irritability are symptoms that could be attributed to: A.) Bipolar 1 disorder, single episode B.) Bipolar 1 disorder, most recent episode manic C.) Bipolar 1 disorder, most recent episode depressed D.) Bipolar 2 disorder

The patient's eyes are closed, but will open them if someone speaks to them. The patient can speak normally, but is confused. The patient does not remember exactly what happened to them, and gives the wrong month when asked the date. The patient is slow to follow commands such as, "show me two fingers", but they are able to do so.

GCS - 13

Oliguric

GFR is at its lowest in this phase of kidney injury

Tea, coffee, cola, chocolate, alcohol

GI stimulants avoided in pancreatitis

Potential Side Effects of Antipsychotic Medications

GI upset, sedation, orthostatic hypotension, metabolic syndrome, anticholinergic effects, ECG changes, reduced seizure threshold, hypersalivation, photosensitivity

O-Negative

Blood type considered to be a universal donor

Heart Rate and Diastolic Blood Pressure

Both go up in early hypovolemic shock

One cardiac complication of chronic kidney disease

CHF

Hypothermia

CO / CI: Decreased SVR: Increased HR: Decreased

Sinus Bradycardia

Rate: less than 60 Rhythm: Regular P-Wave: Present, Upright PR: 0.12 - 0.20 seconds QRS: Less than or equal to 0.12 seconds QT: 0.36 - 0.44 seconds Causes: intrinsic disease of SA node, vomiting, electrolyte imbalances, hypoxia, hypothermia, morphine, digitalis, beta blockers, calcium channel blockers Treatment: Atropine if symptomatic

Cerebral autoregulation

ability of the brain to maintain blood flow; compliance (shunting of CSF and venous blood to make room for expanding brain tissue)

Clozapine

monitor for agranulocytosis (decreased WBCs)

Adenocarcinoma

most common lung cancer of non-smokers

B.) Notify the physician.

While caring for a client who has undergone portal systemic shunting, an increased abdominal girth is noted. What is the best action? A.) Document the finding as the only action. B.) Notify the physician. C.) Irrigate the shunt. D.) Clamp the shunt.

Calcitriol

Hormonally active form of Vitamin D

C.) An effusion of pancreatic juice enclosed by a fibrous wall

How is a pancreatic pseudocyst defined? A.) A collection of pus enclosed by inflammatory walls B.) An area of necrotic infection enclosed by fibrous walls C.) An effusion of pancreatic juice enclosed by fibrous walls D.) A collection of bile and pus enclosed by inflammatory walls.

A.) Intravenous infusion via a central line

How is bone marrow transplant done? A.) Intravenous infusion via a central line B.) Infusion into the bone marrow C.) Surgical implantation into the bone marrow D.) Direct patient to patient transfusion

Positive (+) Inotropes

Increase cardiac contractile force of the heart, ventricles empty more completely; improve cardiac output Ex: Digoxin

Positive (+) Chronotropes

Increase heart rate Ex: Atropine, epinephrine, dopamine

Stage III CKD - GFR 30-59

Increased BUN/Cr Mildly decreased GFR Nephron compensation Stress of illness can compromise this stage fast Medical management very important Control of blood pressure and risk factors

Erythropoietin

Increased production of RBCs

Polyuria

Increased urine output, UO > 2000 mL in 24 hrs.

A.) The normal clotting process is accelerated.

Indicate the true statement about DIC. A.) The normal clotting process is accelerated. B.) The release of thromboplastin is decreased. C.) Heparin therapy is contraindicated. D.) Only the extrinsic pathway is affected.

Calcium Channel Blockers (Diltiazem, Verapimil, Nifedipine)

Indications: A-Fib / Flutter, SVT Action: Slows conduction at AV node, slows excitability at SA node; slows calcium influx (decreased force of contraction) Effects on Action Potential: lengthens Phase 2 (Plateau Phase) Chronotrope: (-) Dromotrope: (-) Inotrope: (-) Side Effects: bradycardia, vasodilation, orthostatic hypotension, headache, acid reflux

Digitalis (Digoxin)

Indications: A-Fib with RVR Type: Unclassified - cardiac glycoside Action: increases "squeeze"; decreases rate and conduction Effect on Action Potential: affects sodium / potassium pump (exact effect is unclear) Chronotrope: (-) Dromotrope: (-) Inotrope: (+) Side Effects: toxicity (severe bradycardia, changes in LOC, visual "halos", anorexia, dizziness

Adenosine

Indications: Supraventricular Tachycardia Type: Antiarrhythmic Action: Inhibits catecholamines (slows/blocks conduction through AV node); decreases automaticity at AV node, coronary vasodilator Effect on ECG: conversion of SVT Chronotrope: (+) Dromotrope: (-) Inotrope: (-) Side Effects: seizure, stroke, MI, ventricular tachycardia Contraindications: second or third degree heart block, MI, ischemic event

Thrombocytopenia

Low platelet count state

Naloxone

Narcotic overdose antidote

Ziprasidone

Need ECG performed before starting treatment

Anuria

No urine is produced

Myocardial cell deficit = Impaired contractility = decreased pumping ability = decreased tissue perfusion and blood pressure "Bad Pump"

Non-Coronary Cardiogenic Shock

Compensatory stage of shock, MAP decreases 10-15mmHg, pale cool clammy skin, decreased urine output, altered LOC, vasoconstriction to restore cardiac output and blood pressure

Non-Progressive Stage of Shock

Irreversible loss of all brain and brain stem function in absence of metabolic or pharmacological inhibitors -OR- Family is discussing withdrawal of life-sustaining measures = potential organ & tissue donor (heart, lungs, liver, pancreas, intestine, kidneys, and tissues)

Non-Recoverable Brain Injury (Ventilator Dependent)

0.12-0.20 seconds

Normal PR interval length

Less than 0.12 seconds

Normal QRS complex length

Pulmonary Artery Pressure (PAP)

Normal Range: 8-20 mmHg Elevated PAP: pulmonary hypertension (which can lead to right-sided heart failure as a result of low cardiac output and arterial hypoxemia). Clinical Manifestations: dyspnea on exertion, fatigue, chest discomfort, palpitations, dizziness, syncope Treatment: diuretics (remove excess fluid), digoxin (assist with pumping of heart), calcium channel blockers (decrease blood pressure)

60 to 100 bpm

Normal rate for sinus rhythm

C.) Maintaining strict fluid control

Nursing care for the patient with syndrome of inappropriate antidiuretic hormone (SIADH) will include: A.) monitoring antidiuretic hormone replacement B.) obtaining daily weights to assess fluid loss C.) maintaining strict fluid restrictions D.) assessing for signs and symptoms of dehydration

Mild Anxiety

Occurs in every day living, disappears once threat is gone, can improve perception and problem-solving, slight discomfort, restlessness, mild tension-relieving behaviors

Decreased glucose

Occurs when abruptly stopping TPN

Dumping Syndrome

Occurs when enteral feeding is administered too quickly.

Sputum and urine

Other worthwhile cultures after blood

Exposure to agents that are harmful when taken in excess

Overdose

Neurogenic shock

Oxygen, atropine, and fluids is a great combination for this type of shock

Paralytic ileus

Peritoneal irritation and seepage of pancreatic enzymes into the abdominal cavity

Inverse Relation to MAP

Present in Distributive Shock (Neurogenic, Anaphylactic, Septic)

Direct Relation To MAP

Present in Hypovolemic and Cardiogenic Shock

Goal of ICP Care

Prevent intracranial hypertension, maintain cerebral perfusion pressure, decrease metabolic rate and O2 consumption

Enteral feedings

Prevents nutritional deficits in severely burned patients.

Impaired gas exchange

Priority nursing diagnosis in early shock

Organs - Heart, liver, pancreas, small bowel, lungs, kidneys Tissues - skin, bones, cornea, heart valves, saphenous veins, bone marrow

Products that Can be Donated

Supraventricular Tachycardia (SVT)

Rate: Atrial: 150-250; Ventricular - 150-250 Rhythm: Regular P-Waves: unable to visualize PR: N/A QRS: less than or equal to 0.12 seconds QT: N/A Causes: underlying cardiovascular disease, rheumatic heart disease, atherosclerotic cardiovascular disease, overexertion, stress, hypoxia, excessive use of stimulants, hypokalemia Treatment: Vagal maneuvers, adenosine

Good sources of iron

Red meat, organ meats, leafy green vegetables

Systemic Vascular Resistance (SVR)

Reflects changes in arterioles, which can affect emptying of left ventricle. Calculated by subtracting right atrial pressure (RAP) or central venous pressure (CVP) from the mean arterial pressure (MAP), divided by cardiac output (CO) multiplied by 80. Normal Range: 700-1500 dynes/second/cm-5 Increased SVR: Diminished ventricular compliance, reduces stroke volume, decreased cardiac output.

Shivering, fever or very cold Extreme pain or general discomfort ("worst ever") Pale or discolored skin Sleepy, difficult to wake up, confused "I feel like I might die" Short of breath

SEPSIS Pnemonic

Paraneoplastic Syndrome

SIADH, Cushing's and blood clots can occur with lung cancer and this

Sepsis

SVR: Decreased BP: Decreased HR: Decreased CO / CI: Increased early, then decreased later

Local infection = systemic infection (early sepsis) = SIRS (Systemic Inflammatory Response Syndrome) = organ failure (severe sepsis) = Multiple Organ Dysfunction Syndrome (MODS / septic shock) = DEATH!!!

Septic Shock

Itching, urticaria, skin rash, swelling lips and tongue, wheezing or stridor, tightness in chest, SOB, bronchospasm, tachycardia, arrhythmias, hypotension

Signs & Symptoms of Anaphylactic Shock

SIRES

Stabilize Identify Reverse Eliminate Support

Must have two or more of the following: - Temperature <38 C or >36 C - Heart rate >90/min - Respiratory rate >20/min or PaCO2 <32mmHg - WBC >12k or <4k or 10% immature bands Lactic acid and procalcitonin levels increased

Systemic Inflammatory Response Syndrome (SIRS)

Schillings Test

Test ordered to diagnose pernicious anemia

a.) Mediterranean

Thalassemia is most common in individuals from which of the following geographical regions? A.) Mediterranean B.) Asian C.) African D.) European

False

The EKG represents mechanical activity of the heart. True / False

D.) Vasodilation

The primary cause of hypothermia in neurogenic shock is: A.) hypertension B.) tachycardia C.) vasoconstriction D.) vasodilation

D.) Give the patient information

The purpose of providing feedback is to: A.) Give the patient good advice B.) Tell the patient how to behave C.) Evaluate the patient's behavior. D.) Give the patient information

decoupling

The term used to describe the process of separating explanations of brain death and requests for organ donation is ______________________________.

Afterload

To Decrease: arterial vasodilators (Nitrogylcerin [1 mcg/kg/min], Hydralazine, Morphine, Nipride, Cardizem, Cardene), ACE inhibitors, ARBs, Intra-aortic balloon pump, Right Ventricle specific (Flolan, Remodulim) To Increase: Vasopressors (Phenylephrine, Norepinephrine, Dopamine, Vasopressin)

Contractility

To Decrease: beta blockers, calcium channel blockers To Increase: Digoxin, Dobutamine, Milrinone, Epinephrine, Dopamine

C.) Systemic vascular resistance

To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which hemodynamic parameter will the nurse monitor? A.) Right atrial pressure B.) Pulmonary capillary wedge pressure C.) Systemic vascular resistance D.) Cardiac index

D.) All of these

To help correct misconceptions about organ and tissue donation, the family needs to be informed that: A.) Their loved ones will not feel pain during the procurement process B.) The procedure associated with the organ donation process will not result in any cost to the patient or the patient's family C.) Only patients who are declared medically and legally dead can be organ or tissue donors. D.) All of these

True

To perform a 12 lead ECG, 12 electrodes are placed on the body to obtain multiple views of the heart. True / False

Magnesium sulfate

Torsades de Pointes is best treated with __________________________.

Treatment for Postrenal AKI

Treat obstruction

Adjustment of immunosuppressant medications

Treatment for Organ Rejection

Forced alkaline diuresis

Treatment for aspirin overdose

Glucagon

Treatment for beta blocker overdose

Calcium Chloride

Treatment for calcium channel blocker overdose

Fomepizole

Treatment for ethylene glycol overdose

"An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards."

Uniform Determination of Death Act

Bradycardia

Unique characteristic of neurogenic shock

Thiamine and folate

Vitamins that need to be replaced due to the liver being unable to store them.

B.) Sphincter of Oddi

When relaxed, which sphincter allows bile to flow into the duodenum? A.) Pyloric sphincter B.) Sphincter of Oddi C.) Ampulla of Vader D.) Ileocecal valve

A.) Participate in group activities.

Which activity should the nurse encourage when working with a client with schizoid personality disorder? A.) Participate in group activities B.) Ignore auditory hallucinations C.) Set self-limits on aggressive behavior. D.) Explore consequences of manipulative behavior.

A.) Being firm, consistent and understanding, while focusing on specific behaviors.

Which approach by the nurse would best maintain a therapeutic relationship with a client with borderline personality disorder? A.) Being firm, consistent, and understanding, while focusing on specific behaviors. B.) Providing an unstructured environment for the client to promote self-expression. C.) Use of an authoritarian approach to help clients learn to conform to the rules of society. D.) Record, but do not provide attention to, marked shifts of mood, suicidal threats, and temper displays.

A.) Neuroleptics

Which class of medications does the nurse recognize that is effective in the treatment of Tourette's syndrome? A.) Neuroleptics B.) Antimanics C.) Tricyclic antidepressants D.) MAOIs (monoamine oxidase inhibitors)

D.) "Taking those pills got out of control. It cost me my job, my marriage, and my children."

Which client statement demonstrates positive progress towards recovery from substance abuse? A.) "I'm ready for discharge and feel better now." B.) "I don't need to be here with these crazy people." C.) "I only used pills to be able to sleep." D.) "Taking those pills got out of control. It cost me my job, my marriage, and my children."

A.) Audible stridor

Which clinical manifestation in the client with suspected inhalation burn would require immediate intervention by the nurse? A.) Audible stridor B.) Blistering in the area of the burn C.) Increased respiratory rate D.) Thick, tan-colored sputum

A.) Hyponatremia B.) Low serum osmolality C.) No evidence of dehydration

Which fluid and electrolyte abnormalities are seen in SIADH? (Choose all that apply.) A.) Hyponatremia B.) Low serum osmolality C.) No evidence of dehydration D.) Edema

C.) Administer Librium for withdrawal symptoms.

Which nursing intervention is most appropriate on the first day of alcohol withdrawal? A.) Strongly encourage the client to attend two AA meetings. B.) Educate the client about the biopsychosocial consequences of alcohol abuse. C.) Administer Librium for withdrawal symptoms. D.) Ensure that the client consumes 95% of his or her meals.

C.) Progressive cyanosis D.) Subcutaneous emphysema

Which of the following are signs and symptoms of a tension pneumothorax? (Select all that apply). A.) Midline trachea B.) Severe hypertension C.) Progressive cyanosis D.) Subcutaneous emphysema E.) A loud bruit on the affected side

B.) Risk for ineffective breathing pattern

Which of the following nursing diagnoses would be the priority for a client admitted with an acute C5 complete spinal cord injury? A.) Risk for autonomic dysreflexia B.) Risk for ineffective breathing pattern C.) Risk for aspiration D.) Risk for impaired skin integrity

A.) Obtaining vital signs on a client receiving a blood transfusion

Which of the following would be an appropriate task to delegate to a nursing assistant working on a medical-surgical unit? A.) Obtaining vital signs on a client receiving a blood transfusion B.) Providing nutritional teaching to a client with iron deficiency anemia C.) Interpreting the vital signs for a patient with hemorrhagic anemia. D.) Assessing skin integrity on an anemic client after a fall.

Diseased coronary arteries = inadequate oxygen to cardiac muscles = decreased heart pumping ability = decreased cardiac output = decreased tissue perfusion and blood pressure

Coronary Cardiogenic Shock

C.) 3000 milligrams

In order to prevent hepatic failure, the nurse knows that the maximum daily dose of acetaminophen (Tylenol) should not exceed: A.) 4000 grams B.) 10 grams C.) 3000 milligrams D.) 1000 milligrams

C.) sternum

In addition to the iliac crest, bone marrow aspiration can be taken from the: A.) skull B.) scapulae C.) sternum D.) femur

Fluids

In cardiogenic shock, this probably won't help.

Incompatibilities

A major complication with TPN.

Atypical Antipsychotics

Clozapine, Risperdone, Paliperidone, Olanzapine, Quetiapine, Ziprasidone, Aripiprazole, Iloperidone

EDS

Excessive Daytime Sleepiness

Symptoms of Intrarenal AKI

Hypervolemia: SOB, jugular vein distention, weight gain, rales, edema, pulmonary edema Symptoms vary based on cause/phase

Symptoms of Postrenal AKI

Hypervolemia: SOB, jugular vein distention, weight gain, rales, edema, pulmonary edema Symptoms vary depending on phase/cause Urinary obstruction: hesitancy, difficulty initiating stream, clots in Foley, distention

Common side effect of hemodialysis

Hypotension

Acute Renal Failure

Hypovolemia

Urine Output

If this drops during shock, your kidneys are in trouble.

Aplastic Anemia

The cells are normocytic, but not enough are produced.

Premature Ventricular Complex (PVC)

The ventricle electrically discharges (contracts) prematurely before the normal electrical impulses arrive at the SA node; most commonly due to electrical "irritability" of the heart muscle of the ventricles; can be unifocal or multifocal. Causes: MI, electrolyte imbalances, oxygen deficits, medications

Cardiac Output (CO)

The volume of blood the heart pumps per minute. Calculated by multiplying the stroke volume (SV) by the heart rate. Predicts oxygen delivery to cells Normal Range: 4-8 L/min.

Polycythemia

Therapeutic phlebotomy is used

Hemodialysis / peritoneal dialysis

Therapy causes an increased protein loss in CKD.

Neutropenia

There are reduced neutrophils and immunosuppression in this condition

white and red blood cells

These cells do not pass through the hemodialysis filter

Platelets

These initiate the clotting cascade

Vitamin B12 Deficiency Anemia

This anemia causes paresthesias.

SVT

This dysrhythmia is defined as a regular rhythm, heart rate greater than 150 bpm and inability to see P waves.

Reed Sternberg cells

This is the defining marker in Hodgkin's lymphoma

Activated charcoal

This method works by absorbing or binding with the toxic substance in the GI tract.

GFR (Glomerular Filtration Rate)

A standard indicator of renal function that declines with age

Stroke Volume (SV)

Determined by preload, contractility, and afterload.

Drugs, allergies (IV contrast, latex, food, bee stings, blood)

Causes of anaphylactic shock

Hemorrhage, dehydration, decreased fluid volume, "third spacing"

Causes of hypovolemic shock

Spinal cord injury, anesthesia, head trauma, pain

Causes of neurogenic shock

Damage to alveolar-capillary membrane increases permeability and causes protein-rich fluid to move into alveoli; alveolar collapse

Carrie is 65 years old. She is admitted with septic shock and is placed on a ventilator because of respiratory distress. Her PaO2 remains low despite a high FiO2 setting. What is the underlying pathophysiology of this condition?

Total protein / albumin

Decreased in Chronic Liver Disease

Fluid Overload

Infuse RBCs as slow as possible in this condition

Tardive Dyskinesia

Involuntary movement of tongue and face, lip smacking, involuntary trunk/arm/leg movements, dysphagia

Serum Potassium

Major cation within the cell. Excreted mainly by the kidney. Decreased GFR causes an increase in this level. Normal Values: 3.5-5.0 mEq/L Critical Values: <2.5 or >6.5 mEq/L

Hypovolemic Shock

PCWP: Decreased CO / CI: Increased early, then decreased later SVR: Increased to compensate for blood loss RAP: Decreased BP: Decreased

pH: 7.30 pCO2: 58 pO2: 88 HCO3: 22 O2 Sat: 92%

PROBLEM: High pCO2 Increase tidal volume and/or increase RR (which will increase ventilation and "blow-off" CO2)

pH: 7.39 pCO2: 44 pO2: 143 HCO3: 23 O2 Sat: 100%

PROBLEM: High pO2 Decrease FiO2 (lower concentration of oxygen) and/or decrease PEEP

pH: 7.48 pCO2: 32 pO2: 92 HCO3: 23 O2 Sat: 95%

PROBLEM: Low pCO2 Decrease tidal volume and/or decrease RR (which will decrease ventilation and help to retain CO2).

pH: 7.46 pCO2: 30 pO2: 90 HCO3: 24 O2 Sat: 94%

PROBLEM: Low pCO2. Decrease tidal volume and/or decrease RR (which will decrease ventilation and help to retain CO2.)

pH: 7.38 pCO2: 37 pO2: 78 HCO3: 24 O2 Sat: 89%

PROBLEM: Low pO2 Increase FiO2 (higher concentration of oxygen) and/or increase PEEP (keeps alveoli open and facilitates improved oxygenation)

pH: 7.41 pCO2: 40 pO2: 65 HCO3: 25 O2 Sat: 86%

PROBLEM: Low pO2. Increase FiO2 (higher concentration of oxygen) and/or increase PEEP (keep alveoli open and facilitates improved oxygenation)

Ventricles

Pacemaker with an intrinsic rate of 20-40 bpm

What is Peritoneal Dialysis?

Performed within the body. The peritoneal cavity in the abdomen holds dialysis solution called dialysate, and the peritoneum, the membrane around the cavity, acts as a filter.

This system regulates blood pressure and fluid balance

RAAS

Pulmonary Hypertension / Emboli

RAP: Increased HR: Increased CO: Increased initially

Cardiac Tamponade

RAP: Increased PAP: Increased

Tachycardia, narrowed pulse pressure, orthostatic BP, decreased SpO2, pale cool clammy skin, cyanosis, decreased capillary refill, increased RR, dyspnea, rales, decreased urinary output, changes in LOC

Symptoms of Cardiogenic Shock

Initial: Tachycardia, increased diastolic blood pressure, decreased pulse pressure, decreased pulses As Progresses: Orthostatic changes, decreased urine output, decreased SpO2, pale cool clammy skin, delayed capillary refill, increased RR, thirst (usually very thirsty), changes in LOC, decreased DTRs

Symptoms of Hypovolemic Shock

Radiation Therapy

Treatment of choice for laryngeal cancer

Treat the Cause

The number one treatment for DIC

True

Typical location of the pain is the mid-epigastric area or LUQ

NG Tube

Used for short-term nutritional support.

Micron filter

Utilized with administration of parenteral nutrition.

Tachycardia at Rest

Vital sign changes common to all anemias

D.) Work with the client to decrease his anxiety and establish trust.

Which initial intervention must be taken by the nurse who is working with a client with paranoid schizophrenia? A.) Allow the client to take charge of his or her self-care independently. B.) Put the client in the first group therapy session with an opening. C.) Help the client to decide where he wants to go in life. D.) Work with the client to decrease his anxiety and establish trust.

D.) Pancrelipase (Viokase)

Which medication is administered to replace pancreatic enzymes? A.) Cholestyramine (Questran) B.) Probenicid (Benemid) C.) Tolazamide (Tolinase) D.) Pancrelipase (Viokase)

C.) Benztropine (Cogentin)

Which medication is most likely to be prescribed for the extrapyramidal side effects (EPS) of antipsychotic medications? A.) Diazepam (Valium) B.) Amitriptyline (Elavil) C.) Benztropine (Cogentin) D.) Methylphenidate (Ritalin)

A.) Offering self

"Please let me know how I can help you" is an example of: A.) Offering self B.) Broad openings C.) General leads D.) Making stereotyped comments

C.) Temperature of 101 degrees F.

A client with schizophrenia takes an antipsychotic agent daily. What assessment finding would be most important for the nurse to recognize? A.) Respirations of 22 breaths/minute B.) Weight gain of 8 pounds in 2 months C.) Temperature of 101 degrees F. D.) Excess salivation

B.) Lung tissue

A pulmonary contusion causes bleeding in the: A.) Alveoli B.) Lung tissue C.) Intercostal space D.) Pleural space

Myocardial Infarction (MI)

A serious risk in cases of cocaine overdose

C.) "Rise slowly when you change positions from lying or sitting to standing."

An aging client with chronic schizophrenia takes a beta-adrenergic blocking agent (propranolol) for his hypertension and an antipsychotic. Given the combined side effects of these drugs, which client teaching is most important? A.) "Make sure you concentrate on taking slow, deep, cleansing breaths." B.) "Watch your diet and try to engage in some regular physical activity." C.) "Rise slowly when you change positions from lying or sitting to standing." D.) "Wear sunscreen and try to avoid midday sun exposure."

Signs & Symptoms of Intracranial Pressure

Changes in LOC (first sign), Cushing's Triad (hypertension - wide pulse pressure, bradycardia, irregular respiration/respiratory depression), seizures, visual/auditory disturbances, weakness, paralysis, headache, papilledema, posturing (late sign), vomiting, hyperthermia, nuchal rigidity

Prerenal

Congestive Heart Failure (CHF) Sepsis Shock

What is CRRT?

Continuous Renal Replacement Therapy - used for Acute Kidney Injury, as well as those not stable enough for hemodialysis. Often performed in the ICU. Known as "low and slow".

D.) pressurized oxygen at the end of expiration to open collapsed alveoli.

Continuous positive air pressure (CPAP) can be provided through an oxygen mask to improve oxygenation in hypoxic clients by providing: A.) 100% oxygen to the client B.) continuous air that the client can breathe. C.) pressurized air so the client can breathe more easily. D.) pressurized oxygen at the end of expiration to open collapsed alveoli

Calcium, Magnesium, Albumin

Decreased in pancreatitis

Causes of Prerenal AKI

Decreased perfusion/bloodflow Hypovolemia: dehydration, excess diuresis, burns, hemorrhage, shock Hypervolemia: Congestive Heart Failure (CHF)

Oliguria

Decreased urine output, UO < 400 mL in 24 hrs.

60/0.8=75 (P/F Ratio is 200 or less in ARDS)

Despite high FiO2 settings, Carrie is unable to maintain adequate oxygenation. She is currently on 80% FiO2 and her PaO2 is 60. Determine Carrie's P/F ratio (PaO2/FiO2)

Oxygen Toxicity

Despite high FiO2 settings, Carrie is unable to maintain adequate oxygenation. She is currently on 80% FiO2 and her PaO2 is 60. What are your concerns for Carrie' being on high FiO2 settings?

Refractory hypoxemia

Despite high FiO2 settings, Carrie is unable to maintain adequate oxygenation. She is currently on 80% FiO2 and her PaO2 is 60. What is the term of this?

To aid in recovery and weaning

Despite high FiO2 settings, Carrie is unable to maintain adequate oxygenation. She is currently on 80% FiO2 and her PaO2 is 60. Why is nutrition important for a client with this condition?

Cerebral Perfusion Pressure

Determined by subtracting MAP - ICP Normal ICP = <15 mmHg Normal CPP = 80-100 mmHg CPP < 60 = cell injury CPP < 30 = cell death / neuronal hypoxia

Normal Saline

Fluid used with all blood products

A.) Narcan

Flumazenil (Romazicon) is to benzodiazepines, as __________________ is to opioids. A.) Narcan B.) Nalmefane C.) Activated charcoal D.) Gastric lavage

C.) Impaired body image

For the client in the rehabilitative phase of burn injury, which of the following nursing diagnoses is likely? A.) Acute pain B.) Potential for infection C.) Impaired body image D.) Fluid volume excess

The patient's eyes will be closed, but will open briefly if someone calls to them loudly. The patient will not answer any questions. If pinched, the patient will groan or yell, but does not say any recognizable words. The patient does not follow any commands, but if pinched will quickly push the nurse's hand away.

GCS - 10

C.) cerebral dysfunction

Hepatic encephalopathy is manifested by: A.) ascites B.) splenomegaly C.) cerebral dysfunction D.) oliguria

Laryngeal Edema

If you suspect anaphylaxis, watch out for this life-threatening condition.

B.) alterations in cognition

In depression, pessimism, self-blame and self-deprecating thoughts are examples of: A.) alterations in affect B.) alterations in cognition C.) alterations in activity D.) alterations in perception

D.) adequate hydration

In order for chelation therapy to be effective the nurse must ensure that the client has: A.) a normal liver profile B.) an oxygen saturation of 92% C.) a lead level below 20 ug/dL D.) adequate hydration

A.) Learned helplessness

In planning care for an abused child, which framework does the nurse recognize that conceptualizes victimization as a process whereby one realizes that regardless of attempts, the outcome of events is largely unpredictable and undesirable? A.) Learned helplessness B.) Cycle of battering C.) Psychodynamic theory D.) Biological theory

C.) 65 year old widowed Protestant lawyer

Which of the following individuals is considered at highest risk for suicide? A.) 45 year old African-American female B.) 50 year old married Jewish farmer C.) 65 year old widowed Protestant lawyer D.) 25 year old Hispanic female, married and Catholic

C.) Has established trust with at least one caregiver

In planning care for an autistic child, which positive and realistic client outcome would the nurse anticipate? A.) Communicates all needs verbally. B.) Participates with peers in a team sport. C.) Has established trust with at least one caregiver D.) Performs all self-care tasks independently.

A.) The client will not harm self.

In planning the care for a suicidal client, which outcome criterion is of the most immediate concern? A.) The client will not physically harm self. B.) The client will express hoe for the future. C.) The client will reveal his or her suicide plan. D.) The client will establish a trusting relationship with the nurse.

Initial Stage

In this stage of shock, heart rate and respiratory rate are only a little high.

B.) When a client hits another client and is threatening to hurt staff.

In what situation is seclusion warranted? A.) When a client is yelling at voices she is experiencing. B.) When a client hits another client and is threatening to hurt staff. C.) When a client is threatening to bang their head against the wall. D.) When a client is loud on the unit and needs to be managed in a quieter place.

Azotemia

Increased BUN and serum Creatinine levels suggestive of renal impairment, but without outward signs and symptoms of renal failure

Beta Blockers (Propranolol, Sotalol, Metoprolol)

Indications: Tachydysrhythmias, slow ventricular rate in A-Fib / Flutter Action: Blocks SNS stimulation at SA node, prolongs AV conduction (PR interval) Effect on Action Potential: depresses Phase 4 (Resting Phase); depresses Phase 2 (Plateau Phase) Chronotrope: (-) Dromotrope: (-) Inotrope: (-) Side Effects: Bradycardia, hypotension, heart failure, fatigue, dizziness, decreased libido / impotence

Antibodies and corticosteroids

Induction Immunosuppressants

Body compensating by vasoconstriction and increased heart rate, MAP decreases by <10mmHg, limited findings (signs and symptoms vague and hard to identify)

Initial Stage of Shock

Disseminated Intravascular Coagulation (DIC)

Initially the clotting system is over-activated

Small-Cell Lung Cancer

Inoperable form of lung cancer

Edema, hypertension, weight gain and elevated CVP are signs and symptoms of this type of kidney injury

Intrarenal

A.) decreased central venous pressure

Intravascular hypovolemia may be assessed upon a patient's return to ICU post-cardiac surgery. Clinical findings would be manifested in: A.) decreased central venous pressure B.) increased pulmonary artery diastolic pressure C.) decreased respiratory rate D.) increased arterial pressure

Spontaneous ventilation

Likely impaired in cases of alcohol overdose

D.) Hydration with IV fluids to prevent complications

Management of multiple myeloma includes: A.) Bed rest to prevent pathological fractures B.) A high protein diet to promote tissue healing C.) Calcium supplements to rebuild bone tissue D.) Hydration with IV fluids to prevent complications

B.) Differentiating between depression and dementia

Marilyn is a 73 year old white female who recently lost her husband of 40 years and who was admitted to the Mental Health Unit. Her daughter reports that she eats little, sleeps little and seems confused at times. The most important concern is: A.) starting her on the correct antidepressant B.) Differentiating between depression and dementia C.) Addressing her basic needs, e.g., sleep, food and proper elimination D.) All of the above

Panic Anxiety

Markedly disturbed behavior, possible loss of touch with reality, erratic behavior, impulsive, uncoordinated, autonomic behaviors used to reduce anxiety

Phosphorus

May go up when calcium goes down

False

Patients with pancreatitis often have Turner's sign, which is a gray-blue discoloration of the abdomen and peri-umbilical area.

Acute Kidney Injury

Rapid but reversible decline in kidney function

Need biopsy to rule out rejection, signs and symptoms indicate advanced rejection (weakness/fatigue, arrhythmias, CHF)

Signs and Symptoms of Heart Rejection

Tenderness or pain, evelated BUN/Cr, decreased urine output, fluid retention

Signs and Symptoms of Kidney Rejection

Elevated heart rate, fever, RUQ pain, jaundice

Signs and Symptoms of Liver Rejection

Torsades de Pointes

Similar to ventricular tachycardia; morphology of QRS complexes show variations in width and shape. Most often triggered by early PVC (R on T phenomenon); may result from hypokalemia, hypomagnesemia, tricyclic antidepressant overdose, and use of antiarrhythmic drugs Treatment: Magnesium sulfate

Carbohydrates

This nutrient in excess can lead to respiratory failure.

Cardiac output

This should improve with positive inotropic medications

Postrenal

Urethral cancer Renal calculi Atony of bladder

Negative (-) Inotropes

Weakens / decreases force of myocardial contraction Ex: beta blockers, calcium channel blockers, Class 1A antiarrhythmic drugs (quinidine, procainamide), Class 1C antiarrhythmic drugs (flecainide, propafenone)

A.) Anemia B.) Bone pain D.) Pathological fractures

What are the symptoms of multiple myeloma? Select all that apply. A.) Anemia B.) Bone pain C.) Plethoric skin appearance D.) Pathological fractures

Fatigue

A common symptom of anemia due to low erythropoietin production.

D.) Arrive carrying a blue bag and wearing black pants.

A community health nurse is assigned to a client who has schizophrenia. The client is to receive an IM medication for the control of hallucinations. The client's prior nurse reports that the client will let the nurse in her house only if the nurse carries a public health-issued blue bag and wears black pants. The nurse is scheduled to visit their client tomorrow. Which of the following is an appropriate action by the nurse? A.) Telephone the client to tell her that the new nurse will be wearing white pants. B.) Arrive as scheduled carrying only a stethoscope, vial, alcohol wipe, and medication syringe. C.) Arrive as scheduled with a police officer. D.) Arrive carrying a blue bag and wearing black pants.

C.) The client cooks her own meals.

A community mental health nurse is assessing a client who has schizophrenia. Which of the following findings indicates the client is meeting her needs for instrumental activities of daily living? A.) The client sleeps 6-8 hours each night. B.) The client has adequate peripheral circulation. C.) The client cooks her own meals. D.) The client's home is free of weapons.

A.) falls at home

A complete spinal cord injury occurring in a 78 year old man is most likely due to: A.) falls at home B.) acts of violence C.) hyperflexion D.) hyperrotation

Thrombocytopenia

A condition that requires special "gentle handling"

Hemodialysis

Most effective treatment for ethylene glycol overdose.

Erythrocytosis

An excessive amount of RBCs

Endotracheal Tube (ET Tube)

Another way to give Epinephrine

Bloodstream, Pulmonary, Urinary or Surgical infections

Causes of septic shock

Disseminated Intravascular Coagulation (DIC)

Consumption coagulopathy

AV junction

If the SA node fails to generate an impulse, the next (escape) pacemaker to generate an impulse

Causes of Increased ICP

Hypoxia, straining, coughing/suctioning, sneezing, blowing nose, suctioning, bending over, head/neck/knee/hip flexion, hyperthermia

True

Large muscle groups and skin folds will increase artifact. True / False

+/- 5000 kcal/day

Nutrition requirements for burns

MI / Heart Failure

PCWP: Increaesed CO / CI: Decreased HR: Increased to compensate Inreased

Bacterial Transfusion Reaction

Reaction seen in the autologous blood transfusion

Sodium / fluids

Restricted to help control ascites.

Sinus tachycardia

SA node firing between 100-180 bpm

In CKD, this electrolyte may rise because the kidneys can no longer excrete it.

Sodium

1 kilogram/day

The desired daily weight gain for parenteral nutrition.

Anuria

Total urine output less than 100 mL/24 hr.

Mucomyst (N-acetylcysteine)

Treatment for acetaminophen overdose

Cellular Hypoxemia

You better apply oxygen if you want to prevent this.

External or internal hemorrhage, fluid shifts, dehydration, relative hypovolemia (third spacing / loss of intravascular volume), excessive diuresis, vomiting diarrhea, Diabetes Insipidus, NG tubes set to suction

Causes of Hypovolemic Shock

Anterior Wall MI, 40% LV Heart Failure, Cardiomyopathy

Causes of cardiogenic shock

Cytotoxics and Antimetabolites - azathioprine (Imuran) - cyclophosphamide (Cytoxan) - mycophelanate (Cellcept)

"Less Specific" Immunosuppressants

Calcineurin Inhibitors - cyclosporine (Sandimmune, Neoral) - tacrolimus (Prograf) Kinase Inhibitors - sirolimus (Rapamune)

"Specific" Immunosuppressants

Corticosteroids: Prednisone (Deltasone)

"Steroid" Immunosuppressants

High FiO2; 70%, 80%, 100% High PEEP; low TV (PVRC)

Despite high FiO2 settings, Carrie is unable to maintain adequate oxygenation. She is currently on 80% FiO2 and her PaO2 is 60. What other ventilator setting adjustments would you anticipate?

Prone

Despite high FiO2 settings, Carrie is unable to maintain adequate oxygenation. She is currently on 80% FiO2 and her PaO2 is 60. What position might be helpful to improve oxygenation?

A.) Headache B.) Dilated pupils D.) Decorticate posturing

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A.) Headache B.) Dilated pupils C.) Tachycardia D.) Decorticate posturing E.) Hypotension

D.) elevated serum amylase value

An early finding of acute pancreatitis is: A.) elevated serum calcium value B.) decreased white blood cell count C.) decreased blood glucose level D.) elevated serum amylase value

A.) airway patency

When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority assessment would be: A.) airway patency B.) patient comfort C.) incisional drainage D.) blood pressure and heart rate

A.) Fluid Volume Deficit

Which of the following is the most appropriate nursing diagnosis for a client with Addison's Disease? A.) Fluid Volume Deficit B.) Urinary Retention C.) Hypothermia D.) Risk for infection

B.) lorazepam (Ativan)

Which of the following medications is used to control the symptoms of agitation associated with alcohol withdrawal? A.) diazepam (Valium) B.) lorazepam (Ativan) C.) zolpidem (Ambien) D.) clonazepam (Klonopin)

D.) None of these

Which of the following nursing actions is appropriate for the patient with a flail chest? A.) Encouraging coughing and deep breathing. B.) Taping the fractured ribs tightly C.) Withholding analgesics D.) None of these

A.) "Psychosis is correlated with excessive dopamine levels in certain parts of the brain."

A 16-year-old-client with paranoid schizophrenia experiences command hallucination to harm others, and has been admitted for trying to jump off a building because he felt the voice of God told him to do so. His parents ask the nurse, "What is it that makes him hear voices?" Which is the appropriate nursing response? A.) "Psychosis is correlated with excessive dopamine levels in certain parts of the brain." B.) "Hallucinations are caused by medication interactions." C.) "Too little serotonin is to blame for delusions and hallucinations." D.) "Changes in hormones during puberty have been shown to cause the voices."

C.) "Neither confirm nor deny the voices, but try to focus on reality."

A 16-year-old-client with paranoid schizophrenia experiences command hallucination to harm others, and has been admitted for trying to jump off a building because he felt the voice of God told him to do so. His parents ask the nurse, "What is it that makes him hear voices?" Which is the appropriate nursing response? A.) "Tell him to stop discussing the voices or sels you will conclude the visit." B.) "Ignore what he is saying and attempt to talk over him." C.) "Neither confirm nor deny the voices, but try to focus on reality." D.) "Tell him that the voices are not real and that he is going to have to stop talking about them."

D.) preventing self-harm

A 40 year old woman is admitted to the Mental Health Unit with severe depression. She tells her nurse she has not been able to sleep or eat for the past month and has lost 20 pounds. She has been spending most of the day in bed and is preoccupied with thoughts of "doing away with it all." The immediate goal of treatment for this patient is: A.) establishing adequate nutrition and hydration B.) restoring normal sleep patterns C.) promoting physical activity D.) Preventing self harm

B.) Sleep apnea

A 75 year old obese patient is snoring loudly and having period of apnea several times each night is most likely experiencing: A.) narcolepsy B.) sleep apnea C.) sleep deprivation D.) paroxysmal nocturnal dyspnea

Atrial

A PAC occurs when _______________________________ tissue is irritable.

False

A beta blocker will shorten the PR interval. True / False

C.) Hypertension

A child who has a severe allergy to bee stings is stung by a bee and is beginning to exhibit anaphylactic shock. The school nurse contacts emergency medical services (EMS). Which assessment finding reported to the EMS personnel should be questioned? A.) Signs of airway obstruction B.) Bronchospasm C.) Hypertension D.) Weak, thready pulse

B.) severe hypotension

A client admitted to the emergency department with a tension pneumothorax and a mediastinal shift following an automobile crash is most likely to exhibit: A.) bradycardia B.) severe hypotension C.) mediastinal flutter D.) a sucking chest wound

A.) Danger to self D.) Inability to care for himself E.) Danger to others

A client arrives at the ER escorted by the police after "disturbing the peace." The client appears confused, disoriented, disheveled, and emaciated. He becomes angry when questioned and states he will hurt the staff or kill someone if anyone moves and closer to him. What criteria would indicate the need for an involuntary committment? Select all that apply. A.) Danger to self B.) Being mentally ill C.) Disrupting the peace D.) Inability to care for himself E.) Danger to others

C.) Restrict caffeine intake 2-3 days prior to the test.

A client being screened for pheochromocytoma is scheduled for a vanillymandelic acid test. When providing client education regarding this test, which of the following should the nurse include? A.) Remain NPO starting at midnight prior to the day of the test. B.) Begin the 24-hr urine collection with the first morning void. C.) Restrict caffeine intake 2-3 days prior to the test. D.) Avoid the use of ibuprofen during the collection period.

C.) Substance-induced mood disorder

A client comes to the Emergency Department complaining of severly depressed mood and suicidal ideation. Toxicology tests shows he was recently abusing cocaine. Because he is unable to contract for safety, he is admitted to the inpatient psychiatric unit for evaluation. Within 2 days, he is in a normal mood, performing all self-care, laughing and interacting with peers, and eating all of his meals. Which condition does the nurse anticipate that the client was likely experiencing? A.) Dysthymia, late onset B.) Major depression, single episode, severe C.) Substance-induced mood disorder D.) Bipolar disorder, type I, most recent manic

B.) Providing temporary and partial relief from her anxiety

A client developed a number of compulsive washing rituals over the years and has sought the help of a psychiatrist, who diagnosed obsessive-compulsive disorder (OCD). What purpose does the nurse recognize that the behavioral rituals serve? A.) Blocking delusions and hallucinations from awareness B.) Providing temporary and partial relief from her anxiety C.) Drawing attention and approval from significant others D.) Increasing the inhibitory powers of her superego

D.) "It calms hyperactivity until the lithium takes effect."

A client diagnosed with Bipolar I disorder had been taking lithium carbonate 300 mg T.I.D. for maintenance therapy. The family reports that the client stopped taking lithium 3 months ago due to weight gain. In the psychiatric unit, the client is agitated, pacing back and forth, talking loudly and abusively as if in response to an unseen person, and flailing arms in exaggerated gestures. The physician orders lithium carbonate and olanzapine (Zyprexa) immediately. What is the appropriate nursing response when the family questions what olanzapine (Zyprexa) is for? A.) "It cures manic symptoms." B.) "It prevents extrapyramidal side effects." C.) "It ensures a good night's sleep." D.) "It calms hyperactivity until the lithium takes effect."

A.) adrenal cortex

A client diagnosed with hyperaldosteronism has an excess of hormone secreted from which of the following glands? A.) adrenal cortex B.) anterior pituitary C.) adrenal medulla D.) posterior pituitary

B.) Rationalization

A client drinks excessive alcohol and has lost privilege to drive his car. He refuses to seek treatment for chronic alcohol use and states, "I work hard every day to provide for my family, I don't see why I can't relax a little." What defense mechanism does the nurse recognize? A.) Projection B.) Rationalization C.) Regression D.) Sublimation

A.) may be dehydrated

A client has a blood urea nitrogen (BUN) of 64 and a creatinine (Cr) of 1.0. What do these values tell you about the client? The client: A.) may be dehydrated B.) may have fluid overload C.) is in renal failure D.) has abnormal kidney function

A.) Assist the client to perform activities of daily living (ADLs) C.) Encourage the client to discuss triggers for relapse. E.) Encourage the wife to discuss triggers for relapse. ????????????????????????WHY??????????

A client has been admitted to a detoxification unit for treatment of alcohol withdrawal. He is estranged from his wife, who has taken their two young children to her parents' house. Because of his alcohol use, he has also recently lost his job, which was the sole source of income for the family. His wife refuses to return home until he commits to sobriety. The nurse concludes that which independent nursing action(s) would be appropriate for this client? *Select all that apply* A.) Assist the client to perform activities of daily living (ADLs). B.) Educate the wife about signs and symptoms of alcohol dependence and withdrawal. C.) Encourage the client to discuss triggers for relapse. D.) Educate the client about signs and symptoms of detoxification. E.) Encourage the wife to discuss triggers for relapse.

B.) Serum BUN, creatinine and potassium increases, and metabolic acidosis occurs.

A client has been admitted to the hospital with oliguric acute renal failure. In the oliguric phase, what changes in laboratory data would you anticipate in this client? A.) Renal function indices return to baseline levels B.) Serum BUN, creatinine and potassium increases, and metabolic acidosis occurs C.) A transient rise in BUN, creatinine and potassium are followed by metabolic alkalosis D.) The BUN level starts to fall and continues to fall as creatinine and potassium levels rise

D.) Behavioral

A client has been depressed since losing his job 5 months ago, and sees a nurse psychotherapist. The client is noted to have poor personal hygiene, an altered activity level, and is withdrawn. Which type of symptoms is the nurse observing? A.) Affective B.) Physiological C.) Cognitive D.) Behavioral

D.) Return to his previous level of functioning with some modifications and supports in place.

A client has been feeling increasingly overwhelmed. He is enrolled full time in a nursing program and works full time to support his wife and two young children. He missed clinical this week because he overslept, and he also failed a test. This evening, his wife found him in the garage assembling a noose. When she questioned him, he began to cry. She immediately brought him to the emergency department. What is the nurse's goal of crisis intervention for the client? A.) Adjust his type A personality traits to more adaptive ones. B.) Cease either full-time school or work. C.) Examine how childhood events led to his overachieving orientation. D.) Return to his previous level of functioning with some modifications and support in place.

C.) Risk for self-directed violence

A client has been feeling increasingly overwhelmed. He is enrolled full time in a nursing program and works full time to support his wife and two young children. He missed clinical this week because he overslept, and he also failed a test. This evening, his wife found him in the garage assembling a noose. When she questioned him, he began to cry. She immediately brought him to the emergency department. Which reflects the priority nursing diagnoses? A.) Ineffective coping B.) Anxiety C.) Risk for self-directed violence D.) Ineffective role performance

C.) Phase III - The Honeymoon Phase

A client in the psychiatric unit states, "I attempted suicide because that is the only way I can get away from him." She is in a severely abusive relationship and fears for her life. Her husband sends flowers to the unit and a card asking her to come back, but taking no responsibility for his behavior. What does the nurse recognize about the husband's behavior? A.) Phase I - The Tension-Building Phase B.) Phase II - The Acute Battering Phase C.) Phase III - The Honeymoon Phase D.) Phase IV - The Forgiveness Phase

C.) Provide patient-controlled analgesia

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which of the following is the priority intervention that the nurse should anticipate implementing? A.) Insert a nasogastric tube. B.) Administer ceftazidime C.) Provide patient-controlled analgesia D.) Monitor for hyperglycemia

A.) there is a strong link between alcohol use and acute pancreatitis.

A client is admitted with a possible diagnosis of pancreatitis. The client rarely drinks alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that: A.) there is a strong link between alcohol use and acute pancreatitis. B.) alcohol intake can interfere with the tests used to diagnose pancreatitis. C.) alcoholism is a major health problem, and everyone is questioned about alcohol intake. D.) the physician must obtain the pertinent facts and religious beliefs cannot be considered.

D.) Correlate the problems in his life to his use of alcohol.

A client is brought to the emergency department because of aggressive behavior; slurred speech; and impaired motor coordination; his blood alcohol level is 347 mg/dL. Although he denies that he is an alcoholic, the nurse encourages him to seek rehabilitative treatment. Which step does the nurse anticipate that the client must accomplish first to be successful in treatment? A.) Identify someone to whom he can go for support. B.) Give up all his old drinking buddies. C.) Understand the effects of alcohol on his body. D.) Correlate the problems in his life to his use of alcohol.

A.) Between 4 AM and noon

A client is brought to the emergency department by the police because of aggressive behavior; slurred speech; and impaired motor coordination; his blood alcohol level is 347 mg/dL. He has been drinking 1 pint of bourbon per day. His wife reports, "He starts drinking in the early afternoon and drinks continually into the night." It is now 12 AM. When would the nurse expect withdrawal symptoms to begin? A.) Between 4 AM and 12 noon B.) Around midnight C.) In 2-3 days D.) Around 4-6 PM

C.) Giving approval; no

A client is currently living in a shelter with her four children after escaping her abusive husband. Early in her stay, she attends but does not participate in the support group held for the residents. One day, the client speaks up and appropriately confronts another peer who had stolen her hair brush. The group leader states, "I am so proud of you for being assertive. You are so good!" Which technique has the leader used, and is it therapeutic? A.) Translating words into feelings; no B.) Providing feedback; yes C.) Giving approval; no D.) Offering reassurance; yes

A.) pedal pulses

A client is diagnosed with Non-Hodgkins lymphoma. An MRI has revealed a mass near the common iliac artery. The nurse will monitor the client's: A.) pedal pulses B.) breath sounds C.) bowel habits D.) urinary output

B.) Risk for suicide related to depressed mood

A client is transported to the Emergency Department by ambulance after telling his son he was thinking of swallowing his whole bottle of fluoxetine (Prozac), which he has been taking for several years. The client has a history of a suicide attempt 20 years ago. In creating a care plan, which would be the priority nursing diagnosis? A.) Risk for self-mutilation related to low self-esteem B.) Risk for suicide related to depressed mood C.) Dysfunctional grieving related to unresolved loss D.) Powerlessness related to dysfunctional grieving process

A.) The more specific the plan is, the more likely the client will attempt suicide.

A client is transported to the Emergency Department by ambulance after telling his son he was thinking of swallowing his whole bottle of fluoxetine (Prozac), which he has taken for several years. The client has a history of a suicide attempt 20 years ago. The nurse initiates suicidal precautions, and understands which concept about suicide? A.) The more specific the plan is, the more likely the client will attempt suicide B.) Clients who talk about suicide never actually commit it. C.) A client who fails to complete a suicide attempt will not try again. D.) The nurse should refrain from actually saying the word "suicide" because this may give the client ideas.

C.) Polyuria and polydipsia

A client on lifelong desmopressin or vasopressin therapy should be taught to monitor for which of the following symptoms as a sign that another dose of the medication is needed? A.) Polyuria and polyphasia B.) Polydipsia and dysphagia C.) Polyuria and polydipsia D.) Polyphagia and dysuria

D.) Labile

A client recently diagnosed with bipolar disorder is admitted to the psychiatric unit. He is highly agitated, paces about the unit, and speaks to unseen others. He fluctuates from fits of laughter to outbursts of yelling. How would the nurse describe the client's mood when documenting? A.) Blunted B.) Flat C.) Depressive D.) Labile

C.) The client attacks another client after being confronted in group therapy.

A client refuses to take medication on the inpatient unit, citing the right of autonomy. Under which circumstances would the nurse have the right to medicate the client against the client's wishes? A.) The client's doctor tells the nurse that she needs to do whatever is necessary to get the medication into the client. B.) The client demonstrates psychotic thinking and believes she's the "devil" C.) The client attacks another client after being confronted in group therapy. D.) The client refuses to bathe and has strong body odor that disturbs other clients.

B.) "Report pulse rates lower than your pacemaker setting."

A client was admitted for a permanent pacemaker insertion. What priority instruction does the nurse include in the client's discharge teaching? A.) "Do not submerge your pacemaker, take only showers." B.) "Report pulse rates lower than your pacemaker setting." C.) "If you feel weak, apply pressure over your generator." D.) "Have your pacemaker turned off before having an MRI."

A.) "You are safe now."

A client who has just been raped arrives at the ED, crying, pacing and cursing her attacker. Which is the priority therapeutic statement for the nurse to make when she arrives at the ED? A.) "You are safe now." B.) "I'll call your husband." C.) "The police will want to interview you." D.) "We'll have to take photographs of those wounds."

A.) Meaningless imitation of movement

A client who has schizophrenia receives a monthly injection of haloperidol decanoate (Haldol LA). Which of the following symptoms are expected to improve? A.) Meaningless imitation of movement B.) Inability to experience pleasure C.) Diminished facial expression D.) Extremities remail in fixed position

C.) You may be rejecting the transplanted liver, and should call the transplant team immediately.

A client who has undergone liver transplantation 2 weeks ago, reports a temperature of 101 degrees F (38 degrees C) and right flank pain. What would be the nurse's best response? A.) The immunosuppressant drugs you are taking may make you susceptible to infection. B.) Take a pain- and fever-reducing medication, such as acetaminophen, every 4 hours until you feel better. C.) You may be rejecting the transplanted liver, and should call the transplant team immediately. D.) You should take an additional dose of cyclosporine today.

C.) Valproic acid (Depakote)

A client who is diagnosed with Bipolar I disorder, current manic episode, refuses to take lithium carbonate due to excessive weight gain while on the medication. Which other medication does the nurse anticipate that the physician will prescribe with or without lithium for managing Bipolar I disorder? A.) Sertaline (Zoloft) B.) Paroxetine (Paxil) C.) Valproic acid (Depakote) D.) Trazodone (Desyrel)

C.) Risk for suicide related to depressed mood

A client with a history of mania is found unconscious, but still breathing, with an empty bottle of sertraline (Zoloft) beside the bed. The family reports that the client has been increasingly depressed lately, will not eat, and has recently been fired from a job. After stabilization in the Emergency Department, the client is admitted to the psychiatric unit with the diagnosis of Bipolar I disorder, current episode depressed. What would be the priority nursing diagnosis for her at this time? A.) Imbalanced nutrition, less than body requirements, related to refusal to eat B.) Anxiety (severe) related to threat to self-esteem C.) Risk for suicide related to depressed mood D.) Dysfunctional grieving related to loss of employment

A.) "This is a normal expected response to this medication."

A client with advanced cirrhosis has begun treatment with Lactulose. The client reports experiencing several soft stools per day. What is the best response? A.) "This is a normal expected response to this medication." B.) "You may take Kaopectate liquid 3 times per day to loose stools." C.) "Do not take any more of the medication until I check with your physician." D.) "We will need to send a stool specimen to the lab for culture and sensitivity."

B.) increased amylase

A client with alcoholism presents to the ED reporting a sudden onset of severe back pain with vomiting over the last 18 hours. Which of the following laboratory results indicate that pancreatitis is the cause of the client's symptoms? A.) serum blood glucose 110 mg/dL B.) increased amylase C.) WBC 9,000/mm3 D.) Decreased bilirubin

B.) Investigate reasons for the behavior.

A nurse is caring for a client who has a diagnosis of obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take? A.) Interrupt the compulsive behavior. B.) Investigate reasons for the behavior. C.) Encourage avoidance of situations that increase anxiety. D.) Provide a strict environment that inhibits obsessive-compulsive opportunities.

C.) "It is after 10:00 PM. You can call tomorrow."

A client with antisocial personality disorder to the nurses' station at 11:00 PM requesting to phone a lawyer to discuss filing for a divorce. The unit rule states that no phone calls are permitted after 10:00 PM. Which nursing response is appropriate? A.) "You may go ahead and use the phone. I know this is hard for you." B.) "You know better than to break the rules. I'm surprised at you." C.) "It is after 10:00 PM. You can call tomorrow." D.) "You really don't want to file for a divorce, do you?"

B.) Communicate thoroughly and effectively through the various shifts, and maintain consistent rules.

A client with borderline personality disorder is angry that the night-shift staff will not let her get a cup of coffee at 3 AM. She brings this up in community meeting and develops a following of patients who demand access to the cafeteria at all hours. How can the nursing staff avoid being "split"? A.) Allow the patients to decide how they want the milieu to operate. B.) Communicate thoroughly and effectively through the various shifts, and maintain consistent rules. C.) Eliminate coffee from the unit. D.) Allow clients to have free access to the cafeteria at all times.

A.) Allow the client to decline taking the medication.

A client with chronic schizophrenia is seen monthly by a community mental health nurse for administration of fluphenazine (Prolixin Decanoate). The client refuses medication at one regularly scheduled monthly visit. Which nursing intervention is ethically appropriate? A.) Allow the client to decline taking the medication. B.) Inform the client that the medication must be taken to avoid hospitalization. C.) Arrange with a relative to add medication to the client's morning orange juice. D.) Call for help to hold the client down while the shot is administered.

A.) "In addition to biological factors, there are numerous environmental and interpersonal events that contribute to the onset of depression."

A client with depression states, "I have a chemical imbalance and have no control over my behavior. I'll just need to wait until my medication kicks in to feel and act differently." Which reflects the most therapeutic response by the nurse? A.) "In addition to biological factors, there are numerous environmental and interpersonal events that contribute to the onset of depression." B.) "Based on current research, you are correct in saying that biological factors are the cause of your depression." C.) "Researchers have not been able to determine the link between nature (biology) vs. nurture (environmental) influences regarding mental illness." D.) "Abuse and trauma as a child has been proved to be the primary reason for depression in adults."

A.) Disturbed sensory perception

A client with psychosis tells the nurse that he is hearing voices telling him to kill the president. Which nursing diagnosis is the most appropriate for this client? A.) Disturbed sensory perception B.) Altered thought processes C.) Self-care deficit D.) Spiritual distress

C.) Learning how to make eye contact when communicating by role-playing.

A client with schizoaffective disorder has been admitted for social skill training. Which skill will the nurse plan to teach? A.) Learning about the side effects of medications B.) Practicing deep breathing techniques to decrease stress C.) Learning how to make eye contact when communicating by role-playing. D.) Performing hygiene and other activities of daily living.

D.) "The voices sound really distressing and scary, but I don't hear them."

A client with schizophrenia approaches you with a look of distress and anguish on his face saying, "Can you hear him? It's the devil. He's telling me I'm going to hell." Which is the best nursing response? A.) "Did you take your medication this morning?" B.) "You are not going to hell. You are a good person." C.) "There is no such thing as the devil. It's all in your mind." D.) "The voices sound really distressing and scary, but I don't hear them."

A.) Agranulocytosis

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Of which potentially fatal side effect must the nurse be aware? A.) Agranulocytosis B.) Akathisia C.) Dystonia D.) Akinesia

D.) WBC count <3000 mm3 and granulocyte <1500 mm3

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which blood test results for a potentially fatal side effect would the nurse expect? A.) WBC count >3000 mm3 and granulocyte >1500 mm3 B.) WBC count <3000 mm3 and granulocyte >1500 mm3 C.) WBC count >3000 mm3 and granulocyte <1500 mm3 D.) WBC count <3000 mm3 and granulocyte <1500 mm3

A.) Auditory hallucination D.) Loose association in thinking

A client with schizophrenia is receiving risperdone (Risperdal) to treat both the positive (type I) and negative (type II) symptoms. Which positive (type I) symptoms would the nurse expect to see decrease while the client is on this medication? (Select all that apply.) A.) Auditory hallucinations B.) Flat affect C.) Anhedonia D.) Loose association in thinking E.) Social withdrawal

B.) Apathy D.) Avolition

A client with schizophrenia is receiving risperidone (Risperdal) to treat both the positive and negative symptoms. Which negative symptoms woul the nurse expect to see decrease while the client is on the medication? (Select all that apply.) A.) Delusional thinking B.) Apathy C.) Use of neologisms D.) Avolition E.) Tangential thinking

C.) Providing long-term coordination of needed services by multiple providers

A client with schizophrenia lives with his mother, who has always managed his affairs. Recently his mother had emergency surgery, at which time the client suffered an exacerbation of his psychosis and was hospitalized. Upon discharge, the physician refers the client for nursing care management. Which statement best describes case management for this client? A.) Reducing residual defects associated with chronic mental illness B.) Providing cost-effective care based on need C.) Providing long-term coordination of needed services by multiple providers D.) Recognizing symptoms and provision of treatment.

C.) "Ask if any prescribed meds, foods, or diagnostic tests pose a risk to your kidney function."

A client with stage 2 chronic kidney disease (CKD) asks you how to prevent further damage to the kidneys. What is your best response? A.) "Unfortunately, further kidney damage is inevitable with time." B.) "You will need to follow a high protein diet to preserve kidney function." C.) "Ask if any newly prescribed meds, foods, or diagnostic tests pose a risk to your kidney function. D.) "The diuretics you are taking will prevent further damage by initiating enough urine to remove wastes."

C.) Dependent personality disorder

A client's husband of 10 years recently died of a heart attack. She reports he was abusive and controlling. She was never allowed to learn to drive or handle household tasks such as paying the bills. She reports, "I feel helpless and lost without him," and asks the others in a group therapy session to tell her what to do. One month later, she has entered another relationship with a very controlling man. Which personality disorder does the nurse recognize that most fits the client's behavior. A.) Avoidant personality disorder B.) Borderline personality disorder C.) Dependent personality disorder D.) Histrionic personality disorder

B.) To reduce psychotic symptoms.

A college student charged his roommate while holding a knife in his hands. Upon admission to the psychiatric unit, the psychiatrist diagnoses him with paranoid schizophrenia and orders 100mg of chlorpromazine (Thorazine) B.I.D. and 2mg of benztropine (Cogentin) B.I.D. PRN. Which rationale does the nurse recognize that supports the order for chlorpromazine? A.) To ensure that the client can get enough sleep. B.) To reduce psychotic symptoms C.) To increase levels of dopamine in the brain. D.) To prevent extrapyramidal symptoms.

A.) "I know that it was not my fault."

A college student experienced a sexual assault when out on a date. After several weeks of crisis intervention therapy, which client statement would indicate to the nurse that the student is making progress? A.) "I know that it was not my fault." B.) "My boyfriend is too passionate for me." C.) "I'll just go on double dates from now on." D.) "Next time I won't wear such a sexy dress."

C.) Ask the client, "What are the voices saying to you?"

A college student has become increasingly suspicious and isolated over the past few months. He is accusing friends of conspiring against him. On admission, the psychiatrist has diagnosed him with paranoid schizophrenia. The nurse recognizes that the client stops in mid-sentence when talking, and tilts his head to the side as if listening to something. Which is the appropriate nursing intervention? A.) Call and report the behavior to the physician. B.) Administer a PRN dose of Benztropine. C.) Ask the client, "What are the voices saying to you?" D.) State to the client, "I see you are distracted right now. We'll talk more later."

C.) Risk for other-directed violence

A college student has become increasingly suspicious and isolated over the past few months. He is accusing friends of conspiring against him. Police take him to a local psychiatric unit after he charged at his roommate with a knife. Upon admission, the psychiatrist has diagnosed him with paranoid schizophrenia. Which is the priority nursing diagnosis? A.) Risk for self-directed violence B.) Disturbed sensory perception C.) Risk for other-directed violence D.) Disturbed thought processes

C.) Upon experiencing tremors and shuffling gait

A college student has become increasingly suspicious and isolated over the past few months. The psychiatrist diagnoses him with paranoid schizophrenia and orders 100mg of chlorpromazine (Thorazine) B.I.D. and 2mg Benztropine (Cogentin) B.I.D. PRN. Which client behavior would warrant the nurse to administer a PRN dose of benztropine? A.) Becomes aggressive B.) Needing to be calmed down before bedtime C.) Upon experiencing tremors and shuffling gait D.) When complaining of constipation

C.) "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety."

A college student who suffers from severe test anxiety frequently calls her instructors complaining of physical health problems to avoid taking examinations. She is temporarily relieved from the anxiety when the professor agrees to postpone the examination. When seeking help, the therapist decides to try systematic desensitization. What is the therapist most likely to tell the client? A.) "Using your imagination, we will attempt to achieve a state of relaxation." B.) "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." C.) "Through a series of increasing anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D.) "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

Metabolic acidosis

A common acid-base imbalance in Acute Kidney Injury

Diabetes mellitus

A common risk factor for end-stage renal disease

E.) that the changes are related to her medication therapy and that she/he will notify the doctor about her concerns.

A female client who has been treated for Addison's disease for several months and expresses concern that she is beginning to look more masculine. The nurse should tell the client: A.) that the changes are a minor inconvenience to dying B.) that the changes are not that noticeable except for her 5 o'clock shadow. C.) to only take her medication every other day. D.) that the changes are only temporary. E.) that the changes are related to her medication therapy and that she/he will notify the doctor about her concerns.

C.) a defense against underlying depression and fear

A female client with chronic kidney disease has been on hemodialysis for two years. She relates to the nurse in the dialysis unit in an angry, critical manner and is frequently noncompliant with medications and diet. The nurse can best intervene by first understanding that the client's behavior is most likely: A.) an attempt to punish the nursing staff B.) a constructive method of accepting reality C.) a defense against underlying depression and fear D.) an effort to maintain life to the fullest extent possible.

Thalidomide

A potent teratogenic and used in the treatment of multiple myeloma.

D.) "Yes, it was a difficult relationship, and he abused the children and me."

A female client, devastated by a divorce from an abusive man, is very depressed and has sought counseling. Which client statement would indicate resolution of grief over the loss of her marriage? A.) "I know things would be different if we could only try again." B.) "He will be back. I know he will." C.) "I'm sure I did lots of things to provoke his anger." D.) "Yes, it was a difficult relationship, and he abused the children and me."

D.) Thioridazine because of cross-sensitivity among phenothiazines.

A graduate student has become increasingly suspicious of others, is experiencing auditory hallucinations, and is brought to the emergency department experiencing a psychotic episode. The client is in good physical health but has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Base on this assessment data, which antipsychotic medication would be contraindicated? A.) Haloperidol because it is used only in elderly patients B.) Clozapine because it is incompatible with desipramine C.) Risperidone because it exacerbates symptoms of depression D.) Thioridazine because of cross-sensitivity among phenothiazines.

B.) "I cannot control my use of heroin. It's stronger than I am. I'm here to find out how to get started on the road to recovery."

A heroin addict of 8 years lost custody of her first two children due to abuse and neglect secondary to her addiction. She is currently 4 months pregnant with her third child and has been admitted to the inpatient substance abuse program for 3 days. Which statement best indicates that the client is working on her substance abuse issues? A.) "I'm not going to use heroin ever again. I know I've got the will power to do it this time." B.) "I cannot control my use of heroin. It's stronger than I am. I'm here to find out how to get started on the road to recovery." C.) "I'm going to get all my children back. They need their mother." D.) "My father abused me as a child, and my mother walked out on us. If anyone's got a right to use heroin, it's me."

A.) Physical and emotional abuse

A kindergarten student is frequently violent toward other children. The school nurse notices that frequent bruises or burns to the face and arms. If he does poorly on an assignment, he is often heard telling himself, "You're so stupid." Which condition does the nurse recognize? A.) Physical and emotional abuse B.) Attention-deficit/hyperactivity disorder (ADHD) C.) Separation anxiety disorder D.) Mental retardation

A.) vein with radiating hepatocytes and sinusoids.

A lobule of the liver contains a centrally located: A.) vein with radiating hepatocytes and sinusoids B.) arteriole with radiating capillaries and Kupffer cells C.) hepatic sinus with radiating sinusoids. D.) hepatic duct with radiating Kupffer cells and cords of hepatic cells

D.) erythrocytosis

A major finding in polycythemia vera is: A.) thrombocytopenia B.) leukopenia C.) anemia D.) erythrocytosis

B.) edema and pruritus

A male client with a history of chronic kidney disease is hospitalized. The nurse assess the client for signs of chronic kidney disease, which include: A.) facial flushing B.) edema and pruritus C.) dribbling after voiding D.) diminished force and caliber of stream

D.) Intellectualization

A male client with an obsessive-compulsive disorder (OCD) spends hours bathing and grooming his hair, especially in the evening. When talking with the nurse, the client discusses the ritual in detail, but not his feelings about it. Which defense mechanism does the nurse identify? A.) Sublimation B.) Dissociation C.) Rationalization D.) Intellectualization

C.) Intimacy vs. Isolation

A married 26 year old client works as a school teacher. She and her husband just had their first child. Which Erickson stage did she successfully pass through? A.) Industry vs. Inferiority B.) Identity vs. Role Confusion C.) Intimacy vs. Isolation D.) Generativity vs. Stagnation

A.) ERCP-induced pancreatitis

A potential complication of ERCP is: A.) ERCP-induced pancreatitis B.) perforated colon C.) Post-ERCP bronchospasm D.) Intractable vomiting

A.) Admit life is unmanageable.

A mental health nurse has referred a client with an alcohol addiction to a 12-step Alcoholics Anonymous program. Which of the following is a basic concept of a 12-step program? A.) Admit life is unmanageable. B.) Detoxify from the addictive substance. C.) Identify stimuli that promote drinking. D.) Include family in counseling sessions.

Protein

A mixture of essential and non-essential amino acids. Restricted to prevent progression of Chronic Kidney Disease (CKD).

A.) Create an environment as free from distractions as possible. B.) Provide immediate reinforcement for acceptable behaviors C.) Break larger projects into smaller, attainable tasks and have him take physical-activity breaks in between D.) Reduce stimulation as much as possible. E.) Allow the child to self-control his behavior.

A mother asks the school nurse about ways to manage her son's ADHD. She reports he has difficulty completing his homework, and she often finds him playing on the computer. Which teaching should the nurse provide? (Select all that apply.) A.) Create an environment as free from distractions as possible. B.) Provide immediate reinforcement for acceptable behaviors C.) Break larger projects into smaller, attainable tasks and have him take physical-activity breaks in between D.) Reduce stimulation as much as possible. E.) Allow the child to self-control his behavior.

D.) "She isn't like my other children."

A mother brings her preschool daughter to the emergency department with multiple bruises and a fractured arm. Which statement by the mother would cause the nurse to suspect child abuse? A.) "She is uncoordinated." B.) "She has a very high IQ." C.) "She runs around all the time." D.) "She isn't like my other children."

B.) "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure or function that are beyond your control are to blame."

A mother of a child newly diagnosed with autistic disorder is sobbing as the nurse enters the room. Upon inquiring, she cries, "I'm such a terrible mother. What did I do to cause this behavior in my son?" Which nursing response is appropriate? A.) "Researchers really don't know what causes autism." B.) "Research has shown that abnormalities in brain structure or function that are beyond your control are to blame." C.) "The mother appears to play a greater role in the development of the disorder than the father." D.) "Lack of early infant bonding with the mother may be a cause of autism. Did you breast-feed or bottle-feed?"

Pulmonary Artery (PA) Catheter

A multi-lumen catheter placed in the pulmonary artery with the capacity to measure right atrial and indirect left atrial pressures or pulmonary artery wedge pressure (PAWP). Cardiac output measurement may also be obtained, as well as cardiac index and systemic and pulmonary vascular resistance

C.) Fulfillment of basic needs takes priority over self-actualization.

A newly admitted client who is homeless refuses to go to group therapy and instead is found in his room, lying on the floor with many food items in his pocket. Which statement accurately reflects an understanding of this client's situation according to Maslow's Heirarchy of Needs? A.) Some clients are not capable of achieving self-actualization B.) A degree of nonconformity is characteristic of a self-actualized individual. C.) Fulfillment of basic needs takes priority over self-actualization. D.) Psychological health is less important than physical health in achieving self-actualization.

D.) Weight 28% above ideal body weight

A nurse assesses a female client who has signs of obesity. Which of the following indicates the client is obese? A.) Body fat of 22% B.) BMI of 28 C.) Waist circumference of 32 inches D.) Weight 28% above ideal body weight

A.) Daily weights

A nurse at the beginning of a shift is assessing a client who has Cushing's disease. Which of the following is the priority assessment? A.) Daily weights B.) Fatigue C.) Fragile skin D.) Joint pain

C.) deviation of the trachea toward the side opposite the pneumothorax

A nurse establishes the presence of a tension pneumothorax when assessment findings reveal: A.) dull lung sounds on the affected side B.) inability to auscultate tracheal breath sounds C.) deviation of the trachea toward the side opposite the pneumothorax D.) the point of maximal impulse shifting to the left

A.) Cirrhosis

A nurse in a clinic is caring for a client who has a history of alcohol abuse and reports bruising and frequent nosebleeds. For which of the following is the client at risk? A.) Cirrhosis B.) Diabetes C.) Hepatitis A D.) Malnutrition

D.) Agoraphobia

A nurse in a mental health clinic is assessing a client whose adult daughter brought her in, stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias? A.) Xenophobia B.) Acrophobia C.) Mysophobia D.) Agoraphobia

D.) Establish a reward system for positive behavior.

A nurse in a special education program is planning care for a child who has autistic disorder. Which of the following interventions is appropriate to include in the plan of care? A.) Allow for adjustment of rules to correlate with the client's behavior. B.) Provide a flexible schedule to adjust to the client's interests. C.) Allow for imaginative play with peers without supervision. D.) Establish a reward system for positive behavior.

A.) Identify the client's nutritional status

A nurse is admitting a client who has experienced a weight loss of 25 lbs (11 kg) in the past 3 months. The client weighs 88 lb (40 kg) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client? A.) Identify the client's nutritional status B.) Request the mental health consult. C.) Plan a therapeutic diet for the client. D.) Talk to family members to find out more about the client's dietary habits.

D.) A private room in a quiet location on the unit

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should recognize that it is appropriate to admit this client to which of the following? A.) A seclusion room until the activity level becomes more subdued B.) A private room close to the nursing station C.) A semi-private room with a roommate that has a similar problem D.) A private room in a quiet location on the unit

B.) Increased urine output

A nurse is assessing a client who has SIADH. Which of the following findings indicate the client is experiencing a complication? A.) Decreased central venous pressure B.) Increased urine output C.) Distended neck veins D.) Extreme thirst

B.) Gentle constant bubbling in the suction control chamber C.) Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? Select all that apply. A.) Continuous bubbling in the water seal chamber B.) Gentle constant bubbling in the suction control chamber C.) Rise and fall in the level of water in the water seal chamber with inspiration and expiration. D.) Exposed sutures without dressing E.) Drainage system upright at chest level

B.) Viral infection

A nurse is assessing a client who is experiencing chronic stress. Which of the following is an expected finding? A.) Hypotension B.) Viral infection C.) Increased energy D.) Increased cognitive awareness

B.) "How do you get along with people at work?"

A nurse is assessing a client who reports difficulty dealing with stress. Which of the following questions is appropriate to identify potential stressors? A.) "Do you have a car?" B.) "How do you get along with people at work?" C.) "What doe you want to feel at the time of discharge?" D.) "What are your goals for yourself?"

C.) Serum calcium 12.8 mg/dL

A nurse is assessing a client with adrenal insufficiency. Which of the following findings should the nurse expect? A.) Moon face B.) Weight gain C.) Serum calcium 12.8 mg/dL D.) Serum sodium 150 mg/dL

C.) "If I eat one piece of candy, I may as well eat ten."

A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion? A.) "I like to cut my food into small portions." B.) "I really need to get into shape." C.) "If I eat one piece of candy, I may as well eat ten." D.) "I can't afford to gain weight."

D.) Inattention, hyperactivity, and impulsivity

A nurse is assessing an adolescent client who is newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following manifestations should the nurse expect to find? A.) Avoidance, emotional numbing, and withdrawal B.) Elevated moods, hyperactivity, and insomnia C.) Difficulty concentrating, anxiety and inattention D.) Inattention, hyperactivity, and impulsivity

C.) "You should keep your provider's and therapist's number with you."

A nurse is assisting a client who has schizophrenia to develop a Safety Plan to prevent relapse. Which of the following statements by the nurse is appropriate? A.) "You should be aware that excessive sleeping is an early sign of relapse." B.) "Relapse is an indication that you are not taking your medication properly." C.) "You should keep your provider's and your therapist's number with you." D.) "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."

B.) The client's husband died seven months ago

A nurse is caring for a 48-year-old client who is grieving. The client reports that her husband died seven months ago, that she has lost 30 pounds, and that she is having difficulty sleeping. Which of the following items of data indicate that the client is experiencing maladaptive grieving? A.) The client is 48 years old. B.) The client's husband died seven months ago C.) The client has lost 30 pounds D.) The client has difficulty sleeping.

B.) A high level of anxiety underlies the symptom of aphasia.

A nurse is caring for a client diagnosed with conversion disorder who has symptoms of aphasia. Which of the following statements is true about conversion disorder? A.) Conversion disorders are consciously triggered. B.) A high level of anxiety underlies the symptom of aphasia. C.) The client's aphasia is always symbolic of a basic problem. D.) The client's affect is proportionate to symptom severity.

B.) Level transducer to room temperature C.) Zero transducer to room temperature. D.) Observe trends in readings. E.) Compare readings to physical assessment.

A nurse is caring for a client following a coronary artery bypass graft (CABG). Hemodynamic monitoring has been initiated. Which of the following actions by the nurse facilitate correct monitoring readings? Select all that apply. A.) Place the client in a high-Fowler's position B.) Level transducer to phlebostatic axis. C.) Zero transducer to room temperature D.) Observe trends in readings. E.) Compare readings to physical assessment.

B.) Hyperventilate the client (Hyperventilating the client will prevent hypercarbia, which can cause vasodilation) D.) Administer a stool softener (Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP.)

A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16-22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A.) Suction the endotracheal tube. B.) Hyperventilate the client. C.) Elevate the client's head on two pillows. D.) Administer a stool softener. E.) Keep the client well hydrated.

A.) Anhedonia

A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in my life." Which of the following terms should the nurse use when documenting this finding? A.) Anhedonia B.) Anergia C.) Anosognosia D.) Akathisia

What is Hemodialysis?

A treatment that replaces kidney function. A therapy that filters waste, removes excess fluid, and balances electrolytes (sodium, potassium, bicarbonate, chloride, calcium, magnesium, and phosphate).

D.) Liquid concentrate

A nurse is caring for a client who has a psychotic disorder and is prescribed chlorpromazine. The client pretended to swallow the medication so it could be spit out later and hoarded. The nurse decides to change from the tablet to a formulation that will discourage this from happening. Which of the following dosage forms should the nurse determine to be an appropriate choice? A.) Suppository B.) Time-release capsule C.) Intramuscular injection D.) Liquid concentrate

B.) Associative looseness

A nurse is caring for a client who has acute schizophrenic disorder says to a nurse, "Yester noon the sun moon went over the rover to see the lawnmower." Which of the following manifestations is the client displaying? A.) Delusional disorder B.) Associative looseness C.) Hallucinations D.) Anhedonia

D.) You will need to stop this medication if you experience diarrhea, vomiting and/or excessive sweating

A nurse is caring for a client who has been prescribed lithium carbonate (Eskalith) for the treatment of bipolar disorder. Which of the following should the nurse include in her teaching with the client and family regarding this medication. A.) You will need to consume a low-salt diet while on this medication. B.) You will not need your blood levels during the first month. C.) You will need to take this medication on an empty stomach. D.) You will need to stop this medication if you experience diarrhea, vomiting and/or excessive sweating.

A.) Thyroid hormone panel

A nurse is caring for a client who has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed? A.) Thyroid hormone panel B.) Liver function tests C.) Erythrocyte sedimentation rate D.) Complete blood cell count

B.) Hygiene

A nurse is caring for a client who has depression and is discussing ADLs with his family. The nurse identifies that after discharge, the client is able to perform which of the following if independent with ADLs? A.) Driving B.) Hygiene C.) House cleaning D.) Grocery shopping

C.) Presence of ketones

A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse anticipate? A.) Absence of glucose B.) Decreased specific gravity C.) Presence of ketones D.) Presence of red blood cells (RBCs)

D.) Walk with the client at a gradually slower pace.

A nurse is caring for a client who has generalized anxiety disorder on the mental health unit. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. Which of the following interventions is appropriate for the nurse to take? A.) Instruct the client to sit down and stop pacing. B.) Allow the client to pace alone until physically tired. C.) Escort the client to bed to suggest the client rest. D.) Walk with the patient at a gradually slower pace.

B.) Hyponatremia

A nurse is caring for a client who has increased ICP and a new prescription for mannitol (Osmitrol). For which of the following adverse effects should the nurse monitor? A.) Hyperglycemia B.) Hyponatremia C.) Hypervolemia D.) Oliguria

A.) changes in weight

A nurse is caring for a client who has major depressive disorder (MDD). Which of the following is an expected finding? A.) changes in weight B.) hyperexcitability C.) exaggerated response of pleasure to stimuli D.) attention seeking behavior

A.) Extrapyramidal symptoms

A nurse is caring for a client who has schizophrenia and is receiving treatment with haloperidol. The nurse identifies movement disorders as an adverse effect of the medication and should document the findings as which of the following? A.) Extrapyramidal symptoms B.) Autonomic dysreflexia C.) Reflex sympathetic dystrophy D.) Muscular dystrophy

B.) "I know which of my hallucinations trigger a relapse."

A nurse is caring for a client who has schizophrenia. Which of the following statements indicates a client understanding for a relapse prevention plan? A.) "I can remember when my hallucinations first began." B.) "I know which of my hallucinations trigger a relapse." C.) "I record the number of hallucinations I have each day." D.) "I will read as much information as I can about schizophrenia."

A.) "I am aware that each problem has only one solution."

A nurse is caring for a client who has schizophrenia. Which of the following statements indicates concrete thinking? A.) "I am aware that each problem has only one solution." B.) "I am a prophet of God." C.) "The voices tell me that I must avoid large crowds." D.) "I know that you are trying to poison me and can't convince me otherwise."

A.) Decreased serum sodium C.) Serum osmolality 230 mOsm/L

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect? (Select all that apply.) A.) Decreased serum sodium B.) Urine specific gravity 1.001 C.) Serum osmolality 230 mOsm/L D.) Polyuria E.) Increased thirst

A.) "Wear a hat and long-sleeved shirt."

A nurse is caring for a client who is receiving chlorpromazine and is given a pass to attend a family outing on a sunny day. Which of the following is the most important for the nurse to include in the client's teaching about the side effects of chlorpromazine? A.) "Wear a hat and a long-sleeved shirt." B.) "Suck on hard candy." C.) "Drink plenty of fluids." D.) "Limit alcoholic beverages to one beer only."

A.) Heart failure B.) Cor pulmonale D.) Pulmonary hypertension E.) Peripheral edema

A nurse is caring for a client who is receiving hemodynamic monitoring and has the following hemodynamic readings: PAS 34 mmHg, PAS 21 mmHg, PAWP 16 mmHg, and CVP 12 mmHg. For which of the following is the client at risk? Select all that apply. A.) Heart failure B.) Cor pulmonale C.) Hypovolemic shock D.) Pulmonary hypertension E.) Peripheral edema

B.) An increase in the prescribed dosage of the medication.

A nurse is caring for a client who receives a new prescription for chlorpromazine hydrochloride. The client states, "I was embarrased to tell you earlier when you asked, but I am a pretty heavy smoker." Based on this new information the nurse should expect which of the following from the provider? A.) A change from chlorpromazine hydrochloride to clozapine. B.) An increase in the prescribed dosage of the medication C.) A discontinuation of antipsychotic medications until the client stops smoking. D.) An additional prescription for an antihypertensive medication.

A.) "This side effect should decrease after several weeks of treatment."

A nurse is caring for a client who reports dizziness upon getting out of a chair or bed since recently starting a prescription for a tricyclic antidepressant. Which of the following is an appropriate response by the nurse? A.) "This side effect should decrease after several weeks of treatment." B.) "Avoiding foods that contain tyramine can help diminish your dizziness." C.) "Dizziness is usually a result of skipping a dose of medication." D.) "Your provider will need to discuss discontinuation of this medication."

A.) Hemoconcentration B.) Dehydration

A nurse is caring for a client with diabetes insipidus (DI). Which of the following should the nurse anticipate? (Select all that apply.) A.) Hemoconcentration B.) Dehydration C.) Hyponatremia D.) Concentrated urine

C.) Amylase

A nurse is caring for a hospitalized client with acute pancreatitis. After treatment begins, the nurse anticipates that which serum laboratory value will return to normal within 72 hours? A.) Adolase B.) Lipase C.) Amylase D.) Lactic dehydrogenase

C.) Scissors

A nurse is caring for a patient with a Sengstaken-Blakemore tube in place should have which of the following items in close proximity in case of an emergency? A.) IV Magnesium Sulfate B.) The obturator C.) Scissors D.) A 60 cc syringe

A.) "It sounds like you're having a difficult time."

A nurse is caring for a young adult client who says he is experiencing increasing anxiety and the inability to concentrate. Which of the following is an appropriate response by the nurse? A.) "It sounds like you're having a difficult time." B.) "Have you talked to your parents about this yet?" C.) "Why do you think you are so anxious?" D.) "How long has this been going on?"

D.) Bloating

A nurse is caring for an adolescent admitted with anorexia nervosa. Which of the following findings is associated with this diagnosis? A.) Diarrhea B.) Hypertension C.) Tachycardia D.) Bloating

D.) alcohol usage

A nurse is completing an admission history and assessment on a client admitted with an exacerbation of chronic pancreatitis. The nurse recognizes that which of the following findings is likely to be the cause of chronic pancreatitis? A.) High calorie diet B.) Prior GI illness C.) Tobacco usage D.) Alcohol usage

B.) Limit the number of questions asked during assessments.

A nurse is developing a plan of care for a client who has schizophrenia. Which of the following interventions is appropriate to include in the plan of care? A.) Place the client in seclusion if visual hallucinations are present. B.) Limit the number of questions asked during assessments. C.) Provide diversion with consistent, stimulating activities. D.) Directly tell the client that delusions are not real.

C.) "A client who has alcohol tolerance has a decreased physical response to alcohol."

A nurse is discussing alcohol tolerance with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A.) " A client who has alcohol tolerance develops physical changes when they haven't recently ingested alcohol." B.) "Alcohol tolerance causes the client to have an increased effect when taking opiates." C.) "A client who has alcohol tolerance has a decreased physical response to alcohol." D.) "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal."

A.) Post-traumatic Stress Disorder

A nurse is discussing guided imagery with peers. When discussing indications for this treatment the nurse should include which of the following diagnoses? A.) Post-traumatic Stress Disorder B.) Schizophrenia C.) Pedophilia D.) Paranoid personality disorder

A.) "I need to make a voluntary choice to stop my feelings of depression."

A nurse is discussing health promotion with a client who has depression. Which of the following client statements indicate a need for further education? A.) "I need to make a voluntary choice to stop my feelings of depression." B.) "I can help manage my depression with lifestyle changes." C.) "I should participate in psychotherapy to improve long-term management of my depression." D.) "I will plan on continuing medication for my treatment of depression."

C.) "I just don't like going to the movies like I did before."

A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further intervention? A.) "I had a great trip to the Smokey Mountains. It was fun." B.) "Going back to work, well, it's not bad; it's ok." C.) "I just don't like going to the movies like I did before." D.) "I can't wait to go to my son's wedding next weekend. It will be nice to have the whole family together."

D.) "A chest x-ray is needed to verify placement."

A nurse is orienting a newly licensed nurse on the care of a client who is receiving hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates the teaching was effective? A.) "Air should be instilled into the monitoring system." B.) "The client should be in the prone position." C.) "The transducer should be level with the 2nd intercostal space." D.) "A chest x-ray is needed to verify placement."

A.) "Has alcohol use affected your performance at work?"

A nurse is performing a psychosocial assessment of a client who has a history of alcohol abuse. Which of the following questions asked by the nurse indicates that the client may have a Substance Abuse Disorder? A.) "Has alcohol use affected your performance at work?" B.) "Have you received prior mental health treatment?" C.) "Do you receive treatment for any mental health disorders?" D.) "At what age did you begin drinking alcohol?"

A.) Sit with the client and offer simple, direct information.

A nurse is planning a unit orientation for a newly admitted client who is severely depressed. Which of the following should be the nurse's approach? A.) Sit with the client and offer simple, direct information. B.) Take the client on a tour of the unit and introduce him to other clients. C.) Explain the unit policies to the client and answer any questions they may have. D.) Introduce the client to all the staff members on duty.

A.) Encourage the client to cough every 2 hours. B.) Check the continuous bubbling in the suction chamber. E.) Obtain a chest x-ray.

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? Select all that apply. A.) Encourage the client to cough every 2 hours. B.) Check for continuous bubbling in the suction chamber. C.) Strip the drainage tubing every 4 hours D.) Clamp the tube once a day. E.) Obtain a chest x-ray.

C.) Institute consequences for manipulative behavior.

A nurse is planning care for a client who has a personality disorder and demonstrates manipulative behavior. Which of the following interventions is appropriate to include in the plan of care? A.) Allow manipulation so as to not raise the client's anxiety. B.) Create a strict schedule for the client's activities to discourage manipulation. C.) Institute consequences for manipulative behavior. D.) Bargain with the client to discourage manipulative behavior.

A.) Assist the client in practicing meditation.

A nurse is planning care for a client who has generalized anxiety disorder. Which of the following interventions is appropriate to promote relaxation? A.) Assist the client in practicing meditation. B.) Recognize the client's spiritual preferences. C.) Encourage the client to identify his positive qualities. D.) Help the client identify his previous accomplishments.

A.) The client will make a promise not to harm self.

A nurse is planning care for a newly admitted client who has severe depression following the loss of her spouse. When planning appropriate goals, which of the following should the nurse identify as the highest priority? A.) The client will make a promise not to harm self. B.) The client will exhibit behaviors of the normal grieving process. C.) The client will identify positive qualities about herself. D.) The client will assume an active role in her care planning process.

A.) Dialectical behavior therapy (DBT)

A nurse is planning discharge teaching for a clint who has borderline personality disorder. Which of the following is appropriate for the nurse to include in the teaching? A.) Dialectical behavior therapy (DBT) B.) Behavioral contract C.) Bibliotherapy D.) Safety plan

C.) The client has separated himself from his identity.

A nurse is reading the history and physical on a client who has schizophrenia. The provider indicates that the client exhibits depersonalization. Which of the following is the most appropriate interpretation of this finding? A.) The client discontinues all of his personal relationships. B.) The client personalizes all threats and uses projection to protect herself. C.) The client has separated himself from his identity. D.) A client believes that his environment has changes and is unfamiliar.

A.) Peripheral saline lock C.) Port of proximal (CVP) lumen of pulmonary artery (PA) catheter

A nurse is reviewing a new prescription to administer 0.9% sodium chloride IV at 50 mL/hr. to a client who is receiving hemodynamic monitoring and has an indwelling IV catheter in the left hand. Which of the following sites can be used for administering the solution? Select all that apply. A.) Peripheral saline lock B.) Port of the arterial line C.) Port of proximal (CVP) lumen of pulmonary artery (PA) catheter D.) Port of distal lumen of PA catheter E.) Balloon inflation port

A.) Tardive dyskinesia

A nurse is reviewing the history and physical for a client who has schizophrenia. Reported findings include jerky chorieform movements, lip smacking, and neck and back tonic contractions. These findings are chronic despite the discontinuation of chlorpromazine. The nurse should suspect that the client has developed which of the following adverse effects? A.) Tardive dyskinesia B.) Pseudoparkinsonism C.) Dystonia D.) Akathisia

D.) "We will need to check your lithium levels within one week of starting treatment."

A nurse is teaching a client about a new prescription for lithium carbonate (Eskalith). Which of the following statements by the nurse is appropriate to include in the teaching? A.) "Lithium will be tapered in 6 months to prevent addiction." B.) "Weight gain is a sign of lithium toxicity." C.) "Your provider will prescribe a diuretic while you are taking lithium." D.) "We will need to check your lithium levels within one week of starting treatment."

D.) "Your provider will monitor your blood pressure closely while you are taking this medication."

A nurse is teaching a client about a new prescription for perphenazine. Which of the following statements is appropriate for the nurse to include in the teaching? A.) "Your provider will discontinue the medication if you experience any psychotic episodes." B.) "You should increase your dietary intake of potassium while taking the medication." C.) "You can expect to experience unusual movements of your tongue while taking this medication." D.) "Your provider will monitor your blood pressure closely while you are taking this medication."

A.) Osteoporosis B.) Development of moon-shaped face C.) Increased risk of infection D.) Muscle wasting of extremities

A nurse is teaching a client who has an autoimmune disease about the side effects of long-term corticosteroid therapy. Which of the following would be appropriate to include? *Select all that apply.* A.) Osteoporosis B.) Development of moon-shaped face C.) Increased risk of infection D.) Muscle wasting of extremities E.) Weight loss

C.) "I am powerless about my addiction to alcohol."

A nurse is teaching a client, who currently abuses alcohol, about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts? A.) "I am responsible for my alcoholism." B.) "I need to identify things that cause me to be an alcoholic." C.) "I am powerless about my addiction to alcohol." D.) "I need to see a counselor who will be responsible for my recovery."

A.) Alcohol

A nurse is teaching a community education course about the physical complications related to substance abuse. Which of the following should the nurse identify as a primary cause of cirrhosis? A.) Alcohol B.) Caffeine C.) Cocaine D.) Inhalants

D.) Give the dose in the morning to help prevent insomnia.

A nurse is teaching the parents of a school-age child who has a new prescription for atomoxetine. Which of the following is appropriate to include in the teaching? A.) Limit caloric intake to prevent excessive weight gain. B.) Avoid crowds due to the increased risk of infection. C.) Expect hyperactivity as a common side effect. D.) Give the dose in the morning to help prevent insomnia.

A.) Denial

A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which of the following responses should the nurse manager expect? A.) Denial B.) Repression C.) Rationalization D.) Projection

C.) State Board of Nursing

A nurse manager is preparing to report disciplinary action of a staff nurse for substance abuse. Which of the following has the authority to revoke a professional nurse's license? A.) Civil judicial process B.) Chief nursing officer of a hospital C.) State Board of Nursing D.) American Nurses Association

C.) "Psychological factors have been found to affect medical conditions as well."

A nurse on a medical-surgical unit is caring for a client with a cardiac condition. When asked psychological questions from the assessment, the client states: "I'm here for my heart problems, not mental health problems. What's that got to do with it?" Which is the nurse's best response? A.) "It's just a routine part of our assessment. All clients are asked the same questions." B.) "You sound concerned about these types of questions. What seems to be the problem?" C.) "Psychological factors have been found to affect medical conditions as well." D.) "We can skip these questions if you would like since they do not apply to you."

D.) Foresee anxiety-provoking circumstances.

A nurse on a psychiatric unit is caring for a client who has moderate anxiety disorder. Which of the following measures should the nurse include in the immediate plan of care? A.) Circumvent a discussion about concerns. B.) Remain near the client. C.) Encourage the client to sit for a while. D.) Foresee anxiety-provoking circumstances.

D.) Sit with the client during meals and snacks.

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following is an appropriate nursing intervention for helping this client at this time? A.) Instruct the client about the importance of eating. B.) Weigh the client at the same time every morning. C.) Ask provider to arrange an nutritional consultation. D.) Sit with the client during meals and snacks.

C.) Neologism

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating, "The mazukas are coming. The mazukas are coming." The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech? A.) Echolalia B.) Clang association C.) Neologism D.) Word salad

D.) Provide sufficient personal space so that the client's boundaries are not invaded.

A nurse recognizes that a client with paranoid schizophrenia is acutely disturbed and agitated. Which nursing intervention would be helpful in providing an appropriate environment, based on the assessment? A.) Provide bright lights and soft music. B.) Maintain intense eye contact throughout the interview. C.) Touch the client occasionally to increase trust and rapport. D.) Provide sufficient personal space so that the client's boundaries are not invaded.

C.) Refrain from giving any information to the caller, citing the principle of confidentiality.

A nurse working on the inpatient unit receives a call asking if an individual has been admitted to the psychiatric unit. Which nursing response reflects appropriate legal and ethical obligations? A.) Agree that the person has been admitted to the facility but give no further information. B.) Tell the caller that you will need to discontinue the phone call. C.) Refrain from giving any information to the caller, citing the principle of confidentiality. D.) Suggest that the caller speak to the client's therapist.

B.) "Tolerance to heroin develops quickly, leaving the addict searching to achieve that first-time high." ??????????????????????????????ask SOPER

A nurse working with substance-abuse clients evaluates which statement as a knowledge deficit? A.) "Although it's legal, alcohol is one of the most widely abused drugs in our society." B.) "Tolerance to heroin develops quickly, leaving the addict searching to achieve that first-time high." C.) "The effects of LSD, including flashbacks and hallucinations, may recur spontaneously weeks or months afterwards." D.) Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

Respiratory Distress

A paracentesis is performed when the client shows signs of:

D.) Do not eat foods containing tyramine while taking this medication.

A patient who is prescribed an MAO inhibitor for depression should have which of the following as part of his/her medication education? A.) There is a possibility for sexual dysfunction with this medication. B.) Maintain adequate protection from the sun because of photosensitivity. C.) This medication may cause pulse irregularities. D.) Do not eat foods containing tyramine while taking this medication.

C.) Autonomic dysreflexia

A patient with a T6 spinal cord injury suddenly develops a blood pressure of 200/120, a severe headache, blurred vision and bradycardia. That patient is experiencing: A.) extreme spinal shock B.) acute anxiety C.) autonomic dysreflexia D.) parasympathetic areflexia

B.) Schedule the same nurse to provide care.

A preschool child is admitted to the psychiatric unit with a diagnosis of autism. To help the child feel more secure on the unit, which should the nurse include in the plan of care? A.) Encourage peer contact. B.) Schedule the same nurse to provide care. C.) Provide a variety of daily activities. D.) Cuddle the child several times a day.

A.) Risk for self-mutiliation

A preschool child with autism is referred for evaluation. This mother reports he has begun head banging since she returned to full-time employment. She has had difficulty finding adequate and appropriate caregivers for her son. Which is the priority nursing diagnosis? A.) Risk for self-mutiliation B.) Impaired social interaction C.) Impaired verbal communication D.) Dysfunctional grieving

B.) Aspiration

A primary (direct) insult that can lead to ARDS is: A.) Heroin overdose B.) Aspiration C.) Sepsis D.) DIC

A.) Continuous rocking or swaying B.) Intense fascination with moving objects C.) Lack of eye contact

A psychiatric nurse frequently visits a school-age child with autism and his family, which includes a second son, who is 3 years old. Which behaviors would the nurse regard indicative of autistic disorder? A.) Continuous rocking or swaying B.) Intense fascination with moving objects C.) Lack of eye contact D.) Drinking large quantities of fluids

D.) Alcoholics Anonymous

A recently divorced 43-year-old career woman suffering emotional upheavel began drinking daily. After losing her job due to her drinking problem, she received treatment for the acute stage of her illness and is being discharged from the hospital. Which outpatient therapy should the nurse plan to discuss in the discharge teaching? A.) Aversion therapy B.) Controlled drinking C.) Detoxification D.) Alcoholics Anonymous

Premature Atrial Complex (PAC)

A single, electrical impulse that originates outside the SA node in the atria; individual complex arises earlier than the next expected complex of the underlying rhythm. Can occur in atria, AV junction, or ventricles. Causes: Stimulants (alcohol, caffeine), hypoxia, increased sympathetic tone, imbalance of electrolytes, digitalis toxicity, underlying cardiovascular disease Treatment: None

A.) Physical neglect

A teacher notices that a third grader has had an open lesion on her left arm for 1 week. It has never been covered with a bandage, and now is infected. The child is often absent from school, and seems apathetic and tired when she attends. Which does the school nurse recognize? A.) Physical neglect B.) Emotional injury C.) Physical abuse D.) Sexual abuse

C.) Altered nutrition, less than body requirements

A teenage female client is admitted to the adolescent unit of the psychiatric hospital for observation, diagnosis, and treatment of possible anorexia nervosa. She is 65 inches tall and weighs 85 pounds. On admission, she tells the nurse, "I don't know why my parents admitted me. I'm just trying to lose enough weight to say on the gymnastic team." Which is the priority nursing diagnosis? A.) Anxiety B.) Altered growth and development C.) Altered nutrition, less than body requirements D.) Self-esteem disturbance

Serum Creatinine

A waste product of muscle metabolism. Skeletal muscle consumes a great deal of energy in this form. Generated at a consistent rate and filtered by the kidneys and excreted in the urine. Elevations in level suggest impaired renal function. Increased in both AKI and CKD. Normal values: Male: 0.60-1.20 mg/dL Female: 0.5-1.1 mg/dL Critical Value: > 4 mg/dL

B.) Yelling at her son for slouching in his chair.

A wife routinely uses the defense mechanism of displacement. Her husband yells at her for not having dinner ready when he comes home from work. Which client reaction would the nurse anticipate from the wife? A.) Telling her husband that he has no right to yell at her. B.) Yelling at her son for slouching in his chair. C.) Burning dinner on purpose. D.) Stating, "I'll do better tomorrow."

C.) "Let's talk about your options so that you don't have to go home."

A woman comes to the emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse and worse and I'm afraid to go home because next time he may kill me." Which is the appropriate nursing response? A.) "I wouldn't want to go home either." B.) "There are things you can do to prevent him from losing control." C.) "Let's talk about your options so that you don't have to go home." D.) "I'll call the police so that they can confront your husband about his behavior."

A.) Providing for one's basic physiological needs.

A young college woman who just discovered the body of her roommate who committed suicide is brought to the emergency department. She is lying on the gurney, curled in a ball, shaking with anxiety and fear. The nurse interrupts the initial assessment to obtain a blanket and cover the client. Which reflects an appropriate rationale? A.) Providing for one's basic physiological needs. B.) Encouraging reality orientation and focusing on the present. C.) Providing a concrete demonstration of caring that promotes trust. D.) Modeling positive behaviors to the client.

D.) compensate for both insensible and expected urinary output for the next 24 hours

A young woman is admitted to the hospital in an oliguric phase of acute renal failure. The client estimates the urine output for the last 12 hours to be less than a cup. The nurse realizes that the rationale for an order of 700 mL of water orally over the next 24 hours is that this amount of fluid will A.) equal the expected urinary output for the next 24 hours B.) prevent the development of complicating hypostatic pneumonia C.) prevent hyperkalemia, which could lead to serious cardiac dysrhythmias D.) compensate for both insensible and expected urinary output for the next 24 hours

B.) A client is exhibiting violent behavior towards another client.

According to Maslow's Heirarchy of Needs, which situation on an inpatient psychiatric unit would require priority intervention by the nurse? A.) A client is rudely complaining about limited visiting hours. B.) A client is exhibiting violent behavior towards another client. C.) A client states, "No one cares about me." D.) A client verbalizes feelings of being a failure.

Causes of Intrarenal AKI

Actual renal damage Acute Tubular Necrosis: ischemia, toxins, drugs, contrast agents, prolonged prerenal (decreased perfusion/bloodflow), myoglobin, hemolytic anemia Glomerular Nephritis Vascular Issues

Occurs 1 week to 3 months after transplantation, two mechanisms: - Antibody-mediated vasculitis = leads to blood vessel necrosis - Cytotoxic / cytolytic = T cells, natural killer cells cause lysis of the organ cells Diagnosis: labs, symptoms, biopsy Treatment: Immunosuppression

Acute Graft Rejection

C.) is diagnosed by endomyocardial biopsy

Acute rejection for the heart transplant patient: A.) happens immediately after transplant and results in thrombosis and graft necrosis B.) occurs 6 months to years following transplantation C.) is diagnosed by endomyocardial biopsy D.) is characterized by angina and decreased exercise tolerance

Epinephrine

After oxygen and establishing 2 IV lines, you might have to administer this in anaphylactic shock

B.) Initiative vs. Guilt

After receiving poor grades, a college student is admitted to the hospital following a suicide attempt. "I'm a failure, I should have done better. I'm never going to amount to anything if I'm not the best." He has a history of being severely punished by his mother as a child when he did not perform to her expectations. According to Erickson, which task has the client not adequately achieved? A.) Trust vs. Mistrust B.) Initiative vs. Guilt C.) Intimacy vs. Isolation D.) Identity vs. Role Confusion

A.) determined by systolic vascular resistance and the condition of the aortic valve

Afterload is: A.) determined by systolic vascular resistance and the condition of the aortic valve B.) the force of the ejection of the heart's blood volume C.) the volume of blood ejected into the ventricles by the contraction of the atria D.) the volume of blood ejected by each ventricle per minute

A. awakening nausea

All of the following signs and symptoms are frequently seen in a client with sleep apnea except: A.) awakening nausea B.) snoring C.) hypertension D.) irregular heart beat E.) irregular respirations

D.) "I will call the social worker, they can arrange transportation to the clinic."

An elderly client who lives alone is tearful and does not know who she will get to the clinic once a week for her dose of IM Iron Dextran. Your best response would be: A.) "Make some calls, I am sure someone will give you a ride." B.) "You live close by, walking might help you feel more energetic." C.) "You can keep the medication at home and self administer it weekly." D.) "I will call the social worker, they can arrange transportation to the clinic."

D.) Continue attempts to establish a positive working relationship with the client.

An involuntarily committed client is angry and verbally abusive to staff and repeatedly threatening to sue various staff members. The client records staff member's full names and their supervisor's phone numbers. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A.) Verbally redirect the client and then avoid one on one interactions. B.) Consult the hospital's legal advisor as soon as possible. C.) Notify the client that threats of legal action are inappropriate. D.) Continue attempts to establish a positive working relationship with the client.

C.) both the liver and the gallbladder.

An obstruction of the common bile duct would cause blockage of bile coming from: A.) the gallbladder B.) the liver but not from the gallbladder C.) both the liver and the gallbladder D.) the pancreatic duct but not from the gallbladder

Antigen-antibody reaction (antigen stimulates production of IgE, attaches to mast cells & basophils, cell degranulation - leakage of histamine, bradykinin, and heparin)

Anaphylactic Shock

Treatment of EPS

Anitcholinergic drugs to increase dopamine, stabilize ACTH Amantadine Benztropine Diphenhydramine Trihexyphenidyl

Negative Symptoms of Schizophrenia

Apathy, alogia, avolition, ambivalence, anhedonia, associality, angeria, affect flattening

Positive (upright) in Lead II

Appearance of the P waves that originate from the SA node

Mesothelioma

Asbestosis cancer

Cardiac Index (CI)

Assessment of cardiac output value based on person's body size. To find cardiac index, divide cardiac output by patient's body surface area (BSA).

B.) spontaneously initiate an electrical impulse without being stimulated.

Automaticity is the ability of cardiac cells to: A.) Reach threshold and respond to a stimulus B.) Spontaneously initiate an electrical impulse without being stimulated C.) Receive an electrical stimulus and conduct that impulse to an adjacent cell D.) shorten, causing contraction of cardiac muscle in response to an electrical stimulus.

B.) Replace intravascular volume

Autotransfusion is the collection and re-infusion of a patient's own blood for what purpose? A.) Re-establish negative thoracic pressure B.) Replace intravascular volume C.) Maintain hemodynamic analysis. D.) Re-establish contaminations of transferred blood.

Hypertension

BP: Increased SVR: Increased CO / CI: Decreased

C.) Rigid and inflexible

Behavior and characteristics of individuals with personality disorders are best described as: A.) Controlling B.) Provocative C.) Rigid and inflexible D.) Obnoxious and irritating

Loss of cardiac function, loss of respiratory function = potential organ donor (corneas, heart valves, skin, long bones, saphenous veins)

Cardio-Respiratory Death

Fluid is accumulating in her lungs because of the inflammation around the lung's blood vessels.

Carrie is 65 years old. She is admitted with septic shock and is placed on a ventilator because of respiratory distress. Her PaO2 remains low despite a high FiO2 setting. Explain the pathophysiology in lay man's terms to her husband.

Normal PCWP

Carrie is 65 years old. She is admitted with septic shock and is placed on a ventilator because of respiratory distress. Her PaO2 remains low despite a high FiO2 setting. What cardiac pressure reading would support this diagnosis?

Acute Respiratory Distress Syndrome (ARDS)

Carrie is 65 years old. She is admitted with septic shock and is placed on a ventilator because of respiratory distress. Her PaO2 remains low despite a high FiO2 setting. What do you suspect is happening?

High risk for infection

Carrie requires long-term mechanical ventilation. In this stage, what is your priority concern for Carrie?

Late or chronic ARDS, pulmonary fibrosis, permanent lung changes (if she survives), prevent sepsis/pneumonia/MODS; long-term ventilator support (6-12 months); rehabilitation; home ventilator support

Carrie requires long-term mechanical ventilation. What stages of this condition is Carrie most likely in when they are unable to wean her off the ventilator.

Paralytic ileus

Changes in chest & abdominal pressure can cause this.

Hodgkin's / Non-Hodgkin's Lymphoma

Characterized by enlarged, painless lymph nodes.

Salivation Lacrimation Urination Defecaton GI cramping Emesis Examples: Insecticides Treatment: Atropine

Cholinergic overdose symptoms

A.) Congestion of the spleen B.) Decreased production of clotting factors C.) Decreased vitamin K storage

Choose *all* of the following that can contribute to the depressed clotting ability in the client with hepatic failure? A.) Congestion of the spleen B.) Decreased production of clotting factors C.) Decreased vitamin K storage D.) Loss of vascular osmotic pressure

A.) CRH is secreted by the hypothalamus, CRH stimulates the pituitary gland with releases ACTH, ACTH stimulates the adrenal glands and cortisol is released into the blood stream.

Choose the correct sequence leading to cortisol release. A.) CRH is secreted by the hypothalamus, CRH stimulates the pituitary gland with releases ACTH, ACTH stimulates the adrenal glands and cortisol is released into the blood stream. B.) ACTH is released by the hypothalamus, ACTH stimulates the pituitary to release CRH, CRH stimulates the adrenal glands to release cortisol into the bloodstream C.) Aldosterone stimulates the pituitary gland to release CRH, CRH stimulates the adrenal glands to release cortisol into the bloodstream. D.) CRH is secreted by the pituitary gland, CRH stimulates the hypothalamus to release ACTH, ACTH stimulates the adrenal glands to release cortisol into the bloodstream

Longstanding continuous ischemia, blood vessel injury, inflammation, functional tissue replaced with fibrotic scarlike tissue, organ cannot function appropriately. Treatment: Good control of host immune function May eventually need retransplantation

Chronic Rejection

Pulmonary Artery Wedge Pressure (PAWP)

Closely reflects left atrial pressure and Left Ventricular End Diastolic Pressure (LVEDP) in patients with normal left ventricular function, normal heart rates and no mitral valve disease Normal Range: 4-12 mmHg Elevated PAWP: left ventricular failure, hypervolemia, mitral regurgitation, or intracardiac shunt. Decreased PAWP: hypovolemia, afterload reduction

B.) lung cancer

Co-morbidities associated with sleep apnea include all of the following except: A.) hypertension B.) lung cancer C.) myocardial infarctions (MI) D.) cerebral vascular accidents (CVA)

Hyperglycemia and hypoglycemia

Complications of parenteral nutrition.

The microsurgical reconstruction and transplantation of a graft involving multiple tissues (skin, muscle, tendon, bone, cartilage, fat, nerves, blood vessels) Hand, face and abdominal wall transplants - designed to restore function - becoming a standard of care for those who have lost extremities

Composite Tissue Allotransplantation (CTA) or Vascularized Composite Allograft (VCA)

A.) Stay with the client during meals, allowing him or her to take as long as needed to consume 90% of the meal.

Concerning mealtimes, which intervention is appropriate when the nurse is working with clients with eating disorders? A.) Stay with the client during meals, allowing him or her to take as long as needed to consume 90% of the meal. B.) Encourage the client to journal all types, consistencies, and textures of foods, as well as nutritional information such as calories, fat grams, and carbohydrate amounts. C.) Restrict the client's privileges if he or she does not consume at least 50% of the meal within 20 minutes. D.) Remaining with the client for at least 1 hour after the meal to prevent discarding of stashed food or self-induced vomiting.

Septic shock

Condition that causes a rise in lactate and procalcitonin

Prerenal

Conditions that decrease bloodflow to the kidney cause this type of kidney injury

Disseminated Intravascular Coagulation (DIC)

Consumption of clotting factors and microthrombi formation

D.) administering the iron with a straw and rinsing the mouth

Correct administration of liquid iron would include: A.) administering the iron with a cup then rinsing the mouth B.) administering the iron with milk to avoid GI distress C.) administering the iron between meals for better absorption. D.) administering the iron with a straw and rinsing the mouth

Calcium, RBCs, H&H

Decreased in Chronic Kidney Disease (CKD)

Sedatives, then paralytics

Despite high FiO2 settings, Carrie is unable to maintain adequate oxygenation. She is currently on 80% FiO2 and her PaO2 is 60. What medications could be given to ease the work of breathing?

A.) Asbestos exposure B.) Cigarette smoking D.) Radon exposure

During admission of a patient diagnosed with non small-cell carcinoma of the lung, the nurse questions the patient related to a history of which of the following risk factors for this type of cancer? (Select all that apply). A.) Asbestos exposure B.) Cigarette smoking C.) Croup as an infant D.) Radon exposure

C.) "These women often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation." D.) "A combination of physical threats made to her and her children and a sense of powerlessness and low self-esteem paralyzes her into inaction."

During shift report, several nurses receive information about a new client in the psychiatric inpatient unit who is in a severely abusive relationship and fears for her life. One nurse cynically asks, "Why doesn't she just leave him?" Which is the appropriate nursing response from another nurse? *Select all that apply.* A.) "They don't know life any other way." B.) "These women have limited cognitive skills and few vocational abilities to be able to make on their own." C.) "These women often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation." D.) "A combination of physical threats made to her and her children and a sense of powerlessness and low self-esteem paralyzes her into inaction."

Stable mood Improved sleep patterns Clarity of thinking

Evaluation of the patient with a positive response to Lactulose will demonstrate:

Stage V CKD - GFR < 15

Excessive waste products Increased BUN/Cr Dialysis Mildly decreased GFR Stress of illness can compromise this stage fast Medical management very important Control of blood pressure and risk factors Severe volume overload Renal osteodystrophy

Stage IV CKD - GFR 15-29

Excessive waste products Increased BUN/Cr Mildly decreased GFR Stress of illness can compromise this stage fast Medical management very important Control of blood pressure and risk factors Electrolyte and acid-base imbalances Planning for end-stage renal failure

Cardiac output (pump failure)

Factor influencing MAP in Cardiogenic Shock

Size of Vascular Bed

Factor influencing MAP in Distributive Shock (Neurogenic, Anaphylactic, Septic)

Blood volume

Factor influencing MAP in Hypovolemic Shock

Acute Stress Disorder

Exposure to traumatic event; symptoms occur from 1 day to 1 month; numbing; detachment; amnesia

Vitamin C

Facilitates absorption of iron

A.) Individuals with avoidant personality disorder desire intimacy but fear it, and persons with schizoid personality disorder prefer to be alone.

Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing response? A.) Individuals with avoidant personality disorder desire intimacy but fear it, and persons with schizoid personality disorder prefer to be alone. B.) People with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, while persons with avoidant personality disorder are generally normal in appearance. C.) Persons with avoidant personality disorder are more eccentric, and those with schizoid personality disorder are dull and vacant. D.) Individuals with schizoid personality disorder have a history of psychotic thought processes, while persons with avoidant personality disorder remain based in reality.

Treatment for Prerenal AKI

Fluid challenge, diuretics, renal protection (hydrate, bicarbonate, mucomyst, stop nephrotoxic drugs); Treat low cardiac output (inotropes, afterload reduction, optimize pressures)

C.) Cough after swallowing to remove any food from the top of the vocal cords

Following a partial laryngectomy, the patient is taught how to use the supraglottic swallow to minimize aspiration. In teaching the patient this technique, the nurse instructs the patient to: A.) perform the valsalva maneuver immediately after swallowing B.) breathe deep while doing the valsalva maneuver. C.) cough after swallowing to remove any food from the top of the vocal cords. D.) practice by swallowing thin, watery liquids

Uremia

Full-blown manifestations of renal failure. Sometimes referred to as uremic syndrome, especially if cause of renal failure is unknown. Results from the accumulation of nitrogenous waste products in the blood, a result of renal failure. Manifestations include: anorexia, nausea/vomiting, muscle cramps, pruritus, fatigue and lethargy.

The patient's eyes are closed even if someone talks to them or pinches them. The patient answers questions correctly. The patient states that "his head hurts". When asked to open eyes, the patient refuses stating, "the light makes my eyes hurt really bad." The patient follows commands appropriately, but does not open eyes when doing so.

GCS - 12

B.) Autonomy

Group therapy is strongly encouraged by not mandatory for clients on an inpatient unit, therefore, clients can make a choice about whether or not to attend. The policy preserves what ethical principle? A.) Justice B.) Autonomy C.) Veracity D.) Beneficence

Serum calcium

Half of this exists in blood in its free form, while the other half exists in protein-bound form. Decreased in both AKI and CKD. Normal Values: 9.0-10.5 mg/dL Critical Values: <6.0 or >13 mg/dL

Causes of Increased ICP

Head trauma, cerebral edema, hemorrhage, hematoma, hydrocephalus, hypertension, tumors

C.) state law Pennsylvania Act 102

Health care providers are required to notify the organ procurement organization regarding potential donors because of: A.) increased black market organ sales B.) the establishment of brain death criteria C.) state law Pennsylvania Act 102 D.) federal government requires donation

Chelation therapy

Heavy metal treatment

Daily weights

Helps monitor fluid retention in patients with CKD & ascites.

Daily weight and abdominal girth

How will the nurse assess the progression of ascites?

Begins immediately, antibody-mediated response, cannot be stopped, organ must be removed immediately

Hyperacute rejection

Multiple Myeloma

Hypercalcemia can be a complication of this disease

A common risk factor for end stage kidney disease

Hypertension

Symptoms of Prerenal AKI

Hypovolemia: hypotension, oliguria, decreased cardiac output an central venous pressure, tachycardia Hypervolemia: SOB, jugular vein distention, weight gain, rales, edema, pulmonary edema

Massive loss of intravascular volume, decreased oxygenation and perfusion = organ failure, kidneys cannot secrete enough bicarb to compensate, so lactic acidosis occurs

Hypovolemic Shock

Treatment of NMS

ICU, stop antipsychotic medications immediately, cooling blankets, flush with cold IV fluids, antipyretics to help with fever, dantrolene (muscle relaxant), bromocriptine (anticholinergic)

Lactulose pulls ammonia from the bloodstream into the bowel and produces 2-3 soft stools per day.

Identify the medication that is used to treat hepatic encephalopathy. Explain the mechanism of action.

Infuse fluids, blood and clotting factors. Possibly insert an esophageal tamponade tube.

If GI bleeding occurs due to esophageal varices the nurse will expect to:

Cardiac monitoring

Important to watch in cases of tricyclic antidepressant overdose

Uremic frost

In CKD, this is left on the skin after sweating.

D.) restore the fluid volume

In acute pancreatitis, the first priority is to: A.) infuse IV nitroglycerin B.) titrate dietary protein intake C.) administer IV antibiotics D.) restore the fluid volume

C.) Tachycardia and hypertension

In addition to diaphoresis and tremors, which symptoms would the nurse expect to see as a client undergoes alcohol withdrawal? A.) Bradycardia and hypertension B.) Bradycardia and hypotension C.) Tachycardia and hypertension D.) Tachycardia and hypotension

Dopamine

In low doses, may be used to improve urine output

Respiratory muscles

In malnutrition, these lose strength and mass

A.) the tissue damage likely results from release of pancreatic enzymes

In pancreatitis: A.) the tissue damage likely results from release of pancreatic enzymes B.) high cholesterol intake is causative C.) diabetes is uncommon in chronic pancreatitis D.) bacterial infection is the etiological cause

D.) Ego Integrity vs. Despair

In planning a care plan for a senior citizen, which Erickson's developmental stage would be most appropriate for this client? A.) Generativity vs. Stagnation B.) Identity vs. Role Confusion C.) Intimacy vs. Isolation D.) Ego Integrity vs. Despair

B.) Serum ammonia

In reviewing the laboratory data of a client admitted with cirrhosis of the liver, which serum levels would one expect to be elevated? A.) Serum amylase and lipase B.) Serum ammonia C.) Serum CEA D.) Serum calcium

Hyperdynamic Phase

In this phase, you will see an increase in cardiac output with warm, flushed skin

Benzodiazepines (Alprazolam, lorazepam, clonazepam, diazepam, oxazepam, chlordiazepoxide)

Increase GABA, physically and psychologically addictive; for short term use only; withdrawal symptoms when meds are stopped abruptly;

Potassium Channel Blockers (Amiodarone, Dofetilide, Ibutilide)

Indications: Ventricular dysrhythmias, A-Fib / Flutter Action: Prolongs cardiac repolarization and lengthens refractory period in Phase 3; increases action potential duration; decreases contractility; decreases automaticity Effect on ECG: prolonged QT interval Chronotrope: (-) Dromotrope: (-) Inotrope: (-) Side Effects: QT prolongation, thyroid dysfunction, hepatotoxicity, pulmonary fibrosis, photosensitivity, visual changes, nausea

D.) symptom severity

Most commonly, the extent of the rejection process is determined by: A.) tissue biopsy B.) body temperature C.) weight changes D.) symptom severity

Obsessive-Compulsive Disorder (OCD)

Intrusive thoughts and ritualistic behaviors used to alleviate anxiety; creates humiliation and shame; drastically interferes with daily functioning

What are the nursing considerations before these treatments.

Labs are reviewed to determine which electrolytes need removal or replacement (potassium, calcium, CO2, BNP are the primary monitored values) The patient is weighed and assessed for signs and symptoms of fluid overload (crackles, edema, SOB) The access is assessed for signs and symptoms of infection and/or dysfunction.

Schizophrenia

Most debilitating mental illness

B.) False

Most depression is a reaction to loss or failure. A.) True B.) False

B.) Paranoid

James has been suspicious of other clients on the unit, is often angry at others' comments, and carries a grudge against his roommate because the roommate accidentally used James's bath towel yesterday. Which of the following personality disorders is most likely James's diagnosis? A.) Antisocial B.) Paranoid C.) Borderline D.) Histrionic

D.) 54%

Joe Firefighter has sustained burns to all surfaces of his chest, back, abdomen, and arms. What percentage of his total body surface has been burned? A.) 36% B.) 44% C.) 60% D.) 54%

A.) 10,800 mL/24 hr.; 675 mL/hr

Joe Firefighter has the burns described above. He weighs 110 lbs. Using the Parkland formula, how much fluid should Joe receive in the first 24 hours and what would his hourly rate be in the first 8 hours? A.) 10,800 mL/24 hr.; 675 mL/hr. B.) 5,400 mL/24 hr; 338 mL/hr. C.) 23,760 mL/24 hr.; 1485 mL/hr. D.) 11,880 mL/24 hr; 743 mL/hr.

Serum Phosphate (Phosphorus)

Levels are determined by calcium metabolism, parathyroid hormone, renal excretion and, to a lesser degree, intestinal absorption. Reduced excretion is an early effect of CKD. Increased in both AKI and CKD. Normal Values: 3.0-4.5 mg/dL Critical Values: < 1.0 mg/dL

Whole Bowel Irrigation

Most effective treatment for a "body packer" transporting illicit drugs

Localized infection = WBCs = cytokines = local inflammatory response = increased nutrients to infected tissues, duration is several days, response limited to affected area, no fever or tachycardia, decreased SpO2 or urine output

Local Infection

Positive Symptoms of Schizophrenia

Loose association, tangential speech, circumstantial speech, concrete speech, echolalia, clang associations, word salad, mutism, perseveration, catatonia

Typical Antipsychotic Medications

Loxapine, Trifluoperizine, Thiothixine, Haloperidol, Pimozide, Chlorpromazine, Fluphenazine, Mesoridizine, Perphenazine, Prochlorpramazine, Thioridazine

Treatment for Intrarenal AKI

Low-dose dopamine, calcium channel blockers, stop nephrotoxic drugs/contrast agents, plasmapheresis, treat blood pressure, surgery, diuretics

Multiple organ failure, uncontrolled bleeding, severe HYPODYNAMIC cardiac function, cellular ischemia = continuous capillary leakage and poor cardiac contractility, signs and symptoms resemble late stages of hypovolemic shock, death rate >50%

MODS (Septic Shock)

A.) dialysis

Magnesium levels in the chronic kidney disease patient are controlled by: A.) dialysis B.) dietary restriction C.) phosphate binders D.) milk of magnesia

2 or 3 medications at lower dosages (specific, less specific, corticosteroids), used indefinitely

Maintenance Immunosuppressants

Serum Sodium

Major cation in extracellular space. With acute renal failure, levels may be normal or decreased due to hemodilution from __________________ and water retention. Can be increased or decreased in both AKI and CKD. Normal Values: 135-145 mEq/L Critical Values: <120 or >160 mEq/L

Jejunal tube feeding

May be used for 24-48 hours at the onset of pancreatitis.

Oozing

May occur in late septic shock

Insulin, Ranitidine, and Heparin

Medications that can be added to parenteral nutrition.

Continuous drip method

Method of enteral feeding that is recommended for critically ill patients.

Ingestion Inhalation Absorption - Dermal - IV - Insufflation - Rectal - Intravaginal

Methods of Absorption of Substances

Stage II CKD - GFR 60-89

Mildly decreased GFR Nephron compensation Hypertension Stress of illness can compromise this stage fast Medical management very important Control of blood pressure and risk factors

Acute Tubular Necrosis (ATN)

Most common cause of intrarenal AKI

C.) Yes, because 3% saline needs to be given slowly.

Mr. H has tuberculosis, serum sodium is 121 mEq, he is also stuporous. The doctor's order indicates that the patient should receive 3% saline IV. The doctor orders that the saline solution should be run at 150 mL/hr. Would you question this order? A.) No, 3% saline is an isotonic solution. B.) No, you are going to give it through a filtered line C.) Yes, because 3% saline needs to be given slowly. D.) Yes, 3% saline is more likely to cause edema

B.) Binds with phosphorus to eliminate it from the body.

Mrs. L., a client with chronic kidney disease, asked you why she must continuously take aluminum hydroxide gel with her meals. What is the BEST rationale for this medication in Mrs. L's treatment? A.) This medication helps prevent ulcer formation B.) Binds with phosphorus to eliminate it from the body. C.) The medication helps to prevent constipation. D.) Binds with potassium to eliminate it from the body.

What are the nursing consideration after these treatments?

Needles are removed and most patients hold their sites for 10-15 minutes. Central venous catheters are dwelled with heparin or saline. Bandages are applied and removed within hours or by the next day. Post-vitals are obtained and an assessment is done. Weight is taken to determine if the "dry weight" was achieved.

Residual

Needs to be checked every 4-6 hours during tube feedings.

Feeding bag & tubing

Needs to be replaced every 24 hours

Stage I CKD - GFR 90+

Nephron compensation Stress of illness can compromise this stage fast Medical management very important Normal kidney function Control the blood pressure and risk factors

Glomerulus

Network of twisted capillaries that acts as a filter for the passage of protein; free and RBC-free filtrate to the proximal convoluted tubule

Decreased sympathetic and increased parasympathetic nervous system activation, decreased vascular motor tone = massive vasodilation, decreased venous return, decreased cardiac output, decreased tissue perfusion, occurs in injuries at T6 or above, BRADYCARDIA!!!!, hypotension, hypothermia

Neurogenic Shock

Causes of Postrenal AKI

Obstruction of Urine Flow Prostate: BPH, Cancer Bladder, urethral, ureteral, renal obstruction: clot, stones, stricture, cancer inside or outside of structure

C.) seizures

The nurse assesses the child exposed to high doses of lead for: A.) flushing B.) hypoglycemia C.) seizures D.) hypocalcemia

C.) chest tubes

On completion of open-heart surgery, the cardiac patient will most likely return to the postoperative setting with: A.) a permanent pacemaker B.) a Venti-mask C.) chest tubes D.) an intra-thoracic balloon pump

B.) Low fat, no alcohol or caffeine

On discharge, proper diet instruction includes: A.) Low salt, low sugar and no caffeine B.) Low fat, no alcohol or caffeine C.) No alcohol, caffeine, or sugar D.) Low protein and low carbohydrate

D.) Paranoid

On receiving a gift from another client, the second client thinks, "I wonder what he wants from me?" The nurse recognizes that this type of thinking may be associated with which personality disorder? A.) Schizotypal B.) Narcissistic C.) Avoidant D.) Paranoid

A.) corticosteroid boluses

One treatment for organ rejection is: A.) corticosteroid boluses B.) decreasing dosages of immunosuppressants C.) antibiotic therapy D.) histamine 2 receptor antagonists

Left lateral position

Optimal patient position during gastric lavage

Life expectancy less than one year, age generally less than 65, absence of active infection, stable psychosocial status, no evidence of drug or alcohol abuse

Organ Donation Recipient Requirements

Diffuse tissue hypoxia, cell death and organ dysfunction, widespread microthrombi = DIC (may use heparin to prevent DIC), increased capillary leakage, endothelial cell damage = more clotting, anaerobic metabolism, hyperglycemia, may present over 24 hours and may be missed, cardiac function = HYPERDYNAMIC phase to increase CO

Organ Failure (Severe Sepsis)

A.) Treating symptoms in a matter of fact manner.

Organic etiologies have been ruled out as a cause for a client's impairment to use his lower extremities. The client is admitted to the psychiatric unit with the diagnosis of conversion disorder. Which nursing care should be included for this client? A.) Treating symptoms in a matter of fact manner. B.) Challenging the validity of physical symptoms. C.) Promoting dependence until the physical limitations subside. D.) Encouraging a discussion of feelings about the lower extremity problem.

Empty containers

Providers should look for this when evaluating for suspected overdose

Oxygen

Used to treat carbon monoxide poisoning

Type I allergic reaction, antigen/antibody reaction, (allergen, IgE, basophils, mast cells = damages cells, histamine released, dilation and capillary leak, hypovolemia and vascular collapse), bronchial edema and obstruction

Patho for Anaphylactic Shock

Decreased heart pumping ability (CAD), inadequate O2 to cardiac muscles, decreased cardiac output, decreased tissue perfusion & BP, nonischemic, myocardial cell deficit, impaired contractility, decreased pumping ability

Patho for Cardiogenic Shock

Blood volume loss or shift, decreased intravascular volume, decreased ventricular filling pressures, decreased venous return, decreased preload, decreased stroke volume, decreased cardiac output, decreased BP / decreased MAP, decreased tissue perfusion, decreased oxygen and nutrients to cells

Patho for Hypovolemic Shock

Disruption of communication pathways between Upper Motor Neurons & Lower Motor Neurons, decreased SNS & PNS activation, reflex function is completely lost in all segments below the lesion, decreased vascular tone (decreased sympathetic nerve impulse control to blood vessels = massive vasodilation), decreased venous return, decreased cardiac output, decreased tissue perfusion

Patho for Neurogenic Shock

Nasogastric Tube (NGT)

People with this are at risk for hypovolemic shock

Esophageal speech

Patient must have good hearing to utilize this type of speech

GCS - 14

Patient's eyes are open and looking at you while you are examining them. Speech is clear, but confused. The patient does not know what happened to them and states the wrong month when asked the date. The patient is slow to follow commands when asked to show two fingers, but is still able to do so.

GCS - 15

Patient's eyes are open and the patient is speaking to you as you are examining them. The patient is speaking normally and answering questions appropriately. The patient is able to follow commands like "show me two fingers".

GCS - 3

Patient's eyes remain closed, even when pinched. The patient does not make any sounds, even if pinched, and he/she does not follow commands. Finally, the patient will not moved, even if pinched.

What are the difference among these types of dialysis?

Peritoneal - uses the highly vascular, semi-permeable peritoneal membrane; solution high in glucose instilled, wastes cross through membrane, left in until concentration on both sides is equal, and then drained; repeated over and over as prescribed by the nephrologist; can be done automatically overnight with a "cycler" Hemodialysis - blood is removed from the body and filtered through a man-made membrane called a dialyzer (or artificial kidney) and then the filtered blood is returned to the body; only one pint of blood is outside the body at any time.

B.) positioning joints with minimal flexion and support

Physical mobility in the burn client is best maintained by: A.) positioning joints in a flexed position with support B.) positioning joints with minimal flexion and support C.) ambulating the client when skin grafts are complete. D.) having the client wear elasticized garments during waking hours.

Exposure to elements that are harmful

Poisoning

A.) Primary prevention

Providing nursing education on drug abuse to a high school class is an example of which type of care? A.) Primary prevention B.) Secondary prevention C.) Tertiary prevention D.) Primary intervention

Sinus Tachycardia

Rate: greater than 100 Rthythm: Regular P-Wave: Present, upright PR: 0.12 - 0.20 seconds QRS: less than or equal to 0.12 seconds QT: 0.36 - 0.44 seconds Causes: Exercise, fear, stress, pain, anxiety, stimulants (alcohol, caffeine), hypovolemia, heart failure, severe dehydration, acute MI

Intermediate stage, MAP decreased by 20 mmHg, cell death and tissue damage occurring, arterial vasoconstriction, cold and clammy skin, severe changes in LOC, decreased urine output, narrowed pulse pressure

Progressive Stage of Shock

Less than 60 bpm

Rate associated with sinus bradycardia

Ventricular Tachycardia

Rate: 100-250 Rhythm: Atrial - N/A; Ventricular - Regular P-Waves: N/A PR: N/A QRS: greater than 0.12 seconds (wide / bizarre) QT: N/A Causes: myocardial infarction, hypoxia, electrolyte imbalances, cardiomegaly, myocarditis, valvular heart disease, anxiety, overexertion, underlying heart disease Treatment: cardioversion, defibrillation

Normal Sinus Rhythm

Rate: 60-100 Rhythm: Regular P-Waves: Present, Upright PR: 0.12-0.20 QRS: less than or equal to 0.12 seconds QT: 0.36 - 0.44 seconds

First-Degree Heart Block

Rate: 60-100 Rhythm: Regular P-Waves: Present, upright PR: greater than 0.20 seconds QRS: less than or equal to 0.12 seconds QT: 0.36 - 0.44 seconds Causes: may occur in patients with no heart history, or patients taking medications, such as beta blockers, calcium channel blockers, and digoxin. Treatment: None

Atrial Flutter

Rate: Atrial - 250-300; Ventricular - Variable Rhythm: Atrial - Regular; Ventricular - Regular or Irregular P-Waves: absent, replaced by F waves (sawtooth) PR: N/A QRS: less than or equal to 0.12 seconds QT: N/A Causes: Acute MI, hypoxia, digitalis poisoning, congestive heart failure, SA node disease, pulmonary embolism Treatment:

Atrial Fibrillation

Rate: Atrial - 350-400; Ventricular - Variable Rhythm: Irregularly Irregular P-Waves: Absent (replaced by F waves) PR: N/A QRS: less than or equal to 0.12 seconds QT: N/A Causes: underlying heart disease, congestive heart failure, rheumatic heart disease, acute MI, common electrolyte imbalances, hypoxia, myocardia ischemia, digitalis toxicity Treatment: Beta blockers, calcium channel blockers, Digoxin

Third-Degree (Complete) Heart Block

Rate: Atrial - 60-100; Ventricular - based on site of escape pacemaker Rhythm: Atrial - Regular; Ventricular - Regular P-Waves: No relationship with QRS PR: Variable QRS: Based on escape pacemaker QT: Causes: coronary ischemia, degenerative changes in electrical conduction system (with advanced age), acute myocarditis, myocardial infarction, drug toxicity Treatment: Pacemaker, atropine, pacing (transcutaneous / transvenous)

Ventricular Fibrillation

Rate: cannot be determined Rhythm: Irregular (coarse or fine) P-Waves: N/A PR: N/A QRS: N/A QT: N/A Causes: Acute MI, drug toxicity / overdose, hypoxia, coronary artery disease, cardiomyopathy Treatment: Defibrillation

Irreversible stage, cell death and tissue damage, death imminent, decreased cardiac output cerebral blood flow and acidosis, Multi-Organ Dysfunction Syndrome (MODS)

Refractory Stage of Shock

Tonsils, adenoids, and uvula

Removing this/these may help to prevent nighttime airway obstruction

Post-Traumatic Stress Disorder (PTSD)

Repeated re-experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others; any event that is outside the range of usual experience; symptoms often begin within three months of the trauma; intrusive thoughts/dreams

Used with signs and symptoms of rejection are occurring, dosages are adjusted or increased, antibodies and corticosteroids

Rescue Immunosuppressants

Sodium intake and fluids

Restricted based on weight gain, BP, and urine output in CKD patients.

Thrombotic Thrombocytopenia Purpura (TTP)

Results in pathological clotting

D.) Carry the number of a safe house for battered women.

Returning to work after three sick days, a married woman's facial bruises cannot be concealed by makeup. Her coworker recommends that she seek assistance from her employee assistance program. Which teaching should the nurse in the employee assistance program provide? A.) Buy a gun. B.) File for divorce. C.) Press charges for assault and battery. D.) Carry the number of a safe house for battered women.

Hypertension, elevated cholesterol, heart disease, osteoporosis, cancer, renal failure, diabetes mellitus, liver failure, infection

Risks of Immunosuppressant Therapy

Primary bloodstream infections (central line), pneumonia (related to mechanical ventilation or aspiration), urinary tract infections, surgical wound infections, immunosuppression, invasive procedures, transplant recipients

Septic Shock

A.) They have all experienced a recent loss.

Several clients in the inpatient psychiatric unit are experiencing depression. One client was recently laid off, another client's mother passed away last month, and a third client's girlfriend broke up with him. What do all of these depressed clients have in common? A.) They have all experienced a recent loss. B.) They have all chosen to come to the same hospital. C.) They have nothing in common. D.) They have all experienced a change in lifestyle.

A.) Increasing caffeine intake

Since starting college, a client has been irritable and on edge, and unrealistically worried about academic performance and interpersonal relationships. The client cannot sleep or concentrate due to worrying about the numerous assignments that are due over the course of the semester. Which component will the client's treatment plan not include? A.) Increasing caffeine intake B.) Engaging in physical activity three times per week C.) Practicing relaxation techniques D.) Identifying signs and symptoms of escalating anxiety

Hyperkalemia

Sodium Polystyrene Sulfate and Furosemide may be used to treat this life-threatening condition.

B.) Malabsorption

Steatorrhea occurs in pancreatitis because of: A.) an alcohol effect B.) Malabsorption C.) overabundance of pancreatic enzymes D.) a side effect of somatostatin

B.) Loss of purposeful movement

Studies indicate that acetylcholine is drastically reduced in individuals with Alzheimer's disease. Which cognitive deficit is primarily associated with this reduction? A.) Loss of memory B.) Loss of purposeful movement C.) Loss of sensory ability to recognize objects D.) Loss of language ability

A.) Safety and protection from self-harm

Susan has been admitted to the inpatient unit for treatment of her borderline personality disorder. Prior to admission, she was found in her parents' bedroom, burning herself with an iron. The injury required treatment in the burn unit before her transport to the Mental Health Unit. Which of the following is your highest nursing care priority for Susan during the first 24 hours of her admission? A.) Safety and protection from self-harm B.) Social conduct contract C.) Working on Susan's self-esteem D.) Impulse control

Pulmonary contusion

Suspect with flail chest

Pneumothorax

Suspect with splinted rib fracture

Cocaine - hypertension, tachycardia, tachypnea, restless, excess speech Cardiotoxic drugs

Sympathomimetic drugs

Infectious microorganism in bloodstream, usually increased WBC count, usually occurs with SIRS, HYPODYNAMIC STATE, short duration, procalcitonin levels increased

Systemic Infection (Early Sepsis)

D.) Delusions of reference

The nurse begins interviewing a client with paranoid schizophrenia. Which symptom is the nurse assessing when asking, "Do you receive special messages from certain sources, such as the television or radio?" A.) Thought insertion B.) Mind reading C.) Magical thinking D.) Delusions of reference

C.) alcoholism and gallstones

The 2 most common causes of pancreatitis in the U.S. are: A.) pregnancy and malnutrition B.) cystic fibrosis and infectious disease C.) alcoholism and gallstones D.) alcohol abuse and malnutrition

True

The PR interval in 1st degree heart block is greater than 0.20 seconds. True / False

C.) Ventricular depolarization

The QRS complex represents: A.) Atrial contraction B.) Atrial depolarization C.) Ventricular depolarization D.) Ventricular repolarization

B.) microcytic, hypochromic cells

The RBC indices for a patient with iron deficiency anemia would indicate: A.) macrocytic, hyperchromic cells B.) microcytic, hypochromic cells C.) normocytic, normochromic cells D.) microcytic, normochormic cells

A.) Every breath

The assist control (AC) mode of mechanical ventilation supports: A.) Every breath B.) Every other breath C.) Every fourth breath D.) Only spontaneous breaths.

A.) 1st degree AV block

The atrioventricular block occurring when the PR interval remains constantly elongated throughout the entire strip. A.) 1st degree AV block B.) Sinus bradycardia C.) Supraventricular Tachycardia D.) Complete heart block

Mean Arterial Pressure (MAP)

The average pressure in a patient's arteries during one cardiac cycle. Considered a better indicator of perfusion of vital organs than systolic blood pressure (SBP). Calculated by doubling diastolic pressure and adding the sum of the systolic blood pressure, then dividing by 3 Normal Range: 70-100 mmHg

Sickle Cell Anemia

The cells become misshapen when exposed to low oxygen conditions

C.) secrete enzymes, which digest food in the small intestine

The chief role played by the pancreas in digestion is to: A.) secrete insulin and glucagon B.) churn the food and bring it into contact with digestive enzymes C.) secrete enzymes, which digest food in the small intestine D.) assist in absorbing the digested foods.

D.) Check the client's oxygen saturation by pulse oximetry.

The client being mechanically ventilated has become more restless over the course of the shift. What is the best action? A.) Darken the room and ask visitors to leave. B.) Document the observation as the only action. C.) Administer a dose of pain medication or sedative. D.) Check the client's oxygen saturation by pulse oximetry.

C.) Have the client turn the head from side to side 90 degrees every hour while awake.

The client has a deep partial-thickness injury to the posterior neck. Which intervention should the nurse use during the acute phase to prevent contractures associated with this injury? A.) Place a towel roll under the client's neck or shoulder. B.) Keep the client in a supine position without pillows. C.) Have the client turn the head from side to side 90 degrees every hour while awake. D.) Keep the client in a semi-Fowler position and actively raise the arms about the head every hour while awake.

A.) Loss of capture

The client has an epicardial pacemaker. The nurse observes the presence of a pacing spike but no QRS complex on the client's ECG tracing. How does the nurse interpret the event? A.) Loss of capture B.) Ventricular fibrillation C.) Failure to sense D.) A normal tracing

B.) "I can understand that you are feeling depressed right now. It was a very difficult decision to make. I'll sit with you for a while."

The client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which of the following statements by the nurse conveys sympathy? A.) "I know you are feeling very depressed right now. I felt the same way when I decided to leave my husband. But I can tell you from personal experience, you are doing the right thing." B.) "I can understand that you are feeling depressed right now. It was a very difficult decision to make. I'll sit with you for a while." C.) "You seem depressed. It is a difficult decision you are making. Would you like to talk about it?" D.) "I know this is a difficult time for you. It might help you if you talked about your feelings."

Chelation therapy

Used to treat lead or iron poisoning

D.) Use a manual resuscitation bag to ventilate the client.

The client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic with the tracheostomy tube lying on his chest. What is the best fires immediate reaction? A.) Attempt to reinsert the tube, taking care to use the obturator. B.) Assess the client's breath sounds bilaterally. C.) Notify the physician. D.) Use a manual resuscitation bag to ventilate the client.

A.) "If I develop an infection, I should stop taking my corticosteroid."

The client is getting ready for discharge after a solid organ transplant. Which of the following statements made by the client alerts the nurse to the need for clarification of the post-transplant drug regimen? A.) "If I develop an infection, I should stop taking my corticosteroid." B.) "If I have tenderness over the area of the transplant, I will call the transplant team right away." C.) "I should avoid people who are ill or who have an infection because I am somewhat immunosuppressed now." D.) "I should mix my cyclosporine exactly the way I was taught because it won't work as well if I change my routine."

A.) A 75 pack-year smoking history

The client is suspected of having cancer of the head and neck. Which of the following personal data related by the client increases the risk for this type of cancer? A.) A 75 pack-year smoking history B.) Adult-onset diabetes mellitus C.) Surgery for colorectal cancer 7 years ago D.) Worked as an operating room nurse for 30 years

B.) Instruct the client to report reddened or irritated skin areas.

The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? A.) Discuss how to properly remove the insertion pins. B.) Instruct the client to report reddened or irritated skin areas. C.) Inform the client that the vest liner cannot be changed D.) Encourage the client to remain in the recliner as much as possible.

B.) "You feel this way because of your high hormone levels. The doctor can order an antianxiety drug for you."

The client with adrenal hyperfunction screams at her husband, bursts into tears and throws her water pitcher against the wall. She tells the nurse, "I feel like I am going crazy." What is the nurse's best response? A.) "I will tell your doctor to order a psychiatric consult for you." B.) "You feel this way because of your high hormone levels. The doctor can order an antianxiety drug for you." C.) "You feel this way because you are frightened about having a chronic disease. Would you like me to give you information about a support group?" D.) "You must learn to control your behavior. Because you are disturbing others, I am going to keep the door to your room closed and restrict your visitors."

A.) Central (neurogenic) diabetes insipidus

The client with diabetes insipidus responds to the administration of antidiuretic hormone (ADH). How should the nurse interpret the response? The disorder is: A.) central (neurogenic) diabetes insipidus B.) most likely nephrogenic diabetes insipidus. C.) likely to be drug-related diabetes insipidus D.) most likely a curable condition

A.) Avoid salt substitutes

The client with hyperaldosteronism is being treated with spironolactone therapy. What precautions should the nurse teach this client? A.) Avoid salt substitutes B.) Avoid adding salt to food. C.) Avoid excessive exposure to sunlight. D.) Avoid acetaminophen and acetaminophen containing products.

A.) The hypodynamic phase

The client with septic shock has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing? A.) The hypodynamic phase B.) The compensatory phase C.) The hyperdynamic phase D.) The progressive phase

C.) Institute bleeding precautions.

The client's platelet count is 30,000/mm3. What is the nurse's first best action? A.) Document the report as the only action B.) Administer oxygen by nasal cannula. C.) Institute bleeding precautions. D.) Notify the physician.

C.) Systemic gram-negative infection

The client, who is two weeks post-burn with a 40% deep partial thickness injury, still has open wounds. On taking the morning vital signs, the nurse fingds the client has a below-normal temperature, is hypotensive, and has diarrhea. To what problem should these findings alert the nurse? A.) The findings are expected and normal for clients during the acute phase of recovery B.) Systemic gram-positive infection C.) Systemic gram-negative infection D.) Systemic fungal infection

Azotemia

The collection of metabolic waste in the body

A.) Initial

The development of lactic acidosis occurs in which stage of shock? A.) Initial B.) Compensatory C.) Progressive D.) Refractory

C.) Neurotransmitters

The distraught parents of an adolescent escort their child to the emergency room because of disrespectful and bizarre behavior. The nurse expects that this behavior is due to a chemical imbalance. Which part of the nervous system contributes to the alteration of chemicals in the brain? A.) Dendrites B.) Axons C.) Neurotransmitters D.) Synapses

Atropine sulfate

The drug of choice for symptomatic bradycardia

D.) atropine

The drug of choice to treat organophosphate pesticide poisoning is: A.) insulin B.) hydralazine (Apresoline) C.) lorazepam (Ativan) D.) atropine

A.) "I am very sorry this happened to you." C.) "You are safe here." D.) "You are not to blame. It was not your fault." E.) "I am glad you are alive."

The emergency room nurse is caring for a rape victim. Which should the nurse communicate to the client? *Select all that apply.* A.) "I am very sorry this happened to you." B.) "You will feel better if you help the police catch your attacker." C.) "You are safe here." D.) "You are not to blame. It was not your fault." E.) "I am glad you are alive."

C.) ducts

The exocrine portion of the pancreas contains: A.) alpha cells B.) beta cells C.) ducts D.) islets of Langerhans

B.) "No, limiting fluid intake keeps the client's blood from becoming more dilute and causing other complications."

The family of a client with SIADH asks you if the water restriction is a punishment for the client's uncooperative behavior. What is your best response? A.) "No, limiting fluid decreases the risk of kidney failure." B.) "No, limiting fluid intake keeps the client's blood from becoming more dilute and causing other complications." C.) "No, limiting water intake prevents the client from losing too much fluid by vomiting." D.) "No, limiting fluid decreases the client's sense of thirst and prevents him from drinking fluids that contain excess sodium."

False

The first intervention for ventricular tachycardia is administering a beta blocking drug. True / False

B.) produce erythrocytes

The human adult liver *DOES NOT*: A.) store glycogen B.) produce erythrocytes C.) convert ammonia to urea D.) produce blood coagulation proteins

C.) "It is likely that my wife will have a recurrence of her illness at some time in her life."

The husband of a patient who is being discharged from an inpatient unit after her first manic episode would indicate understanding of the nature of bipolar disorder if he made which of these statements: A.) "Since my wife has the manic form of this illness, I don't have to worry about her becoming depressed." B.) "As long as my wife remains in therapy, she is not likely to have a recurrence of her illness." C.) "It is likely that my wife will have a recurrence of her illness at some time in her life." D.) "After my wife takes lithium for a few months and her moods are stabilized, she will be able to discontinue the medication."

40; 60

The inherent pacing of the AV node is _________ to ___________ bpm.

BUN

The liver forms urea, a nitrogen containing compound, when protein is broken down. Thus a product of protein metabolism. Levels can vary based on protein intake. Provides valuable information on hydration status, as well as kidney function. Changes to expansion of plasma volume or dehydration will affect levels. Indirect measurement of renal function and GFR. Increased in both AKI and CKD. Normal values: 10-20 mg/dL Critical Values: >100 mg/dL

D.) esophageal bleeding

The most common manifestation of portal hypertension is: A.) rectal bleeding B.) cirrhosis C.) intestinal bleeding D.) esophageal bleeding

D.) Iron Deficiency Anemia

The most common type of anemia worldwide is: A.) Aplastic anemia B.) B12 Deficiency anemia C.) Folic Acid deficiency anemia D.) Iron deficiency anemia

D.) Sotalol

The most likely cause of a bradycardic rhythm is: A.) Sympathetic stimulation B.) Adenosine C.) Caffeine D.) Sotalol

A.) Childhood-onset conduct disorder is more severe than adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood.

The mother of an adolescent with conduct disorder says, "Oh, fighting and stealing - yeah, he's always been this way. Inf fact, when he was 8 years old, he was already in trouble with the law." Which factor regarding the adolescent's behavior does the nurse recognize? A.) Childhood-onset conduct disorder is more severe than adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. B.) Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. C.) Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 8 years, so the client is more likely to improve. D.) Childhood-onset conduct disorder has no treatment or cure, and children with this diagnosis should be removed from society, because they are likely to develop antisocial personality disorder.

B.) Partial-thickness superficial

The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A.) Superficial B.) Partial-thickness superficial C.) Partial-thickness deep D.) Full thickness

C.) The client is having difficulty forming words.

The nurse documents that a client diagnosed with Alzheimer's disease presents with aphasia. Which behavior supports this finding? A.) The client is sad and has no ability to experience pleasure. B.) The client is extremely emaciated and appears to be wasting away. C.) The client is having difficulty forming words. D.) The client is no longer able to speak.

A.) Hypokalemia

The nurse has administered Lactulose to a client with cirrhosis. The following day, the client reports having severe loose stools in the past 12 hours. What alteration in laboratory data would you expect to be present in this client as a result? A.) Hypokalemia B.) Hyponatremia C.) Hypercalcemia D.) Hyperglycemia

A.) Recognize signs of escalating anxiety. C.) Utilize relaxation techniques to limit anxiety. D.) Maintain anxiety at a manageable level without the use of medications E.) Discuss plans to handle panic attacks if they occur.

The nurse has been caring for a client with generalized anxiety disorder. Which client outcomes would signal the nurse that the care has been effective? (Select all that apply.) A.) Recognize signs of escalating anxiety. B.) Avoid any situation that causes stress. C.) Utilize relaxation techniques to limit anxiety. D.) Maintain anxiety at a manageable level without the use of medications E.) Discuss plans to handle panic attacks if they occur.

A.) Check cuff pressure/pilot balloon.

The nurse hears a whooshing sound around the endotracheal tube after the low pressure alarm sounds for a patient who is receiving mechanical ventilation. Which of the following actions should the nurse take next? A.) Check cuff pressure/pilot balloon. B.) Suction the airway. C.) Check tube placement. D.) Check for a kink in the ventilator tubing.

A.) Monitor the pulse oximetry reading. C.) Encourage coughing and deep breathing. D.) Assess for autonomic dysreflexia E.) Administer intravenous corticosteroids.

The nurse in the neuro intensive care unit is caring for a client with a new C6 SCI whi is breathing independently. Which nursing interventions should be implemented? Select all that apply. A.) Monitor the pulse oximetry reading. B.) Provide pureed foods six (6) times a day. C.) Encourage coughing and deep breathing. D.) Assess for autonomic dysreflexia E.) Administer intravenous corticosteroids.

D.) "In my dreams, all I can see are the wounded reaching out and trying to grab me."

The nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse suspects that the client is suffering from post-traumatic stress disorder when the client states: A.) "I check any room I enter because the enemy is still after me and could be hiding anywhere." B.) "My child was born with a birth defect; I believe that it is due to an exposure I had overseas." C.) "I killed four enemy soldiers with my bare hands and saved my entire battalion." D.) "In my dreams, all I can see are the wounded reaching out and trying to grab me."

B.) increased blood viscosity

The nurse is caring for a client with a diagnosis of Polycythemia Vera. The client asks, "Why do I have an increased risk of having a stroke or heart attack?" The nurse's best response is, "This is normal due to: A.) elevated blood pressure B.) increased blood viscosity C.) elevated platelet count D.) immaturity of red blood cells

C.) Document the findings in the client's chart.

The nurse is caring for a client with a temporary pacemaker. The client's bedside monitor shows a spike followed by a QRS complex. What is the nurse's best action? A.) Remove the pacemaker; it is not needed. B.) Decrease the threshold of the pacemaker. C.) Document the finding in the client's chart. D.) Set the pacemaker to the synchronous mode.

A.) Personality traits are deeply ingrained and difficult to modify. C.) Use of manipulation by the clients make treatment difficult. D.) Poor impulse control hinders compliance with plan of care. E.) Secondary diagnoses of substance abuse and depression are common.

The nurse is caring for a group of clients with antisocial and borderline personality disorders. Which factor(s) must the nurse consider when planning care for these clients? Select all that apply. A.) Personality traits are deeply ingrained and difficult to modify. B.) Medications are available to effectively treat these personality disorders. C.) Use of manipulation by the clients make treatment difficult. D.) Poor impulse control hinders compliance with plan of care. E.) Secondary diagnoses of substance abuse and depression are common.

B.) Monitor blood pressure.

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? A.) Maintain body temperature. B.) Monitor blood pressure. C.) Pad all bony prominences. D.) Use proper handwashing.

D.) Tension pneumothorax

The nurse is caring for a patient on mechanical ventilation with 10 cm/H2O of positive end expiratory pressure (PEEP). The patient suddenly becomes dyspneic. The trachea is deviated to the left and breath sounds are absent on the right. The nurse suspects which of the following complications? A.) Atelectasis B.) Pulmonary edema C.) Right mainstem intubation D.) Tension pneumothorax

B.) Contact the nurse if having suicidal thoughts

The nurse is developing a "no suicide" (safety) contract with a severely depressed patient. It is essential for the contract (verbal or written) to specify that the patient will: A.) Refrain from having suicidal thoughts B.) Contact the nurse if having suicidal thoughts C.) Write down any suicidal plans in a journal. D.) Focus on cheerful thoughts rather than suicidal thoughts

B.) The client is in denial about the problem.

The nurse is obtaining an admission history from a patient who has been abusing drugs and alcohol for years, lost his job several months ago. His wife recently left him and is now living with their two children at her parents' house. He tells the nurse, "I wouldn't use drugs and booze if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How would the nurse interpret this statement? A.) This is a dysfunctional family. B.) The client is in denial about the problem. C.) The client is under a lot of stress. D.) The prognosis for recovery is slim.

Risk for bleeding Potential for Infection Activity Intolerance

The nurse is providing care to a patient with splenomegaly; identify 2 nursing diagnoses:

A.) "Do not eat foots containing tyramine while taking the medication."

The nurse is providing discharge instructions to a client taking a benzodiazepine. All of the following instructions apply except: A.) "Do not eat foods containing tyramine while taking the medication." B.) "Do not stop taking this medication abruptly because serious complications may arise." C.) "Do not use this medication in combination with alcohol or any other central nervous system depressant." D.) "Take only the dose your doctor has prescribed and for the period of time the doctor has indicated because addiction can occur."

D.) Muffled heart sounds

The nurse is recovering a client after insertion of an implantable cardioverter-defibrillator (ICD). What complication must the nurse intervene for immediately? A.) 2/4 bilateral peripheral edema B.) Heart rate of 56 beats/minute C.) Temperature of 96 F D.) Muffled heart sounds

C.) light blue discoloration around the umbilicus

The nurse noting Cullen's sign in a patient with acute pancreatitis would observe: A.) blue ecchymosis on bilateral flank areas B.) deep purple dilated veins in the abdomen C.) light blue discoloration around the umbilicus D.) split and brittle finger and toe nails

D.) injury to the alveolar-capillary membrane

The nurse recognizes that the primary pathophysiologic alteration that initiates the pulmonary changes that occur in ARDS is: A.) remodeling of the lung by fibrous tissue B.) increased production of surfactant C.) capillary damage from pulmonary hypertension D.) injury to the alveolar-capillary membrane

C.) decreased tissue oxygenation

The nurse recognizes that the trigger for erythropoiesis is: A.) decreased iron B.) increased hematocrit C.) decreased tissue oxygenation D.) decreased hemoglobin

A.) Identifying limits in a clear manner without apologizing

The nurse sets limits in a therapeutic manner by doing which of the following? A.) Identifying limits in a clear manner without apologizing B.) Negotiating limits appropriate for the individual patient C.) Providing various reasons that limits are important D.) Substituting persuasive statements for specific limits

A.) A decreased level of consciousness with intermittent hypervigilance

The nurse suspects a client is experiencing delirium. Which specific assessment information would support this suspicion? A.) A decreased level of consciousness with intermittent hypervigilance B.) Oriented to time and place with no wandering C.) Onset is insidious and relentless D.) The symptoms last for 1 month or longer.

B.) Tuberculosis

The nurse understands that which disease has recently become more prevalent among the homeless community? A.) Meningitis B.) Tuberculosis C.) Encephalopathy D.) Mononucleosis

C.) low white cells, low red cells, and low platelets

The nurse would expect which of the following lab values for a client with aplastic anemia: A.) high white cells, low red cells, and low platelets B.) low white cells, high red cells, and low platelets C.) low white cells, low red cells, and low platelets D.) high white cells, low red cells and high platelets

C.) Jaundice

The nurse would identify which of the following signs when assessing the client with hemolytic anemia? A.) Red facial complexion B.) Red swollen tongue C.) Jaundice D.) Angular stomatitis

A.) An acutely suicidal teenager

The nurse would not recommend a structured day program setting for which client? A.) An acutely suicidal teenager B.) A chronically mentally ill woman who has a history of medication noncompliance C.) A socially isolated elderly individual D.) A depressed individual who is able to contract for safety

True

The pain of acute pancreatitis is often described as intense, piercing, and continuous.

C.) is a gland with its duct ultimately opening into the duodenum.

The pancreas: A.) lies mostly on the left side of the abdominal cavity, anteriorly to the stomach and the spleen B.) secretes all of its products directly into the bloodstream. C.) is a gland with its duct ultimately opening into the duodenum D.) contains cells with endocrine function for the determination of secondary sex characteristics. E.) is classified as a digestive exocrine gland, not having endocrine functions.

D.) the autodigestion of the pancreas caused by its enzymes

The pathophysiology of pancreatitis is: A.) a severe inflammatory response to endotoxins B.) overproduction of vasoactive enzymes from the acinar cells C.) overwhelming infection of the pancreatic ducts D.) the autodigestion of the pancreas caused by its enzymes

GCS - 9

The patient has their eyes closed at first, but opens them if their name is called loudly. The patient does not say any recognizable words. When asked a question, the patient looks confused and says, "mmm?" without opening their mouth. The patient does not follow commands, but if pinched, they pull away.

C.) Splitting

The patient with a borderline personality disorder tells the nurse that he is the best nurse in the hospital, until the nurse sets limits on client behavior. Then the patient complains the nurse is cruel and a "poor excuse for a person." The nurse interprets the behavior as a demonstration of: A.) Denial B.) Rationalization C.) Splitting D.) Projection

GCS - 10

The patient's eyes remain closed, even if someone calls loudly. However, the patient will open eyes if pinched. The patient states "don't" or "stop" when pinched, but does not speak in whole sentences and does not answer any questions. The patient does not follow any commands, but if pinched, will quickly push the nurse's hand away.

GCS - 8

The patient's eyes remain closed, even when pinched. He/she groans in response to being pinched, but does not say any recognizable words. The patient does not follow any commands, but if pinched will try to push the nurse's hand away.

GCS - 11

The patient's eyes will open and will be looking around with an anxious expression on their face. The patient will not answer any questions at all. If pinched the patient will groan, but does not say any recognizable words. The patient does not follow any commands, but if pinched will quickly push the nurse's hand away.

B.) Give the medication after the child has breakfast.

The physician orders methylphenidate (Ritalin) for a child with the diagnosis of attention deficit hyperactivity disorder. Which teaching should the nurse provide to the parent? A.) Double the next dose if one dose is missed. B.) Give the medication after the child has breakfast. C.) Administer the medication just before going to bed. D.) Crush the medication before putting it in applesauce.

C.) Jejunostomy tube

The preferable route for early nutrition in acute pancreatitis is: A.) mouth B.) nasogastric tube C.) Jejunostomy tube D.) IV line (TPN)

Central Venous Pressure (CVP)

The pressure recorded form the right atrium, is representative of the filling pressure of the right side of the heart Normal Range: 0-6 mmHg Elevated CVP: right ventricular failure, tricuspid stenosis or regurgitation, pericardial effusion, constrictive pericarditis, fluid overload, high PEEP settings.

A.) Relieve pain and decrease myocardial oxygen demand.

The primary purpose of administering morphine sulfate to the cardiogenic shock patient is to: A.) Relieve pain and decrease myocardial oxygen demand. B.) Increase preload and afterload to the heart. C.) Relieve anxiety by calming the patient. D.) Relieve pain by decreasing shortness of breath.

1.3-1.5g/kg of ideal body weight

The recommendations for protein intake for the critically ill patient.

A.) air that is not involved in alveolar gas exchange.

The term "dead space" refers to: A.) air that is not involved in alveolar gas exchange B.) the total lung capacity minus the tidal volume C.) the tendency of the alveoli to collapse. D.) the amount of air inhaled with each breath.

A.) Positive inotropes B.) IABP D.) Diuretics

The treatment for cardiogenic shock includes: (Select all that apply.) A.) Positive inotropes B.) IABP C.) IV fluid bolus D.) Diuretics

B.) "Eating disorders have been correlated to certain familial patterns; without addressing these, her disorder is likely to continue."

The treatment team working with a teenage client with anorexia calls for a family meeting. The client's mother inquires of the nurse, "What is it that you want to ask us? My daughter's problem has now become the family's problem. We are tired of dealing with her issues." Which is the appropriate nursing response? A.) "Don't be so defensive. Every client is required to participate in two family sessions." B.) "Eating disorders have been correlated to certain familial patterns; without addressing these, her disorder is likely to continue." C.) "Family dynamics are not at all linked to eating disorders. The meeting is to provide her with love and support." D.) "Anorexic individuals cause disruptions in the family system that need to be addressed."

Age and weight

This patient information is important with respect to the effect of what was ingested

Convalescent

This phase can last up to 12 months and may or may not see total restoration of baseline kidney function.

Injury

This stage of kidney disease examines creatinine, GFR and urine output

CT Scan

This test is usually done without contrast to evaluate for obstruction or hydronephrosis

CRRT

This type of dialysis is used to filter toxins without concerns of removing fluid

Preload

To Decrease: venous vasodilators (Morphine, Nitroglycerine), diuretics, ACE inhibitors, ARBs To Increase: Crystalloids (NS, LR), Colloids (Albumin, Blood, Blood Products), vasopressors

D.) avoid taking medications in front of children.

To avoid accidental poisoning: A.) store medication in unlabeled containers, in locked cabinets, out of reach of children. B.) only share prescription medication with your immediate family. C.) close all doors and windows before spraying cleaners in enclosed space to decrease airflow out of the room. D.) avoid taking medications in front of children.

D.) Pulmonary artery catheter

To monitor mixed venous oxygen levels, which one of the following is needed? A.) Arterial line B.) Angioplasty C.) Electrocardiographic monitor D.) Pulmonary artery catheter

Stent attaches portal to hepatic vein, directs to IVC. Increases risk of hepatic encephalopathy.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) How is the procedure performed? The procedure puts the patient at greater risk for:

Airway management, EPINEPHRINE, IV fluids, Diphenhydramine (H1 blocker), H2 antagonist (Zantac), hydrocortisone / methylprednisolone, albuterol nebulizer

Treatment for Anaphylactic Shock

Oxygen or ventilation support, positive inotropes (Digoxin), vasopressors (nitrates), vasodilators (decrease preload), diuretics, IABP (decrease afterload), PTCA / Revascularization, LVAD

Treatment for Cardiogenic Shock

Restore Volume: control bleeding, warmed crystalloids, dextran, transfusions Prevent Complications of Ischemia: supplemental oxygen, mechanical ventilation Monitor: VS, hemodynamics, I&O, Labs

Treatment for Hypovolemic Shock

Spinal immobilization, IV fluids, OXYGEN THERAPY, vasoactive medications, atropine / pacemaker, high-dose methylprednisolone, elastic pressure stockings, elevate foot of bed, temperature regulation

Treatment for Neurogenic Shock

Oxygen Therapy (mechanical ventilation), drug therapy (increase CO, restore intravascular volume, treat sepsis/adrenal insufficiency/hyperglycemia/clotting problems), antibiotics, low-dose corticosteroids, insulin therapy, heparin therapy, synthetic activated protein C, blood products

Treatment for Septic Shock

High flow oxygen. If COHgb level >25% - hyperbaric oxygen

Treatment of CO2 poisoning

Sepsis Resuscitation Bundle - serum lactate levels, broad spectrum antibiotics AFTER CULTURES ARE DRAWN, IV crystalloids or colloids, IV vasopressors Sepsis Management Bundle - low dose steroids, insulin drip, mechanical ventilation SEPSIS IS A RAPIDLY PROGRESSING EMERGENCY!!!

Treatment of Septic Shock

D.) Notify the physician.

Two hours after the client with an endotracheal tube has been extubated, the nurse hears stridor on inspiration. Which is the best first action? A.) Document the observation as the only action. B.) As the client to cough and deep breathe. C.) Suction the client's mouth and pharynx. D.) Notify the physician.

The patient may have enough energy to formulate and carry out a suicide plan.

Two to three weeks after beginning an antidepressant is a period of risk for the suicidal patient. Discuss why this is so.

Head trauma Cerebrovascular accident Non-metastatic brain tumor Conditions causing cerebral anoxia - drowning - smoke inhalation - prolonged cardiac arrest

Types of Injuries Resulting in Brain Death

D.) the patient is positioned laterally with the HOB flat.

Upon entering the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection, a nurse should recognize a need to intervene when finding: A.) the NG tube is clamped. B.) there are blood-tinged secretions being coughed up from the tracheostomy. C.) 50 mL of serosanguinous drainage in the patient's JP drain. D.) the patient is positioned laterally with the HOB flat.

This syndrome typically occurs when the BUN is greater than 100

Uremic Syndrome

Urine Alkalization

Used for the elimination of salicylates

Metabolic cart

Used to determine energy intake.

Heparin

Used to prevent clotting in the hyperdynamic phase of septic shock

Intrarenal

Vasculitis Exposure to nephrotoxins Renal artery stenosis or thrombosis

C.) Increase the vigilance regarding the client's suicidal precautions.

When antidepressant therapy begins to take effect for a severely depressed, suicidal client, the nurse finds that the client's mood improves and the client is much more communicative. Which nursing action is imperative at this time? A.) Allow the client to have unsupervised passes to his or her home. B.) Encourage the client to participate in group activities. C.) Increase the vigilance regarding the client's suicidal precautions. D.) Recognize that the client's suicidal potential has decreased.

C.) Dorso-cervical adipose tissue

When assessing a client with Cushing's disease, the nurse would expect to find: A.) Hypotension B.) Thick, coarse hair C.) Dorso-cervical adipose tissue D.) Weight gain in arms & legs

D.) Assess airway and breathing.

When caring for a client showing signs and symptoms of shock, the nurse would do which of the following? A.) Obtain intravenous access and hang fluid. B.) Obtain vital signs including oximetry. C.) Assess neurological status and pupil size. D.) Assess airway and breathing.

B.) Irregular atrial and ventricular rhythms C.) PR interval between 0.12 & 0.20 seconds E.) Wide and bizarre QRS complex

What are the characteristics of a PVC? Select all that apply. A.) Atrial rate below 60 bpm. B.) Irregular atrial and ventricular rhythms C.) PR interval between 0.12 & 0.20 seconds D.) PR interval greater than 0.20 seconds E.) Wide and bizarre QRS complex F.) QT interval within normal limits

D.) PR interval greater than 0.20 seconds F.) QT interval within normal limits

What are the characteristics present in first degree AV block? Select all that apply. A.) Atrial rate below 60 bpm. B.) Irregular atrial and ventricular rhythms C.) PR interval between 0.12 & 0.20 seconds D.) PR interval greater than 0.20 seconds E.) Wide and bizarre QRS complex F.) QT interval within normal limits

ALT 8-20 U/L AST 5-40U/L

What are the two lab tests that are initially elevated in hepatic failure and what are the normal values?

C.) Hypotension, tachycardia & decreased CVP

What assessment findings in a post open-heart surgery client indicates to the nurse that the client may be bleeding internally? A.) Hypertension, tachycardia & decreased CVP B.) Hypertension, bradycardia & increased CVP C.) Hypotension, tachycardia & decreased CVP D.) Hypotension, bradycardia & increased CVP

Excessive serum ammonia

What causes hepatic encephalopathy?

C.) Autoimmune Thrombocytopenia Purpura (ATP)

What condition causes circulating platelets to decrease but production of platelets remain normal? A.) Thrombotic Thrombocytopenia Purpura (TTP) B.) Disseminated Intravascular Coagulation (DIC) C.) Autoimmune Thrombocytopenia Purpura (ATP) D.) Non-Hodgkin's lymphoma

C.) Release of glycogen

What function of carbohydrate metabolism does the liver carry out in response to increased energy requirements? A.) Storage of fatty acids and triglycerides B.) Activation of Kupffer cells C.) Release of glycogen D.) Removal of ammonia

C.) It increases.

What happens to the PaCO2 in hypovolemic shock? A.) It remains the same. B.) It decreases. C.) It increases.

C.) Allograft

What is a biological dressing called that uses skin from a cadaver provided by a skin bank? A.) Heterograft B.) Xenograft C.) Allograft D.) Autograft

D.) repeated arousal causes increased catecholamines

What is the pathophysiology for hypertension related to sleep apnea? A.) daytime drowsiness causes increased stress which increases SVR B.) poor sleep diminishes melatonin C.) morbid obesity contributes to vascular plaque D.) repeated arousal causes increased catecholamines

D.) Acute pain

What is the priority nursing diagnosis for acute pancreatitis? A.) Risk for fluid volume overload B.) Nausea C.) Risk for infection D.) Acute pain

A.) Control the client's maladaptive behaviors.

What is the purpose for behavioral modification programs designed for clients with eating disorders? A.) Control the client's maladaptive behaviors. B.) Ignore the client's maladaptive behaviors. C.) Focus on adaptive behaviors. D.) Provide control to the client.

Vasopressin

What medication will decrease portal pressure and control bleeding of esophageal varices?

A.) The high acidity of emesis

What rationale explains why inspection of the teeth and gums of a client with bulimia will most likely reveal deterioration? A.) The high acidity of emesis B.) A lack of dietary calcium C.) Rapid ingestion of good without proper mastication D.) Poor dental and oral hygiene

A.) Depressed mood B.) Fatigue E.) Loss of interest in pleasurable activities

What symptoms are correlated to with decreased thyroid-stimulating hormone (TSH)? Select all that apply. A.) Depressed mood B.) Fatigue C.) Increased libido D.) Mania E.) Loss of interest in pleasurable activities

D.) Obsessive-compulsive

When a nurse tells a client that the nursing staff will start alternating weekend shifts, the client responds, "We can't make these kinds of changes! Who do you think you are? We've always done it this way, and we will continue to do it this way!" Which personality disorder does the nurse recognize? A.) Dependent B.) Histrionic C.) Passive-aggressive D.) Obsessive-compulsive

A.) How close should I sit to the client? B.) In addition to the client, who else should be present for the interview? C.) How will I need to adjust my communication patterns to accommodate this patient? D.) How much eye contact should I have with this client and his family? E.) Should I shake hands with the client and his family?

When interviewing a client from a different culture which questions are important to consider? Select all that apply. A.) How close should I sit to the client? B.) In addition to the client, who else should be present for the interview? C.) How will I need to adjust my communication patterns to accommodate this client? D.) How much eye contact should I have with this client and his family? E.) Should I shake hands with the client and his family? F.) Should I use the family member as an interpreter if language is a barrier?

A.) Cardiac index B.) Pulmonary capillary wedge pressure C.) Urinary output

When monitoring for the effectiveness of treatment for a patient with left ventricular failure, the most important information for the nurse to obtain is: (Select all that apply.) A.) Cardiac index B.) Pulmonary capillary wedge pressure C.) Urinary output D.) Right atrial pressure

B.) Exhibiting suspicious behavior

When orienting a client with paranoid personality disorder to the unit, which client behavior should the nurse anticipate? A.) Display of impulsive acts B.) Exhibiting suspicious behavior C.) Experiencing auditory hallucinations D.) Utilizing engaging social skills

D.) Mucociliary clearance

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60 pack year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defense because of its impairment of which of the following? A.) Reflexive bronchoconstriction B.) Ability to filter particles from the air C.) Stimulation of the cough reflex D.) Mucociliary clearance

A.) It often takes several attempts before a woman leaves an abusive situation. B.) Substance abuse is a common factor in abusive relationships. D.) Women in abusive relationships usually feel isolated and without support.

When planning care for a woman who has been abused, which factors should the nurse recognize? *Select all that apply.* A.) It often takes several attempts before a woman leaves an abusive situation. B.) Substance abuse is a common factor in abusive relationships. C.) Until children reach school age, they are usually not affected by abuse between their parents. D.) Women in abusive relationships usually feel isolated and without support. E.) Economic factors rarely play a role in the decision to stay.

Blood cultures

When sepsis is suspected, should be done before giving antibiotics.

B.) geniuneness

When there is congruence between what the nurse is feeling and what is being expressed, the nurse is conveying: A.) respect B.) genuineness C.) sympathy D.) rapport

A.) Behavior modification B.) Family therapy C.) Psychopharmacology D.) Group therapy

Which are interventions used in the management of children with ADHD? (Select all that apply.) A.) Behavior modification B.) Family therapy C.) Psychopharmacology D.) Group therapy E.) Antianxiety medication

D.) Palpating the abdomen

Which assessment maneuver should the nurse avoid performing with the client suspect of having a pheochromocytoma? A.) Having the client attempt to touch the chin to the chest. B.) Inflating the blood pressure cuff above 200 mmHg C.) Attempting to dorsiflex the foot D.) Palpating the abdomen

D.) Threatening to commit suicide or kill others.

Which client scenario would allow a state to commit a mentally ill citizen? A.) Living under a bridge in a cardboard box. B.) Eating food scraps out of a garbage can. C.) Neglecting to bathe. D.) Threatening to commit suicide or kill others.

B.) A client with unstable angina and inoperable CAD.

Which client would most likely benefit from a transmyocardial laser revascularization? A.) A client who requires bypass with synthetic grafts. B.) A client with unstable angina and inoperable CAD. C.) A client with a lesion of the left anterior descending artery. D.) A client with a discrete, proximal, single vessel, non-calcified lesion

C.) Scar tissue formation

Which clinical manifestation is indicative of wound healing in the acute burn phase? A.) Increased wound drainage B.) Dry, pale wound bed C.) Scar tissue formation D.) Sloughing of the eschar

A.) Poverty B.) Deinstitutionalization C.) Fragmented health care system D.) Addiction

Which condition(s) led to the increase in the number of homeless individuals in our society? (Select all that apply.) A.) Poverty B.) Deinstitutionalization C.) Fragmented health care system D.) Addiction E.) Terrorism

D.) Serum lipase

Which diagnostic test is the most specific in verifying a diagnosis of acute pancreatitis? A.) Alkaline phosphatase B.) Serum alcohol C.) Alanine aminotransferase D.) Serum lipase

D.) Keep the environment humid to prevent the stoma from drying.

Which factor is most important to teach a client regarding the proper care of a laryngectomy patient's stoma? A.) Use a warm moist heating pad over the stoma to loosen dry skin. B.) You can continue to swim since you mention this is your favorite sport. C.) Dry scabs on your stoma are expected and can easily be removed with tweezers. D.) Keep the environment humid to prevent the stoma from drying.

C.) Reliability, honesty, and consistency

Which factor should be recognized as influential in establishing a trusting relationship with a client who has schizophrenia? A.) Prolonged and irregular interpersonal contact B.) Self-disclosure of the nurse's mental struggles C.) Reliability, honesty and consistency D.) The reassuring use of touch

D.) Professional inadequacy

Which feelings do nurses who provide care for the chronic suicidal client often experience? A.) Countertransference from the client B.) Assertive behavior from the client C.) Despair and jubilation D.) Professional inadequacy

A.) Prolonged bleeding after IM injections.

Which hematologic problem would the nurse expect the client with liver failure to have? A.) Prolonged bleeding after IM injections B.) Elevated blood pressure from hypercellularity C.) Increased formation of thromboses in deep veins D.) Spontaneous bleeding from the gums and mucous membranes

C.) Initiating pancreatic enzyme therapy

Which intervention would be *inappropriate* in acute pancreatitis? A.) Keeping the patient NPO B.) Starting an IV of NS and electrolytes at 100 mL/hr per MD orders. C.) Initiating pancreatic enzyme therapy D.) Monitoring amylase and lipase levels

C.) Psychoanalytic psychotherapy

Which is not an integral part of a rehabilitative program for clients with schizophrenia? A.) Teaching clients to identify and manage their symptoms B.) Medication management C.) Psychoanalytic psychotherapy D.) Supportive family therapy

A.) Risk for injury

Which is the priority nursing diagnosis for an individual experiencing alcohol withdrawal? A.) Risk for injury B.) Impaired thought C.) Ineffective Coping D.) Ineffective Denial

B.) Interpersonal relationships tend to be shallow and fleeting, serving the dependency needs of the disordered individual.

Which is true about the quality of relationships a client with histrionic personality disorder may have? A.) Because of their dramatic style, interpersonal relationships tend to be quite interesting and fulfilling for those involved. B.) Interpersonal relationships tend to be shallow and fleeting, serving the dependency needs of the disordered individual. C.) Individuals with histrionic personality disorder tend to have few, if any, friends or acquaintances. D.) Histrionic individuals want to develop deep, nurturing relationships.

E.) gallstone duct obstruction

Which most often causes biliary cirrhosis? A.) malnutrition B.) alcoholism C.) hepatitis A or C D.) autoimmunity E.) gallstone duct obstruction

A.) Convey acceptance of the client

Which nursing action is appropriate when caring for a middle-aged client who acknowledges noncompliance and demonstrates bizarre behaviors, neologism, and thought insertion? A.) Convey acceptance of the client B.) Spend time focusing on thought insertion C.) Ignore the behaviors D.) Assist with identification of target symptoms

A.) Low self-esteem B.) Powerlessness C.) Ineffective coping

Which nursing diagnosis is appropriate for the adult survivor of incest? *Select all that apply.* A.) Low self-esteem B.) Powerlessness C.) Ineffective coping D.) Knowledge deficit E.) Noncompliance

B.) Modify the child's environment to promote independence and impulse control.

Which nursing intervention is important when caring for a mildly retarded child? A.) Encourage the parents to concentrate on the child rather than the rest of the family. B.) Modify the child's environment to promote independence and impulse control. C.) Delay extensive diagnostic studies until the child is older. D.) Provide one-on-one tutorial education, and minimize peer interaction.

B.) The nurse will provide simple directions and praise the client's efforts to independently perform self-care.

Which nursing intervention related to self-care would be appropriate for a moderately mentally retarded teenager? A.) The nurse will perfom all of client's self-care to avoid injury to the client. B.) The nurse will provide simple directions and praise the client's efforts to independently perform self-care. C.) To promote autonomy, the nurse will not interfere with the client's self-care regimen. D.) To promote bonding, the nurse will encourage family members to perform the client's self-care.

A.) Assess the patient's vital signs. B.) Check the latest Magnesium and Potassium levels. C.) Check the patient's oxygen saturation

Which of the following actions should the nurse take when noting increasing PVCs? Select all that apply. A.) Assess the patient's vital signs. B.) Check the latest Magnesium and Potassium levels C.) Check the patient's oxygen saturation. D.) Review the patient's medication record E.) Immediately phone the physician.

C.) 47-year-old male who has had a gastrectomy

Which of the following clients is most at risk for developing a Vitamin B12 deficiency anemia? A.) 26-year-old female in the second trimester of pregnancy B.) 3-year-old female who is a fussy eater C.) 47-year-old male who has had a gastrectomy D.) 64-year-old female with a history of GI bleeding

D.) Educate the patient to follow a low-fat diet.

Which of the following implementations will assist the nurse to decrease the knowledge deficit relating to reduction of pancreatic activity? A.) Instruct the client to include flat sodas with meals. B.) Reinforce the ingestion of fat-soluble vitamins. C.) Emphasize alcohol consumption in moderation is important. D.) Educate the patient to follow a low-fat diet.

A.) It is a mineralcorticoid.

Which of the following is *false* about cortisol? A.) It is a mineralcorticoid. B.) There is an increase in its release during times of stress C.) It suppresses protein synthesis D.) It enhances protein catabolism

C.) Lean away from client.

Which of the following is NOT part of the SOLER acronym for active listening? A.) Sit squarely facing patient B.) Open posture C.) Lean away from client D.) Establish eye contact

A.) 65 year old with end stage cardiomyopathy and cardiac induced renal insufficiency

Which of the following patients is the best candidate for heart transplantation? A.) 65 year old with end stage cardiomyopathy and cardiac induced renal insufficiency B.) 55 year old with three vessel coronary artery disease and mitral regurgitation C.) 50 year old with severe coronary artery disease and diabetic neuropathy D.) 45 year old with severe coronary artery disease and active peptic ulcer disease

B.) Borderline

Which of the following personality disorders is most often treated within the inpatient psychiatric setting? A.) Antisocial B.) Borderline C.) Schizotypal D.) Dependent

B.) Causes plethoric appearance of the face.

Which of the following relates to polycythemia vera? A.) Has the symptoms of hypocellularity B.) Causes plethoric appearance of the face C.) Causes hypotension and thrombosis D.) Can be cured with anticoagulants

C.) Oxygen is delivered at 30%

Which of the following statements about CPAP for sleep apnea is FALSE? A.) A set positive airway pressure is delivered during each breath. B.) The pressure is marinated during inhalation and exhalation. C.) Oxygen is delivered at 30% D.) Proper fit of the mask is key to successful treatment

A.) Receiving a paper cut, Linda yells "Help me quick! I'm bleeding! Someone call 911!"

Which of the following statements would be typical of an individual with histrionic personality disorder? A.) Receiving a paper cut, Linda yells "Help me quick! I'm bleeding! Someone call 911!" B.) Andrew becomes suspicious when John, who had an extra New Year's calendar, left it on Andrew's desk. C.) Fred works long hours in a solitary environment, lives alone, has no friends, and seldom speaks to others. D.) "We've always done it this way, and we will continue to do it this way. These are the rules and they are not to be broken."

C.) Fred works long hours in a solitary environment, lives alone, has no friends, and seldom speaks to others.

Which of the following statements would be typical of an individual with schizoid personality disorder? A.) Receiving a paper cut, Linda yells "Help me quick! I'm bleeding! Someone call 911!" B.) Andrew becomes suspicious when John, who had an extra New Year's calendar, left it on Andrew's desk. C.) Fred works long hours in a solitary environment, lives alone, has no friends, and seldom speaks to others. D.) "We've always done it this way, and we will continue to do it this way. These are the rules and they are not to be broken."

D.) "We've always done it this way, and we will continue to do it this way. These are the rules and they are not to be broken."

Which of the following would be typical of an individual with Obsessive-Compulsive personality disorder? A.) Receiving a paper cut, Linda yells "Help me quick! I'm bleeding! Someone call 911!" B.) Andrew becomes suspicious when John, who had an extra New Year's calendar, left it on Andrew's desk. C.) Fred works long hours in a solitary environment, lives alone, has no friends, and seldom speaks to others. D.) "We've always done it this way, and we will continue to do it this way. These are the rules and they are not to be broken."

A.) Presence of fever and night sweats.

Which of the following would indicate the presence of B symptoms? A.) Presence of fever and night sweats B.) Right sided upper abdominal pain during palpation C.) Unexpected weight gain during the past month D.) Enlarged supraclavicular lymph nodes

D.) Altered Nutrition: Less than Body Requirements

Which of the following would most likely be a major nursing diagnosis for a client with acute pancreatitis? A.) Impaired tissue perfusion: peripheral B.) Fluid Volume Excess C.) Impaired Swallowing D.) Altered Nutrition: Less than Body Requirements

A.) A 42-year-old man with a history of alcoholism

Which patient is at highest risk for acute pancreatitis? A.) a 42-year-old man with a history of alcoholism B.) A 37-year-old woman with Crohn's disease C.) A 56-year-old man with brittle diabetes D.) An 18-year-old woman with positive HIV.

B.) "Avoid flossing your teeth until platelets return to normal."

Which precaution has the highest priority for instruction of the client going home with thrombocytopenia? A.) "Drink at least 3 liters of fluid each day." B.) "Avoid flossing your teeth until platelets return to normal." C.) "Avoid drinking alcoholic beverages until your CBC is normal." D.) "Avoid the use of salt substitutes that contain potassium chloride."

C.) Physical health complications are likely to arise from antidepressant therapy.

Which primary rationale does the nurse understand that substantiates why a full physical health assessment is warranted for clients with depressive symptoms? A.) The attention afforded to the client during the assessment is beneficial in decreasing social isolation. B.) Physiological changes may ben the underlying cause of depression, and, if present, must be addressed. C.) Physical health complications are likely to arise from antidepressant therapy. D.) Depressed clients are less likely to complain about their physical health an may have an undiagnosed medical problem.

B.) Process his/her own attitudes and perceptions regarding substance abusers.

Which process must be completed by the nurse before caring for clients with substance abuse disorders? A.) Recognize that their personal potential for addiction is very low. B.) Process his/her own attitudes and perceptions regarding substance abusers. C.) Avoid being confrontational with clients. D.) Encourage clients to identify the role that others play in creating and perpetuating substance abuse.

B.) Clients with certain substance addictions develop a higher tolerance to pain medications, thus may require increased doses to achieve effective pain control.

Which rationale explains why a client requiring intervention for pain management should be assessed for a history of substance abuse? A.) Narcotic pain medication is not permitted for clients with active substance abuse problems. B.) Clients with certain substance addictions develop a higher tolerance to pain medications, thus may require increased doses to achieve effective pain control. C.) Clients with an active substance abuse disorder have a higher tolerance for pain, so they should be given less medication to achieve effective pain control. D.) Clients who use substances should be encouraged to use non-pharmacologic alternative for pain management because they are not permitted to take narcotics.

D.) They have a penchant for mobility.

Which reflects an accurate concern in attempting to provide health care services to the homeless? A.) Most of them do not want help. B.) They are suspicious of anyone who offers help. C.) Most are proud and will refuse charity. D.) They have a penchant for mobility.

A.) Expressing empathy towards others B.) Identifying their limitations C.) Acknowledging the strengths others possess

Which represents a positive outcome for a client with narcissistic personality disorder? Select all that apply. A.) Expressing empathy towards others B.) Identifying their limitations C.) Acknowledging the strengths others possess D.) Acknowledging the strengths they possess E.) Expressing sympathy for oneself

A.) Serum sodium 150 mmol/L; Serum potassium 2.5 mmol/L

Which serum electrolyte values alert the nurse to the possibility of hyperaldosteronism? A.) Serum sodium 150 mmol/L; serum potassium 2.5 mmol/L B.) Serum sodium 140 mmol/L; serum potassium 5.0 mmol/L C.) Serum sodium 130 mmol/L; serum potassium 2.5 mmol/L D.) Serum sodium 130 mmol/L; serum potassium 7.5 mmol/L

A.) "The enzyme will be administered with meals."

Which statement by a student nurse regarding enzyme replacement therapy indicates that need for further study? A.) "The enzyme will be administered with meals." B.) "The patient will take the drugs with a glass of water or juice." C.) "The effectiveness of pancreatic enzyme treatment is monitored by the frequency and fat content of stools." D.) "If the patient has difficulty swallowing, I will mix it with foods containing protein."

A.) "Power and control are central to the dynamic of domestic violence."

Which statement made by an emergency department nurse indicates a firm knowledge base related to domestic violence? A.) "Power and control are central to the dynamic of domestic violence." B.) "These women must have dependent personality disorders because they can't live without those abusive men." C.) "Abused women will always be attracted to abusive men." D.) "Abuse starts very early in the relationship. I'm not sure why they stay so long."

B.) "I will avoid drinking alcohol and coffee."

Which statment indicates your patient teaching has been successful? A.) "I will eat the 3 meals a day that I am used to." B.) "I will avoid drinking alcohol and coffee." C.) "I am eating tacos for my first meal back home.: D.) "I will limit the amount of protein in my diet."

B.) Suicidal gestures are designed to elicit a rescue response from significant others.

Which suicidal behavior would the nurse anticipate in a client with borderline personality disorder? A.) Use of a highly lethal method to commit suicide. B.) Suicidal gestures are designed to elicit a rescue response from significant others. C.) Suicidal behaviors assist the borderline individual in getting in touch with his or her true self. D.) These behaviors tend to lower the pain threshold and decrease endorphins in the body.

B.) Inappropriate, intense anger

Which symptoms would the nurse expect to assess related to anger expression in a client diagnosed with borderline personality disorder? A.) Controlled, subtle anger B.) Inappropriate, intense anger C.) Inability to recognize anger D.) Substituting of physical symptoms of anger

B.) With the client's eyes closed, move a toe up and down.

Which technique will the nurse use to assess proprioceptive function of the lower extremities in a client with suspected spinal cord injury? A.) Ask the client to flex and extend the ankles. B.) With the client's eyes closed, move a toe up and down. C.) Apply resistance while the client plantar flexes the feet. D.) Assess sensations of sharp and dull in the lower extremities.

B.) Percussion

Which technique would be most appropriate for the nurse to use to measure the liver span of a client admitted with cirrhosis? A.) Auscultation B.) Percussion C.) Inspection D.) Palpation

C.) Deinstitutionalization

Which term does the nurse recognize that reflects the movement of mental health care from inpatient facilities to outpatient mental health agencies? A.) Desegregation B.) Demoralization C.) Deinstitutionalization D.) Decommittment

D.) Withdrawal

Which term would the nurse utilize to describe a syndrome that occurs after stopping the use of a drug to which one is addicted? A.) Codependence B.) Tolerance C.) Guilt D.) Withdrawal

D.) Making an observation

Which therapeutic communication technique is being used in the following example? PATIENT: "Every time I get angry, I wind up getting into a fistfight with my wife or I take it out on the kids." NURSE: "I notice that you are smiling as you talk about your physical violence." A.) Restating B.) Exploring C.) Formulating a plan of action D.) Making an observation

C.) Formulating a plan of action

Which therapeutic technique is being used in the following example? PATIENT: "Every time I get angry, I wind up getting into a fistfight with my wife or I take it out on the kids." NURSE: "What other alternatives have you thought about other than physical violence when dealing with your anger?" A.) Restating B.) Exploring C.) Formulating a plan of action D.) Making observations

A.) Restating

Which therapeutic technique is being used in the following example? PATIENT: "Every time I get angry, I wind up getting into a fistfight with my wife or I take it out on the kids." NURSE: "You express your anger through physical violence directed at your family." A.) Restating B.) Exploring C.) Formulating a plan of action D.) Making observations

B.) Hemolytic

Which type of jaundice is due to increased destruction of erythrocytes? A.) Obstructive B.) Hemolytic C.) Hepatocellular D.) Both B and C are correct

D.) Clients can refuse treatment, but professionals can override this right when clients are a danger to themselves or others.

Which would the nurse expect regarding the client's right to refuse treatment? A.) Clients can refuse pharmacological but not psychological treatment. B.) Clients can refuse any treatment at any time. C.) Clients can refuse only electroconvulsive therapy (ECT). D.) Clients can refuse treatment, but professionals can override this right when clients are a danger to themselves or others.

C.) Obtain a physician's order for supplemental oxygen to be used during ambulation and other activities.

While ambulating a client with metastatic lung cancer, the nurse observes a drop in the oxygen saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these findings? A.) Continue with the walk as this is an expected response to activity. B.) Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity. C.) Obtain a physician's order for supplemental oxygen to be used during ambulation and other activities. D.) Obtain a physician's order for an arterial blood gas to verify the saturation.

D.) A panic attack

While stuck in traffic, a cab driver unexpectedly began to feel lightheaded, tremulous, and sweaty. His heart began pounding and his breathing became rapid and labored. He thought he was having a heart attack. An extensive cardiac workup in the emergency department revealed no abnormalities. Which diagnosis does the nurse anticipate? A.) Generalized anxiety disorder B.) A specific phobia C.) Post-traumatic stress disorder D.) A panic attack

A.) No, the insulin will help your body handle a chemical called potassium."

While the nurse is at the bedside of a client in acute renal failure, the client states, "My doctor said that I will be getting some insulin. So I also have diabetes? My blood sugar was normal." The response that best demonstrates an understanding of the use of insulin in acute renal failure would be: A.) "No, the insulin will help your body handle a chemical called potassium." B.) "Why don't you ask that question when the doctor comes to see you today." C.) "You probably have an elevated blood sugar level, so your doctor is being cautious." D.) "No, but insulin will lower the toxins in your blood by lowering your metabolic rate."

A.) Taking no action is still considered an action by the co-worker.

Without obtaining prior authorization by a physician, the nurse administers an extra dose of tranquilizer to an elderly client who is cursing at staff. The nurse's co-worker recognizes an ethical violation has occurred, but says nothing for the fear of personal repercussion. Which of the following is the ethical interpretation of this coworker's lack of involvement? A.) Taking no action is still considered an action by the co-worker. B.) Taking no action releases the co-worker from ethical responsibility. C.) Taking no action is advised when potential adverse consequences are foreseen for the co-worker. D.) Taking no action is acceptable since the co-worker was a bystander.

B.) hypertensive crisis

You are caring for a client with suspected pheochromocytoma. What is the most likely complication you would be assessing for in this client? A.) ARDS B.) hypertensive crisis C.) pancreatitis D.) acute renal failure

A.) Increased heart rate B.) Increased respiratory rate C.) Decreased blood pressure

You are caring for a patient that is in early sepsis. Which of the following are criteria for systemic inflammatory response syndrome (SIRS)? (Select all that apply.) A.) Increased heart rate B.) Increased respiratory rate C.) Decreased blood pressure D.) Negative fluid balance

C.) Hypertension

You are monitoring a client who is receiving a dopamine hypochloride drip for the treatment of shock. What symptom would indicate a possible overdose of this medication? A.) Pallor B.) Increased pulse deficit C.) Hypertension D.) Peripheral edema

D.) Prognosis is good; patients may live years untreated.

Your friend's mother has been diagnosed with indolent lymphoma. She is very distressed and asks if her mother will die soon. What is the prognosis for this disease? A.) Prognosis is grim; patients may live only weeks untreated B.) Prognosis is fair; patient may live several months untreated. C.) Prognosis is fair; patients may live many months untreated. D.) Prognosis is good; patient may live years untreated.

Heart failure due to MI

Your patient is admitted with an MI. You obtain the following hemodynamic readings: BP - 85/20 O2 Sat - 98% PCWP - 18 RAP - 8 PAP - 35/16 CI - 2.0 What is the most likely cause of this deterioration?

Hypothermia and dehydration

Your patient was found homeless in an abandoned building in February. He is unconscious. The following hemodynamic findings are available: PCWP - 2 SVR - 2800 HR - 100 Temp - 95.5 CI - 1.7 EF - 25% What is the probable cause of this condition?

Warm patient, vasodilators, IV fluids, positive inotropes for low EF (dobutamine)

Your patient was found homeless in an abandoned building in February. He is unconscious. The following hemodynamic findings are available: PCWP - 2 SVR - 2800 HR - 100 Temp - 95.5 CI - 1.7 EF - 25% What treatment is needed?

D.) Obtain a sterile cup to culture the tip of the catheter.

Your patient with a temperature of 101.5 degrees is ordered to have his pulmonary artery catheter removed. What do you anticipate to do upon removal? A.) Have the client lie on his left side to prevent air emboli. B.) Tell the client to breathe rapidly to prevent air emboli. C.) Raise the head of the bed to 90 degrees. D.) Obtain a sterile cup to culture the tip of the catheter.

C.) Apply pressure to the site.

Your patient with an arterial line rings his bells and tells you that his site is bleeding. What should the RN do next? A.) Assess the hand color distal to the A-line site. B.) Check the capillary refill in the hand. C.) Apply pressure to the site. D.) Check for a pulse distal to the site.

12 lead ECG, cardiac enzymes, echocardiogram, breath sounds, edema, heart catherization

Your patint is admitted with an MI. You obtain the following hemodynamic readings: BP - 85/20 O2 Sat - 98% PCWP - 18 RAP - 8 PAP - 35/16 CI - 2.0 What additional diagnostic information would be beneficial?

Dobutamine, diuretics, beta blockers

Your patint is admitted with an MI. You obtain the following hemodynamic readings: BP - 85/20 O2 Sat - 98% PCWP - 18 RAP - 8 PAP - 35/16 CI - 2.0 What treatment is needed?

IV fluid bolus 500 mL saline, pericardiocentesis or back to OR if immediately post-op

Your post-open heart surgery patient (CABG x 4) has just had his epicardial pacing wires pulled. He becomes hypotensive and develops tachycardia. You note the following hemodynamic readings: RA(CVP) - 22 PCWP - 22 PAP - 20/14 CI - 1.3 A-Line BP - 70/48 What is appropriate treatment?

Cardiac tamponade

Your post-open heart surgery patient (CABG x 4) has just had his epicardial pacing wires pulled. He becomes hypotensive and develops tachycardia. You note the following hemodynamic readings: RA(CVP) - 22 PCWP - 22 PAP - 20/14 CI - 1.3 A-Line BP - 70/48 What is the probable cause of this deterioration?

Muffled heart sounds, increased heart rate, no chest tube drainage, JVD, hypotension, narrowed pulse pressure

Your post-open heart surgery patient (CABG x 4) has just had his epicardial pacing wires pulled. He becomes hypotensive and develops tachycardia. You note the following hemodynamic readings: RA(CVP) - 22 PCWP - 22 PAP - 20/14 CI - 1.3 A-Line BP - 70/48 What other symptoms would you expect to see?

Functional Abnormalities that cause Schizophrenia

abnormal cerebral blood flow, abnormal glucose utilization in frontal lobes (center for personality/intellectual thought)

Hemothorax

blood in thoracic cavity

Schizophrenia Phase 4: Residual

body gets tired of certain types of medications

Cytotoxic cerebral edema

caused by electrolyte imbalances

Interstitial cerebral edema

caused by hydrocephalus

Osmotic cerebral edema

caused by sodium imbalance / dialysis

Vasogenic cerebral edema

caused by trauma

Aspiration

complication of partial laryngectomy

The process by which peritoneal dialysis filters toxins

diffusion

Urine will appear _______________ during the diuretic phase

dilute

Laryngoscope

direct view of the voicebox

Anticholinergic effects

dry mouth, urinary retention, tachycardia, increased intraocular pressure in glaucoma patients

Important for nurses and patients to assess with peritoneal dialysis

effluent

Structural Causes of Schizophrenia

enlarged ventricles, decreased size of temporal lobes (atrophy), decreased cerebral surface area, assymetry of brain

Interventions for OCD

goal is to refrain from ritualistic behavior; first learn coping skills, then start to reduce the number and length of time for performing rituals

Biochemical Causes of Schizophrenia

excessive dopamine and abnormalities in norepinephrine, serotonin, acetylcholine, GABA, glutamate, prostaglandins and endorphins

Panic Disorder

highly genetic; recurrent unpredictable panic attacks; manifested by intense apprehension, fear or terror, often with impending sense of doom; severe, uncontrollable physical symptoms (chest pain, shortness of breath, sweating, tachycardia, dizziness, nausea, cognitive impairment)

This may occur as the body tries to compensate for hypocalcemia

hyperparathyroidism

A common cause of prerenal AKI

hypovolemia

Tricyclics for Anxiety

imipramide, amitryptyline

Cerebral edema

increased brain water content, can be intracellular or extracellular

Continuous Positive Airway Pressure (CPAP)

most common treatment for sleep apnea

Schizophrenia Phase 3: Schizophrenia

must have signs or symptoms of psychosis for at least 6 months (delusions, hallucinations, unable to care for themselves)

Buspirone

not a benzodiazepine, not addictive, used routinely (never PRN), slower acting (3-6 weeks), grapefruit juice contraindicated (increases effectiveness)

Extrapyramidal Side Effects

occurs when dopamine gets too low; Akathisia - restlessness Akinesia - muscle weakness Dystonia - muscle spasms Oculogyric Crisis - eyes roll up Pseudoparkinsonism - intentional tremors, shuffling gait, facial expressions, protruding tongue, drooling

Severe Anxiety

perceptual field greatly impaired, learning and problem-solving are impossible, dazed and confused, unable to make decisions, impending sense of doom

Moderate Anxiety

perceptual field narrows, selective inattention, tension, mild somatic symptoms, increased pulse/respirations, pounding heart

Schizophrenia Phase 2: Prodromal

signs and symptoms of things to come, psychosis begins

Generalized Anxiety Disorder

uncontrollable, excessive worry for more than six months; causes significant impairment in occupational and social functioning; restless, fatigued, irritable, muscle tenseness, sleep difficulties, difficulty concentrating, somatic complaints; usually chronic, occurs in 20's, depressed feelings

Physiological Causes of Schizophrenia

viral infection, anatomical abnormalities, histological changes, physical conditions, genetics

Leukoplakia

white, patchy lesions on the vocal cords