NCLEX 2
what are the four things glucocorticoids do?
1. mood changer (insomnia, depression, psychotic and euphoric) 2. alter defense mechanism - immunosuppressed (remember sugar likes bacteria - diabetics have lots of uti's) high risk for infection (don't put with contageous pt) 3. Breakdown fats and proteins (think this could make them metabolic acidodic with DKA - the body is starving for glucose so it breaks down fats and proteins which produce keytones - the only way to get rid of these is through exhaling / exersize - increase resp.) (there is a note also of small arms and legs with big belly for breakdown of fats and proteins) 4. inhibit insulin - hyperglycemic and do blood glucose monitoring
S/S of fractures
-pain and tenderness -unnatural movement -deformity (possible) -shortening of the extremity (caused by muscle spasm) -crepitus (bones grating together) -swelling -discoloration -worry about compartment syndrome
Carpal tunnel
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Discuss educational challenges in the care of the MR.
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Discuss prenatal, perinatal, and postnatal causes of MR.
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A student nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the instructor best provides information about this aspect of therapeutic communication? A. "Touch carries a different meaning for different individuals." B. "Touch is often used when deescalating volatile client situations." C. "Touch is used to convey interest and warmth." D. "Touch is best combined with empathy when dealing with anxious clients."
ANS: A Touch can elicit both negative and positive reactions, depending on the people involved and the circumstances of the interaction.
Clinical signs of Guillain-Barre Syndrome
Distal symmetrical motor weakness, Mild distal sensory impairments, Transient paresthesias, Weakness progresses from LE to UE, Symptoms peaks within two-four weeks, MM and respiratory paralysis, Absence of DTR, Inability to speak or swallow - Can be life threatening if respiratory system is compromised, 30% of acute on a respirator, Acute onset in 2-4 weeks, f/b 2-4 weeks of static symptoms, gradual recovery over weeks and years
Cataract NSG Diagnosis
Disturbed sensory perception Risk for Injury Social Isolation Self-care deficit
Diagnosis
Electromyography - To detect fasciculations Muscle biopsy - To rule out muscle disease Spinal tap - Reveals a higher protein level * motor impairment without sensory impairment**
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
Lamb and peaches
To Treat Spasticity
Stretching, Topical cold, Rotational movement to decrease tone
Describe common symptoms of a TIA.
The warning signs of a TIA are exactly the same as for a stroke. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause
The nurse assisting in the admission of a client with diabetic ketoacidosis will anticipate the physician ordering which of the following types of intravenous solution if the client cannot take fluids orally? a. 0.45% normal saline solution b. Lactated Ringer's solution c. 0.9 normal saline solution d. 5% dextrose in water (D5W)
a. 0.45% normal saline solution
Agnosia
any of many types of loss of neurological function associated with interpretation of sensory information
What has lots of sodium?
anything processed - fruit juice and processed meats and chicken broth - good for addisons
What is the sign of mal-union?
persistent discomfort with moving (broken bones should not be moving under the cast)
what is another symptom of syphilis
rash on hands, feet, body
thymectomy
recommend for pts under 60. taped off steriods. give pyridostigmine given to prevent S&S during surgery. post op care focused on pulmonary hygiene,preventing complications from chest tube & pain control
colchicine
reduce the crystal deposits in the joints and ease the inflammation
Relapsing-remitting MS
relapses that occur with either full or partial recovery - the periods of relapses are characterized by a lack of disease progression
Cushing's disease
a high protein, low carb, low sodium diet with potassium supplement treats _________________
"(SELECT ALL THAT APPLY) After falling off a ladder and suffering a brain injury, a client develops syndrome of inappropriate antidiuretic hormone (SIADH). Which findings indicate that the treatment he's receiving is effective?
(1) Decrease in body weight (4) Increased urine output (5) Decreased urine osmolarity
"(SELECT ALL THAT APPLY) A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which of the following findings is the nurse most likely to observe in this client?
(1) Excessive thirst (4) Excessive hunger (6) Frequent, high-volume urination
A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient? 1) Anticoagulant therapy 2) Diabetes mellitus 3) Hypertension 4) Embolectomy
*1) Anticoagulant therapy*
Cast Care in first 24 hours after molding
-ice packs on the side for the first 24 hours because the cast is still wet -no indentations -use palms of hands for the first 24 hours when cast is still wet -Keep uncovered and allow for air dry -Do not rest cast on hard surface or sharp edge (use soft pillow, no plastic)
Is it ok to massage the stump?
-promotes circulation and decreases tenderness
Explain ketogenic diet.
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Gout: s/s, meds, manifests, dietary restrictions
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Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
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In a small rural hospital they work with a wide variety of clients. Of this afternoon client's admitted, the nurse acknowledges the client with the highest susceptibility to infection is the individual with: 1) Burns 2) Diabetes 3) Pulmonary emphysema 4) Peripheral vascular disease
*1) Burns*
Fracture Healing Concerns
-delayed union (healing does not occur at a normal rate) -Non-union (failure of bone ends to unite; may require bone grafting) -Mal-union: deformity at the fraction site
Evaluating degenerative motor neuron diseases via EMG you will see:
•Chronic partial denervation •Abnormal spontaneous activity at rest •Reduction in the number of muscle units under voluntary control
Risk factors for Cataracts
Age-related Trauma Toxins Diabetes
An adolescent with Type 1 diabetes is experiencing a problem with diabetic ketoacidosis. Which lab results reflect this condition?
Arterial blood ph of 7.28\
Fracture Hesi Hint #6
Assess the 6 P's of neurovascular functioning: pain, paresthesia, pulse, pallor, paralysis, pressure.
Risk for Disuse syndrome for ALS
Assess, provide skin care, active ROM exercises, maintain pos Nitrogen balance & hydration. Monitor for infection
people with hypothyroidism tend to also have:
CAD... though they don't know why (Corinary Artery Disease)
Discuss conditions that result in increased ICP.
Head Injury Hematoma CVA Tumors Infections
Discuss nursing interventions for a patient having a seizure.
Loosening of clothing around the neck Turn client to side Suction at bedside O2 as ordered Record symptoms during seizure Pad side rails Bed in low position Fall pads on floor
Discuss common causes of a head injury.
MVAs, falls, violent assaults, sports injuries, IEDs at war. the cause is what influences the kind of head injury they have.
Interventions for Thyroid Storm
Monitor temp frequently Cooling blankets Tylenol, NO ASA. Higher dose of drugs & fluids Assess LOC frequently Restful environment Airway & Oxygen (resp failure) Vitals & cardiac monitoring
Pin care
Monitor the site sterile technique remove crusts serous drainage is ok
A licensed practical nurse (LPN) is coassigned with a registered nurse (RN) for the care of a client with hemophilia. The physician prescribes a blood transfusion for this client. Which task associated with blood transfusion is the responsibility of the LPN?
Monitoring the client during the transfusion
Pedi HH #3
Pin sites can be sources of infection. Monitor for signs of infection. Cleanse adn dress pin sites as prescribed.
Discuss nursing care of patients with neurological infection or inflammatory disorder.
Preventing injury Monitor for decreased cerebral tissue perfusion. Preventing increased temperature Reducing headache Decreases enviornmental stimulation
Which nursing intervention takes priority for a client with human immunodeficiency virus (HIV) infection?
Protecting the client from infection
The nurs is anssessing an 80 year old client with type 2 diabetes. Which assessment finding would indicate a problem of hyperglycemia associated with older adult clients:
Rapid, deep respirations at a rate of 36 breaths a minute: lethargyl, tachycardia
Which action should the nurse take when a client diagnosed with human immunodeficiency virus (HIV) infection refuses treatment?
Recognize that the client might not be ready to make treatment decisions.
how is HIV spread
When fluids are passed from one person to another through mucus membranes in the body Can be passed from baby to mother
Short Acting Insulin
With meals Regular -onset: 30min-1 hour -peak: 2-5 hours -duration: 5-8 hours ACHS Type 1
"A client is being returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?
Tracheostomy set
Neuropathy
affects clients with DM
Data collection for posttransplant immunosuppressed pt
assess for s/s of opportunistic infections; assess nutritional status; assess for s/s of rejection of transplant
what should a yeast infection feel like
burning, itching, soreness, rash on vagina, pain during sex
primary progressive MS
continuous neurological deterioration from onset of S&S
what are the treatments of genital warts
freezing, burning, or cutting off
what causes herpes
a virus
Bivalving a cast involves what
splitting the cast along both sides to allow space for swelling, facilitate taking x rays, or make a half cast usae as intermittent splint
what disease is adrenocortical insufficiency or not enough _______.
steriods / addison's disease
ACTH are ___________ and are made where? The stimulate what to be made?
steriods and are made in the pituitary and they stimulate cortisol to be made.
hypothyroidism
wt gain, constipation, lethargy, decreased sweating and cold intolerance
Progressive Bulbar Palsy
•Motor nuclei of the cranial nerves are most affected (lower motor neuron) •Patients often present with slurred speech and difficulty chewing and swallowing •Exam: drooping of palate, depressed gag, pooling of saliva, wasted, fasiculating tongue •All cranial nerves have bilateral innervation except: Half of CN7 & CN12
addison's disease means they do not have enough of:
glucocorticiois, mineralocorticoids or sex hormones
Why might sugar be low with addisons?
glucocorticoids are one of the things the adrenal gland and the adrenal gland is not working so glucocorticoids, sex hormones and mineralocorticoids are not in full force... so low glucocorticoids - hypoglycemic. :)
SE of adenocorticosteriods for MS
glucose intolerance, osteoporosis, cataract formation.
what is aka "clap"
gonorrhea
hypercalcemia
hallmark of excess parathyroid hormone levels
hypothyroidism treatment
hormone replacement
personal contact or from food
how can Hep A be spread
Hyperparathyroidism=________________=__________
hypercalcemia=hypophosphatemia
during discharge a client with oteoporosis which statement needs more teaching?
i take ibprofen every morning as soon as i get up-dont take it on empty stomach! ulcerogenic drug
dont restart series no matter how long previous dose
if pt. misses one of the series of Hep A vaccines could they be restarted
may be vaccinated
if severely ill avoid all vaccines, if common cold or minor illness - should they be given vaccine
If a nonplaster (fiberglass) gets wet the client can dry it how
if the cast gets wet, it can be dried with a hair dryer set to a COOL setting to prevent skin breakdown.
Humoral Response
immediate; protects agains acute, rapidly growing bacteria and viruses
nursing care for MG focused on....
ineffective airway clearance, impaired swallowing, PREVENTION of fatigue. keep pt in constant temp. teach to avoid changes in temp.
caring for a client w an external fixator on the lower leg for a fractured tibia, complication
infection
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse s response is based on the understand that this could result in
injury to the brachial plexus nerves
Is there a cure for herpes
no
following a kidney transplant, the nurse notes that the pt's urine is cloudy. how should the nurse respond?
notify the physician
Morning stiffness occurs in
osteoarthritis
how is a yeast infection treated
over the counter medication, but if it is the first time, see a doctor
Complications of ALS:
paralysis, decrease in ADL's, aspiration, loss of verbal communication, pneumonia, resp failure, malnutrition, depression.
Natural Immunity
present at birth; includes biochemical, physical, and mechanical barriers as well as the inflammatory respone
Immune deficiency interventions
prevent infection; promote balanced diet; strict aseptic technique for all procedures; psychosocial support; educate ways to prevent infection
Progressive-relapsing MS
progressive disease from the onset with acute relapses with or without full recovery
where do crabs nest
pubic hair
Make sure for cushings pt's that they have a __________ environment because they can't handle stress.
quiet - the glucocorticoids cause mood altering from psychosis to depression / insomnia etc. / even with more epi and norepi they could fly off the handle... with none they are flat affect.
Acquired immunity
received passively from mother, animal serum (vaccine), or antibodies from previous disease
T-Cells
responsible for rejection of transplant tissues
pathologic fx
results from minimal trauma to a bone weakened by disease
A nurse who is caring for postoperative clients on a surgical unit knows that for 24 to 48 hours postoperatively, clients who have undergone general anesthesia may experience: 1. Colitis 2. Stomatitis 3. Paralytic ileus 4. Gastrocolic reflex
*3. Paralytic ileus*
The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering
*4) Hair covering*
In caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of a. Risk for ineffective airway clearance b. Anxiety related to suctioning c. Social isolation related to altered body image d. Impaired tissue integrity
*a. Risk for ineffective airway clearance* While other diagnoses may be applicable, maintaining a patent airway by tending to excessive secretions is a priority.
The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement a. contact precautions b. droplet precautions c. no precautions d. airborne precautions
*a. contact precautions* Contact precautions are used when "contact" with the infected drainage could lead to transmission of the infection.
During the communication process, "decoding" is a. The selection of words by the sender b. The interpretation of the message by the receiver c. The method by which the message is given d. The way in which feedback is interpreted
*b. The interpretation of the message by the receiver*
For which sleep disorder would the nurse most likely need to include safety measures in the client's plan of care? a. Snoring b. Enuresis c. Narcolepsy d. Hypersomnia
*c. Narcolepsy* Narcolepsy can occur suddenly during the daytime hours when a person is involved in any type of activity. This could put the person at risk for harm depending on the activity in which he is engaged.
The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered a/an a. Focused assessment b. Initial assessment c. Ongoing assessment d. Special needs assessment
*c. Ongoing assessment* This type of assessment can be completed at any time after the initial assessment. Gathering data at the beginning of a shift will enable the nurse to more effectively evaluate how to proceed with the plan of care for the shift.
Of the following interventions for the client who is immobile, the nurse will give priority to a. encouraging a diet high in fiber and extra fluids b. administering the PRN medication for sleep c. having the client use his incentive spirometer q2hrs d. massaging the client's legs every hour
*c. having the client use his incentive spirometer q2hrs* Use of the incentive spirometer helps to prevent atelectasis, which improves oxygenation - a priority need.
It is most important for the nurse to understand the various ways in which pain is classified a. so that he can document the client's pain using accurate terms b. so that he can be clear in his communication with the physician c. so that he can develop an effective pain management plan d. so that he can educate the client thoroughly
*c. so that he can develop an effective pain management plan* ANS: C Different modalities are used in the treatment/ management of pain and are often based on how the pain is classified (e.g., acute vs. chronic).
There is a 24-hour urine collection in process for a client. The NAP inadvertently empties one specimen into the toilet instead of the collection "hat." The nurse should a. Continue with the collection of urine until the 24-hour time period is finished. b. Make a note to the lab to inform them that one specimen was missed during the collection. c. Begin filling a new collection container and take both containers to the lab at the end of the collection period. d. Dispose of the urine already collected and begin an entirely new 24-hour collection.
*d. Dispose of the urine already collected and begin an entirely new 24-hour collection.* Once one specimen is "missed" during a 24-hour urine collection, the results of the lab test will be inaccurate and the collection must be restarted.
Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data, the patient states, "I've taken a tablespoon of Milk of Magnesia every day for 3 years." Which nursing diagnosis is most appropriate for the nurse to use in her plan of care? a. Diarrhea b. Constipation c. Risk for Ineffective Therapeutic Regimen d. Perceived Constipation
*d. Perceived Constipation* Daily laxative use by the patient might suggest that she perceives she is constipated, and the nurse would gather further assessment data related to the client's bowel pattern. There is not enough data to infer actual constipation.
Skeletal Traction
-Applied directly to the bone with pins and wires -Used with prolonged traction is needed
What do you do if your client complains of pain after the cast is dry?
-assess neurovascular -Most pain is relieved by elevation, cold packs, and analgesics (if these things do not relieve pain, think complication)
what to expect with tx for MS?
-at least partial recovery from acute exacerbations -relapses -no means of preventing progression -1/2 of pts are w/o significant disability even 10 yrs after onset of symptoms
Amputations (where are they performed?)
-at the most distal point that will heal -Doc tries to preserve the elbows and knees
What is the purpose of traction?
-decrease muscle spasms -reduces (realigns) -Immobilizes
Elevation post amputation
-it is controversial, because of hip contractures -Only elevate for a short time to reduce swelling -Do not elevate on a pillow, elevate the foot of the bed
Positioning for post-op hip replacement
-neutral rotation-toes to the ceiling -limit flexion; want extension of the hip -Abduction -trochanter roll to promote external rotation -Avoid crossing legs and bending over
Other Notes to remember about traction
-weights should hang freely -keep patient pulled up in bed and centered with a good alignment -exercise non-immobilized joints -ropes should move freely and knots should be secure/tight -special air filled or foam mattress
Describe IQ related to MR.
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Describe a nursing care for the patient with a brain tumor.
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Discuss the nursing care of the newborn and child with Down syndrome.
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Do not abruptly discontinue use of the antiparkinsonism drugs. Can cause malignant-like syndrome.
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Examine safety measures for the child with seizures.
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Explain measures used to keep populations healthy.
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Explain nursing responsibilities included in the referral process.
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Explain the teaching plan for a patient taking anticonvulsants.
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List two community resources for individuals and families of persons with CP.
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List two community resources for individuals and families of persons with MR.
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Coup-contrecoup
..., These injuries to the cerebrum occur when a blow to the head caused the brain to shift towards the area of impact and injure itself by hitting the inner surface of the skull, and then rebounding in the opposite direction and injuring itself again by hitting the skull on the opposite side of the skull where the original blow was delivered.
621. The client has undergone esophagogastroduodenoscopy. The nurse places highest priority on which item as part of the client's care plan?
1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat ***4. Assessing for the return of the gag reflex
What diagnostic tests are used to differentiate BPH from prostate cancer? Slect all that apply.
1. pelvic u/s ***2. digital rectal exam 3. blood chemistry ***4. PSA level 5. sperm count
A home care nurse is preparing the home for a client who is going home following a left hip replacement. The client is cooperative and can partially bear weight. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? 1. A trapeze bar 2. A small transfer board 3. A powered standing-assist device 4. An ankle foot orthotic (AFO) for the affected foot
2. A small transfer board
The most common affective or mood disorder of old age is 1. dementia. 2. depression. 3. delirium. 4. Alzheimer's.
2. depression.
A client who was in a car accident and broke his femur has been immobilized for 5 days. When the nurse gets this client out of bed for the first time, a nursing diagnosis related to the safety of this client will be: 1. Pain 2. Impaired skin integrity 3. Altered tissue perfusion 4. Risk for activity intolerance
4. Risk for activity intolerance
Normal blood glucose
70-110
charge nurse you are making assignments, pulled from pacu for the day
72 yr old with pagets disease returned from surgery tk replacement
A 63-year-old patient is newly diagnosed with type 2 diabetes. When developing an education plan, the nurse's first action should be to a. assess the patient's perception of what it means to have type 2 diabetes. b. demonstrate how to check glucose using capillary blood glucose monitoring. c. ask the patient's family to participate in the diabetes education program. d. discuss the need for the patient to actively participate in diabetes management.
A Rationale: Before planning education, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.
A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). During an acute exacerbation of the patient's arthritis, the health care provider prescribes prednisone (Deltasone) to control inflammation. The nurse will anticipate that the patient may a. require administration of insulin while taking prednisone. b. develop acute hypoglycemia during the RA exacerbation. c. have rashes caused by metformin-prednisone interactions. d. need a diet higher in calories while receiving prednisone.
A Rationale: Glucose levels increase when patients are taking CORTICOsteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a complication of RA exacerbation or prednisone use. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient is likely to have an increased appetite when taking prednisone, but it will be important to avoid weight gain for the patient with RA.
Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness? a. Give the patient a snack of cheese and crackers. b. Have the patient drink a glass of orange juice or nonfat milk. c. Administer a continuous infusion of 5% dextrose for 24 hours. d. Assess the patient for symptoms of hyperglycemia.
A Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.
Cardiac monitoring is initiated for a patient in diabetic ketoacidosis (DKA). The nurse recognizes that this measure is important to identify a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia. b. fluid overload resulting from aggressive fluid replacement. c. the presence of hypovolemic shock related to osmotic diuresis. d. cardiovascular collapse resulting from the effects of hyperglycemia.
A Rationale: The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Fluid overload, hypovolemia, and cardiovascular collapse are possible complications of DKA, but cardiac monitoring would not detect theses.
The nurse identifies the collaborative problem of potential complication: electrolyte imbalance for a patient with severe acute pancreatitis. Assessment findings that alert the nurse to electrolyte imbalances associated with acute pancreatitis include a. muscle twitching and finger numbness. b. paralytic ileus and abdominal distention. c. hypotension. d. hyperglycemia.
A Rationale: Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.
14. A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. The nurse should teach the patient that a. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin. b. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis. c. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes. d. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy.
A Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly. A previous episode of ketoacidosis is not a contraindication for intensive insulin therapy. Intensive insulin therapy is not confined to type 2 diabetics and would prevent microvascular changes as well as macrovascular changes. Intensive insulin therapy and an insulin pump are comparable in glucose control. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Implementation NCLEX: Physiological Integrity
A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is sob and is restless. What does the client most likely have?
A fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever, and petechiae.
After undergoing testing, a client comes to a physician's office for a follow-up appointment. During the appointment, the physician informs the client that she has systemic lupus erythematosus (SLE) . Which resource might be helpful for a nurse to recommend to this client?
A support group for clients with SLE
Discuss the discharge-teaching plan for anticoagulants (and anti-platelets).
A thorough review of the dosage regimen, possible adverse drug reactions, and early signs of bleeding tendencies help the patient cooperate with the prescribed therapy. Teach: -Follow the dosage schedule prescribed by the PHCP, and report any signs of active bleeding immediately. (gums bleeding, bruising, bloody stools, black and tarry stools, vomit that is bright red or looks like coffee grounds). If these are found, d/c the next dose and contact your PHCP immediately. -The INR will be monitored periodically. Keep all appointments, because dosage changes may be necessary. -Do not take or stop taking other drugs except on the advice of the PHCP. -Inform your dentist and other PHCP of therapy. -Take the drug at the same time each day. -Do not change brands of anticoagulants without consulting a physician or pharmacist. -Avoid alcohol unless use has been approved by the primary health care provider. -Be aware of foods high in vit-K, such as leafy green vegetables, beans, broccoli, cabbage, cauliflower, cheese, fish, and yogurt. Maintaining a healthy diet including these foods may help maintain a consistent INR value. -Keep in mind that anti-platelet drugs can lower all blood counts, including the WBC count. Patients may be at greater risk for infection during the first 3 months of treatment. -Use a soft toothbrush. -Use an electric razor when possible. -Wear or carry medical identification.
A barium Enema should be done before an upper gastrointestinal series because of which of the following? A) Retained barium may cloud the colon B)barium Can cause lower Gastrointestinal bleeding C) The physicians orders are in that sequence D)barium Is absorbed readily in the lower intestine
A) Retained barium may cloud the colon The barium And I'm should always perceive the upper gastrointestinal series because retained barium from the latter may take several days to pass through the gastrointestinal tract and may cloud anatomic detail on the barium enema studies
The pathophysiology of systemic lupus erthematosus (SLE) is characterized by a. destruction of nucleic acids and other self-proteins by autoantibodies b. overproduction of collagen that disrupts the functioning of internal organs c. formation of abnormal IgG that attaches to cellular antigens, activating complement d. increased activity of T-suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency
A. destruction of nucleic acids and other self-proteins by autoantibodies
A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats per minute, respiratory rate 14 breaths per minute, and blood pressure 118/76. Four hours later the client's oral temperature is 102.2°F (39°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats per minute? Why?
ANS: 111 BPM. ∆ 1 °F = 10 BPM 102.2 °F - 99.3 °F = 2.9 °F * (10 BPM / 1 °F) = ∆ 29 BPM + 82 BPM = 111 BPM
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Guillain-Barre Syndrome
Acute polyneuropathy, Temporary inflammation and demyelination of the peripheral nerves' myelin sheaths, Results in motor weakness in a distal to proximal fashion with sensory impairment and possible respiratory paralysis. Thought to be an autoimmune response. Recovery is slow and can last 3-12 months.
Sex hormones are secretes by ___________ and this is related to what d/o
Adrenal cortex and cushings.
"The nurse is teaching the client about risk factors for diabetes mellitus. Which risk factor for diabetes mellitus is nonmodifiable?
Advanced age
A P/T has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a FX femur. She says, "It hurts when I try to breath, and I can't catch my breath." Your first action is to:
Assess her vital signs, perform a respiratory assessment, and be prepaid to start oxygen therapy.
"During the first 24 hours after a client is diagnosed with addisonian crisis, which task should the nurse perform frequently?
Assess vital signs.
Atherosclerosis
Associated with low TH levels Angina, heart failure, dysrhythmia, infarction, etc. Begin drug therapy in low doses and monitor for rapid HR, palpitations, and chest pain early in therapy.
When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of a. cigarette smoking. b. alcohol use. c. diabetes mellitus. d. high-protein diet.
B Rationale: Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.
31. A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Which teaching will the nurse implement about exercise for this patient? a. "You should not take the morning NPH insulin before you run." b. "Plan to eat breakfast about an hour before your run." c. "Afternoon running is less likely to cause hypoglycemia." d. "You may want to run a little farther if your glucose is very high."
B Rationale: Blood sugar increases after meals, so this will be the best time to exercise. NPH insulin will not peak until mid-afternoon and is safe to take before a morning run. Running can be done in either the morning or afternoon. If the glucose is very elevated, the patient should postpone the run. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity
13. A patient receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between a. 8:00 and 10:00 AM. b. 4:00 and 6:00 PM. c. 7:00 and 9:00 PM. d. 10:00 PM and 12:00 AM.
B Rationale: The greatest insulin effect with this combination occurs mid afternoon. The patient is not at a high risk at the other listed times, although hypoglycemia may occur. Cognitive Level: Comprehension Text Reference: p. 1260 Nursing Process: Evaluation NCLEX: Physiological Integrity
Your patient complains of an excessive flatulence. When reviewing your patients dietary intake, which foods, if eaten regularly, would you identify as possibly responsible? A) Meet B) Cauliflower C) Potatoes D) Ice cream
B) Cauliflower Cauliflower is a gas producing food that relates in flatulence
One of the benefits of Glargine (Lantus) insulin is its ability to: "a.Release insulin rapidly throughout the day to help control basal glucose.b. Release insulin evenly throughout the day and control basal glucose levels.c. Simplify the dosing and better control blood glucose levels during the day.d. Cause hypoglycemia with other manifestation of other adverse reactions.
B)Release insulin evenly throughout the day and control basal glucose levels"Glargine (Lantus) insulin is designed to release insulin evenly throughout the day and control basal glucose levels.
The nurse works with elderly clients in a wellness screening clinic on a weekly basis. Which of the following statements made by the nurse is the most therapeutic regarding their mobility? A. "Your shoulder pain is normal for your age." B. "Continue to exercise your joints regularly to your tolerance level." C. "Why don't you begin walking 3 to 4 miles a day, and we'll evaluate how you feel next week." D. "Don't worry about taking that combination of medications since your doctor has prescribed them."
B. "Continue to exercise your joints regularly to your tolerance level."
Which of the following statements, made by the daughter of an older adult client concerning bringing her mother home to live with her family, presents the greatest concern for the nurse? A. "If this doesn't work out, she can always go to live with my sister." B. "I don't think she will react very well to me making decisions for her." C. "I'm afraid that mom will be depressed and miss her home." D. "My children will just have to adjust to having their grandmother with us."
B. "I don't think she will react very well to me making decisions for her."
Cataract assessment findings
Blurred vision, decreased color perception: early; diplopia, reduced visual acuity, absence of red reflex; pain and eye redness are associated w late forms
The doctor is interested in how well a client has controlled their blood glucose since their last visit. What lab values could the nurse evaluate to determine how well the client has controlled their blood glucose over the past three months?
C HbgA1c is a blood test used to determine how well blood glucose has been controlled for the last three months.
38. A diabetic patient has a new order for inhaled insulin (Exubera). Which information about the patient indicates that the nurse should contact the patient before administering the Exubera? a. The patient has a history of a recent myocardial infarction. b. The patient's blood glucose is 224 mg/dl. c. The patient uses a bronchodilator to treat emphysema. d. The patient's temperature is 101.4° F.
C Rationale: Exubera is not recommended for patients with emphysema. The other data do not indicate any contraindication to using Exubera. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Assessment NCLEX: Physiological Integrity
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician's prescriptions? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate
CORRECT ANSWER: 3. Intravenous infusion of normal saline Rationale: The primary goal of treatment is hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to restore the fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic keto acidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHNS.
Tx for hypothyroidism
Calcium - may recieve it IV / and phosphorus binding drugs (becuase of that inverse relationship) binding means you can poop out the phospherous)
This drug should be kept at the bedside of a patient who had a thyroidectomy to prevent tetany?
Calcium gluconate
"A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?
Cerebral edema
Discuss common drugs used in the treatment of Alzheimer's disease.
Cholinesterase inhibitor drugs, such as Cognex (40-80mh 4x/day, admin 1hr before or 2hr after meal), Aricept (5-10mg/day bedtime), and Exelon (1.5-6mg b.i.d), Reminyl (4-12mg b.i.d), and Namada (5-10mg b.i.d) block the breakdown of acetylcholine. Slows cognitive decline. Monitor ALT levels with cognex, elevated levels may indicate hepatoxicty Adverse Reactions: N/V/D, HA, confusion, upset stomach. SSRIs such as Prozac treat depression. Risperdal or Seroquel is used to control behavioral symptoms.
NSG Dx Osteoarthritis
Chronic pain Impaired physical mobility Activity intolerance Self-care deficit Disturbed body image
"The nurse should expect to administer which medication to a client with gout?
Colchicine
"A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?
Coma, anxiety, confusion, headache, and cool, moist skin
Which assessment findings would cause the nurse to suspect compartment syndrome after casting of the leg? a) Warm, pink foot and ability to move toes of affected leg b) Low-grade fever, dyspnea, tachycardia, and crackles c) Increased capillary refill and bounding pulses in affected leg d) Complaints of numbness and tingling in toes of affected leg
Complaints of numbness and tingling in toes of affected leg Explanation: Numbness and tingling indicate nerve ischemia and edema, suggesting development of compartment syndrome.
Pituitary
Controlled primarily by the hypothalamus; termed :master gland: as it directly affects the function of other endocrine glands
Which of the following is a term used to describe a soft tissue injury produced by a blunt force? a) Sprain b) Hematoma c) Contusion d) Strain
Contusion Explanation: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling. A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion.
Prodromal manifestations prior to an intracranial aneurysm rupture could be recognized by the nurse as which of the following? Select all that apply. 1. visual deficits 2. headache 3. mild nausea 4. dilated pupil 5. stiff neck
Correct Answer: 1,2,4 Rationale: Often intracranial aneurysms are asymptomatic until rupture but patients can complain of headache and eye pain, and have visual deficits and a dilated pupil. Nausea and vomiting and stiff neck are not usually associated with the prodromal manifestations of an intracranial aneurysm, but may occur with leaking or rupture.
A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching? Select all that apply. 1. how to use a sign board 2. transfer techniques 3. information about impulse control 4. time adjustment to complete activities 5. safety precautions for transferring
Correct Answer: 1,2,5 Rationale: The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The patient also might display overcautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement.
A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.
Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.
A lumbar puncture (LP) is done on a patient to rule out a spinal cord tumor. The cerebrospinal fluid (CSF) is xanthochromic, has increased protein, no cells, and clots immediately. What syndrome do these findings describe? 1. Glasgow's syndrome 2. Froin's syndrome 3. cord tumor syndrome 4. reflex syndrome
Correct Answer: 2 Rationale: Froin's syndrome is seen with spinal cord tumors. A lumbar puncture, x-rays, CT scans, MRI, and myelogram are all common tests that are used to diagnose a spinal cord tumor. Glasgow's syndrome, cord tumor syndrome, and reflex syndrome are not terms associated with the symptoms of spinal cord tumor described.
An industrial nurse is conducting a class to teach methods to prevent back pain. What is the correct of steps for lifting heavy objects? Choice 1. Spread the feet apart to broaden the base of support. Choice 2. Use large leg muscles to push when lifting. Choice 3. Stand as closely as possible to the object to be moved. Choice 4. Rolling or pushing the obect insrtead of lifting.
Correct Answer: 2,3,1,4 Rationale: In teaching prevention of back injuries the nurse would incorporate principles of proper body mechanics, which are work as close to the object as possible, spread feet apart, use large leg muscles for leverage. Sometimes rolling or pushing will enable movement of a heavy object.
A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction
Correct Answer: 2,5 Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.
The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.
Correct Answer: 3 Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.
Laboratory findings that the nurse would expect to be present in the patient with RA include a. polycythemia b. increased IgG c. decreased WBC d. increased C-reactive protein (CRP)
D. increased C-reactive protein (CRP)
"The nurse is planning care for a 52-year-old male client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?
Decreased cardiac output
Why are beta-blockers used in hyperthyroid patients (3)? In other words, what do they decrease?
Decreased myocardial contractility, decreased cardiac output, decreases HR/BP.
A 39-year-old client has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicated intact but malpositioned bones, what would you expect the physician to diagnose? a) Fracture b) Strain c) Sprain d) Dislocation
Dislocation Explanation: In joint dislocation, radiographic films show intact yet malpositioned bones.
Aclient is admitted with a diagnosis of Cushing's syndrome. What is an important consideration for the nurse to make in caring for this client?
Due to decreased inflammatory response the client will be at increased risk for infections.
24 hr
Duration of long-lasting insulins
What will the nurse teach the diabetic client regarding exercise in their treatment program?
During exercise the body will use carbohydrates for energy production, which will decreased the need for insulin
Osteoarthritis Dx Tests
ESR: elevated due to synovitis Radiograph: structural changes
A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? a) Maintaining the client on complete bed rest b) Elevating the stump for the first 24 hours c) Removing the pressure dressing after the first 8 hours d) Applying heat to the stump as the client desires
Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.
Corticosteroid
Florinef (fludrocortsone)-prevents the release of substances in the body taht cause inflamation. Used to treat conditions in which the body does not produce enough of its own steroids such as addisons disease, help restore electrolyte balance.
Pedi HH #1
Fractures in older children are common because they fall during play and are involved in MVAs. Spiral fractures (caused by twisting) and fx in infants may be related to child abuse. Fractures involving the epiphyseal plate can have serious consequences in terms of the growth of the affected limb.
List at least 4 signs and symptoms of hypothyroidism (temperature, GI).
GI is slow. Weight increased. Fatigued. Cold skin. Speech is slow. Lack of expression.
Glaucoma Hesi Hint #1
Glaucoma is often painless and symptom free. It is usually picked up as part of a regular eye examination.
A disease that causes hyperthyroidism is ________ disease. Name 6 out 10 s/s of hyperthyroidism (don't forget temp/GI/eyes/attention span).
Graves Disease. Nervousness, decreased attention span, irritable, increased sweat/heat, decreased weight, increased appetite, exophthalamos, GI = diarrhea, increased blood pressure, increased thyroid
"Which instructions should be included in the discharge teaching plan for a client after a thyroidectomy for Graves' disease?
Have regular follow-up care.
Joint Replacement Hesi Hint #5
Hazards of Immobility: Immobile clients are prone to complications: skin integrity problems; formation of urinary calculi (client's milk intake may be limited); and venous thrombosis (client may be on prophylactic anticoagulants).
"Which of the following would the nurse expect to find in a client diagnosed with hyperparathyroidism?
Hypercalcemia
"A client with type 1 diabetes has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
Hypoglycemia
"For a client with hyperglycemia, which data collection finding best supports a nursing diagnosis of Deficient fluid volume?
Increased urine osmolarity
Triggers of Thyroid Storm
Infection (pulmonary) Sepsis Diabetes Stress Trauma or surgery Abrupt withdrawal from thyroid meds
"The nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare to absorption at other sites?
Insulin is absorbed more rapidly at abdominal injection sites than at other sites.
Cerebellar dysfunction
Intention tremors, Vary from mild to massive involuntary movements Tremors can impose significant limitations in activity
Osteoarthritis S/S
Joint pain & stiffness Pain with ROM Crepitus Herberden's nodes Inflammation
Addisons crisis
LIFE THREATENING triggered by surgey, acute systemic illness trauma, or abrupt withdrawl of long therm corticosteroids therapy
Homonymous Hemianopia
Loss of vision in half of the visual field on the same side of both eyes
NSG Interventions Meneire's
Low sodium, no caffeine, no alcohol Potassium foods Bedrest Antihistamines, Valium. Quiet environment, low lighting.
Progressive spinal muscular atrophy
Lower motor neuron deficit in the limbs due to degeneration of the anterior horn cells in the spinal cord
Discuss prenatal, perinatal, postnatal, causes of CP.
May be caused prenatally by the mother contracting rubella or other infection, malnutrition, abnormal attachment of the placenta, toxemia, radiation, or medication. Perinatally, it may be caused by a difficult birth, prolapsed umbilical cord, or multiple births. Postnatally, an infant might develop it as a result of trauma and result in prolonged anorexia or decreased circulation to the brain.
This disease is characterized by abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac causing endolymph to accumulate in the membranous labyrinth.
Meniere's Disease
Compare and contrast four inflammatory neurological conditions.
Meningitis: inflammation of the meninges of the brain and spinal cord. Enchephalitis: an acute inflammation of the white and gray matter of the brain. Brain abscess: collection of purulent material within the brain.
Discuss the nursing interventions are for the patient with Parkinson's disease.
Monitor neuro status for changes, monitor respiratory status for changes, encourage self-care, allow patient extra time, encourage exercise; assist with passive ROM if necessary, weigh patient; I&O; explain importance of following med schedule as well as effects of medication wearing off; reduce falls at home.
"A client is prescribed prednisone (Deltasone) daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning?
Morning administration of prednisone mimics the body's natural corticosteroid secretion pattern.
List the common signs and symptoms of Parkinson's diseases.
Muscle rigidity Pin rolling Bradykinesia Stooped posture, and shuffling gait Difficulty swallowing
"Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?
Muscle weakness
is there a cure for herpes
NO
Chronic complications of DM
Neuropathy, retinal impairment, cataracts, renal issues
Which of the following is the most numerous type of white blood cell (WBC)?
Neutrophil
S/S of hyperparathyroidism---Too much _________. Serum calcium is _______. Serum phos is _____. Other s/s? Treatment?
PTH > UP > DOWN > hypercalcemia = sedative properties. --Partial parathyroidectomy
The parathyroids secrete _________ which makes you pull calcium from the ______ and places it in the _____. Therefore, serum calcium will go ______.
PTH > bone > blood > up
What are the classifications of the commonly prescribed eye drops for glaucoma?
Parasympathomimetic for pupillary constriction; beta-adrenergic receptor-blocking agents to inhibit formation of aqueous humor; carbonic anhydrase inhibitors to reduce aqueous humor production; and prostaglandin agonists to increase aqueous humor outflow.
Elderly clients who fall are most at risk for which injuries? a) Cervical spine fractures b) Pelvic fractures c) Wrist fractures d) Humerus fractures
Pelvic fractures Explanation: Elderly clients who fall are most at risk for pelvic and lower extremity fractures. These injuries are devastating because they can seriously alter an elderly client's lifestyle and reduce functional independence. Wrist fractures usually occur with falls on an outstretched hand or from a direct blow. Such fractures are commonly found in young men. Humerus fractures and cervical spine fractures aren't age-specific.
Which factor is most important when planning care for a client with a bleeding disorder?
Prioritization
The RN puts elastic stockings on a P/T following major abdominal surgery. The RN teaches the P/T that the stockings are used after a surgical procedure to:
Promote venous return to the heart.
Describe the criteria for determining dosage of anticoagulant drugs. (PT, INR, APTT)
Prothrombin time (PT) and the international normalized ratio (INR) are used to monitor the pts response to warfarin therapy. The daily dose is based on these labs. Therapeutic range of the PT is 1.2 to 1.5 times the control value (11-13 seconds, think "pre teen"). INR should be maintained between 2 and 3. The The Activated Partial Thromboplastin Time (APTT) determines the overall capacity of the blood to clot for pts on heparin. 1.5-2.5 the control value (25-45 seconds, think "prime teaching time"). The APTT needs to be drawn q6hrs, heparin has a short half-life and so the amount can vary greatly within a short period of time. If the numbers are too low, they are at risk for clots. If too high, then they are at risk for bleeding. There is a narrow therapeutic range for anticoagulants.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Risk for injury
Risk factors for type 2 diabetes include all of the following except: "a. Advanced age b. Obesity c. Smoking d. Physical inactivity"
Smoking "Additional risk factors for type 2 diabetes are a family history of diabetes, impaired glucose metabolism, history of gestational diabetes, and race/ethnicity. African-Americans, Hispanics/Latinos, Asian Americans, Native Hawaiians, Pacific Islanders, and Native Americans are at greater risk of developing diabetes than whites."
Increase what in diet for addisons??
Sodium - remember low aldosterone - not retain sodium and remember if they eat more sodium than they will retain more water.
"Parathyroid hormone (PTH) has which effect on the kidneys?
Stimulation of calcium reabsorption and phosphate excretion
If someone with hypothyroid is getting Synthroid as a treatment and experience signs of Coranary Artery Disease, what do you do?
Stop the infusion!
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
Strawberries
Discuss a teaching plan for the child with a head injury.
Teach patient/parent about: Dizziness, nausea vomiting, when to call HCP Visual disturbances; blurring, pupils Headaches LOC - Keep patient oriented, check pt at least every hour Avoiding contact sports
To diagnosis diff between myasthenic crisis & cholinergic crisis
Tensilon test. Edrophomium chloride (ashort acting anticholinesterase) if symptoms abate for 5 mins, w/ improved muscle strength, then myasthenic crisis. NO imporvement= cholinergic.
Discuss Glasgow Coma scale.
The Glascow Coma Scale provides a quick guide for assesing LOC, It measures how well the pt responds to eye opening and verbal and motor responses.
Which of the following indicates that additional assistance is needed to transfer the P/T from the bed to the stretcher?
The P/T received an injection of morphine 30 minutes ago for pain.
Cataract Hesi Hint #1
The lens of the eye is responsible for projecting light onto the retina so that images can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred.
Osteoporosis Hesi Hint #2
The main cause of fractures in older adults, especially women is osteoporosis. The main fracture sites seem to be hip, vertebral bodies, and Colles fracture of the forearm.
Recognize the patient/family's ability to adapt to role changes.
The middle-aged adult family member may become the care-taker for an older parent. An older adult may be unable to care for a spouse who has had a stroke. They may have to accept placement of the spouse into an LTC. Emphasize that physical function may continue to improve for up to 3 months, and speech may continue to improve even longer.
D
The nurse assesses that an 87 year old woman with alzheimers disease is continually rubbing, flexing, and kicking out her legs throughout the day. THe night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to: a. ask the physician for a daytime sedative for the patient b. request soft restraints to prevent her from falling out of her bed. c. ask the physician for a nightime sleep medication for the patient d. assess the patient more closely, suspecting a disorder such as restless legs syndrome
Neglect Syndrome
The result of certain right parietal lobe lesions that leave a patient completely inattentive to stimuli to her left, including the left side of her own body.
Tx for Hypothyroid include which meds? Do they take these forever?
These meds all sound like they have thyroid in them in a way... levothyroxine (synthroid) thyroglobulin (proloid) liothyronine (cytomel) / Yes
Fat embolism
This is a complication of a fracture, especially of the long bone, that can occur in the first 48-72 h after theinjury.
3
Using maslow's framework which statement charecterizes the highest level of need? 1. Nurse my pain is severe. . . is it time for my shot? 2. I felt welcomed when i first joined the group and i look forward to the monthly meetings 3. Im very proud of recieving the employee of the month award 4. There have been home breakins with burglary in our neighborhood. we are thinking of moving.
Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Subluxation b) Callus c) Volkmann's contracture d) Whiplash injury
Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.
"A client with adrenal hypofunction has been asked to participate in a research study for a new medication. The client is unsure about participating in the study. What would be an appropriate response for the nurse to make to this client?
You have the right to refuse to participate in the study.
The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? Heart rate 86 Reddened area on sacrum Nonproductive cough Urine output of 50 mL/hour
Your Answer: Reddened area on sacrum Rationale: The reddened area of the skin can lead to skin breakdown. The other options are within normal limits. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment.
Beta-blockers
________________ manage tachycardia, anxiety, and tremors associated with hyperthyroidism
"When collecting data on a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:
a blood pressure of 176/88 mm Hg.
PET Scan
a visual display of brain activity that detects where a radioactive form of glucose goes while the brain performs a given task
A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need to have what?
a window cut in the cast. A window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains
The nurse assisting in the admission of a client with diabetic ketoacidosis will anticipate the physician ordering which of the following types of intravenous solution if the client cannot take any fluids orally? " a. 0.45% normal saline solution b. Lactated Ringer's solution c. 0.9 normal saline solution d. 5% dextrose in water (D5W)"
a. 0.45% normal saline solution Helps to hydrate patient and keep electrolyte levels balanced
Blood sugar is well controlled when Hemoglobin A1C is: a. Below 7% b. Between 12%-15% c. Less than 180 mg/dL d. Between 90 and 130 mg/dL
a. Below 7% A1c measures the percentage of hemoglobin that is glycated and determines average blood glucose during the 2 to 3 months prior to testing. Used as a diagnostic tool, A1C levels of 6.5% or higher on two tests indicate diabetes. A1C of 6% to 6.5% is considered prediabetes.
When caring for a patient with primary hyperaldosteronism, the nurse would question a physician's order for the use of a. Lasix b. amiloride (midamor) c. spironolactone (aldactone) d. aminoglutethimide (cytadren)
a. Lasix37 (rationale- hyperaldosteronism is an excess of aldosterone, which is manifested by sodium and water retention and potassium excretion. Lasix is a potassium-wasting diuretic that would increase the potassium deficiency. Aminoglutethimide blocks aldosterone synthesis; amiloride is apotassium-sparing diuretic; and spironolactone blocks mineralocorticoid receptors in the kidney, increasing secretion of sodium and water and retention of potassium.)
patho of ALS
affects anterior horn cells of spinal cord, motor nuclei of brain stem, and upper motor neurons of cerebral cortex. Cells die= axonal degeneration, demyelination, glial proliferation and scarring along corticospinal tract. Cells try to grow new attachments to muscle, but that eventually fails.
After the onset of symptoms of addisons disease of hyperkalemia starting with muscle twitching to flaccid parralysis, then what other symptoms arise?
anorexia / nausea, hyperpigmentation - bronzing color of the skin and mucous membranes, decreased bowel sounds / GI upset (also known of with K+ increase), white patchy area of depigmented skin aka vitiligo, hypotension - b/c of loss of fluid, decrease Na, increased K+ and low sugar-hypoglycemia (remember insulin carries glucose and potassium into the cell so if you have hyperkalemia you can give insulin/glucose to carry k+ into the cell)
active immunity
antibody production is stimulated without causing clinical disease
Receptive Aphasia
aphasia characterized by fluent but meaningless speech and severe impairment of the ability to understand spoken or written words
Care of pt during plasmapheresis
assess VS/Weight, CBC, platelet count, clotting studies. Check blood type & crossmatch, watchfor hypotension, dizziness. Monitor for infection, electrolyte loss,
Nursing care of pt w/ rhizotomy
assess corneal reflex, asses facial nerves ie) blow out cheeks, frown, wink etc. assess oculomotor muscles by following finger with eyes. assess motor portion by pt clenching teeth, apply ice pack, avoid rubbing eye on surgical side,
acromegaly
associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy and joint pain
5 and older
at what age can a child recieve a live attenuated flu vaccine via intranasal form
The nurse is having difficulty obtaining a capillary blood sample from a client's finger to measure blood glucose using a blood glucose monitor. Which procedure will increase the blood flow to the area to ensure an adequate specimen? a. Raise the hand on a pillow to increase venous flow. b. Pierce the skin with the lancet in the middle of the finger pad. c. Wrap the finger in a warm cloth for 30-60 seconds. d. Pierce the skin at a 45-degree angle.
c. Wrap the finger in a warm cloth for 30-60 seconds. The hand is lowered to increase venous flow. The finger is pierced lateral to the middle of the pad perpendicular to the skin surface.
A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. The nurse explains to the patient that the major purpose of this treatment is a. control of fluid and electrolyte imbalance. b. relief from nausea and vomiting. c. reduction of pancreatic enzymes. d. removal of the precipitating irritants.
c. reduction of pancreatic enzymes. Rationale: Pancreatic enzymes are released when the patient eats. NG suction and NPO status decrease the release of these enzymes. Fluid and electrolyte imbalances will be caused by NG suction and require that the patient receive IV fluids to prevent this. The patient's nausea and vomiting may decrease, but this is not the major reason for these treatments. The pancreatic enzymes that precipitate the pancreatitis are not removed by NG suction.
what is the name of the sores involved in syphilis
chancres
diagnosis and monitoring for posttransplant pt
check renal/hepatic fxn; monitor CBC w/ differential to monitor for s/s of infection; assess all body secretions for blood
Osteoporosis
chronic metabolic disease characterized in which bone loss causes decreased density and increased fracture risk
cushings syndrome
condition caused by hypersecretion of cortisol by the adrenal cortex resulting in breakdown of muscle protein and redistribution of body fat,
Routes of latex allergy exposure
cutaneous-latex gloves, balloons; Percutaneous/parenteral-IV lines, catheters, dialysis equip; Mucosal-latex condoms, catheters, airways, nipples; Aerosol- powder from latex gloves
Proliferative retinopathy is often treated using: a. Tonometry b. Fluorescein angiogram c. Antibiotics d. Laser surgery
d. Laser surgery Scatter laser treatment is used to shrink abnormal blood vessels in an effort to preserve vision. When there is significant bleeding in the eye, it is removed in a procedure known as vitrectomy. Tonometry is a diagnostic test that measures pressure inside the eye. A fluorescein angiogram is a diagnostic test that traces the flow of dye through the blood vessels in the retina; it is used to detect macular edema.
hyperadlosteronism (too much aldosterone) makes serum potassium:
decrease
Nursing interventions after cataract surgery
elevate hob 30-45 degrees, maintain eye patch, orient to environment, side rails, assist w ambulation
S/S of Graves disease or hyperthyroidism
elevated metabolic rate, sweating, rapid heartbeat, nervousness, and weight loss. and exophthalmos.
A nurse is caring for a client with fresh application of a plaster leg cast. THe nurse plans to prevent the development of compartment syndrom by doing what?
elevating the limb and applying ice to the affected leg. Compartment syndrom is prevented by controlling edema. This is acheived most optimally with elevation and application of ice
AIDS s/s
flu-like sx; lymphadenopathy for @ least 3mo; presence of opportunistic infections; protozoal infections; Kaposi's sarcoma; Neoplasms; Fungal, viral, bacterial infections
A client takes prednisone (Deltasone), as prescribed, for rheumatoid arthritis. The nurse should tell the client to look for common adverse reactions to this drug, such as:
fluid retention and weight gain.
Recognize changes in neurological status.
glasgow's coma scale, A&O x3, widening pulse pressure, abnormal body posturing, cushing's triad, cranial nerve checks, confusion, hallucinations, out of control emotions diagnostic tests for head injuries blood glucose, ABGs, tox screen, creatinine, BUN, liver function tests, CBC + diff, CT, MRI, LP, cerebral angiography, xray of the brain will be able to determine where the injury is, how big it is with an LP, encourage fluid intake - CSF reproduces after 24h hours when an LP is done, there is a space in the spinal column. pat may complain of HA because the air from that space naturally goes upwards, in this case towards the head. to test to see if leakage is CSF, check for glucose - see halo on gauze.
"A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:
has type 2 diabetes.
Nutrition for ppl w/ MS
have tendency to be overweight due to immobility & depression. Goal to stay at normal weight. Adjust for disphagia,
individuals at risk for latex allergy
health care workers, rubber industry workers, pt having multiple surgeries, individuals with spina bifida, people who frequently wear gloves, people allergic to kiwi, banana, avocado, tropical fruits, potatoes, hazelnuts, water chestnuts
sub Q
how are polio, MMR, and varicella vaccine route
sub q
how is meningococcal vaccine route
2 months to 4-6 years old
how old should child be for DTaP of five injections
11 - 64 years old
how old should person be to recieve Tdap one time only and a Td booster every 10 years
Myxedema
hyposecretion of thyroxine (T4) and T3 causing weakness and fatigue; increased sensitivity to cold, constipation, dry skin, unexplained weight gain, depression, facial edema, goiter, nonpitting puffy appearance
with an addisonian crisis there are what major symptoms?
hypotension and vascular collapse (NO FLUID)
cardiovascular s/s of anaphylaxis
hypotension, dysrhythmias, tachycardia, cardiac arrest
you review the pts understanding of stapedectomy which concerns you
i cant wait to get back to my weight lifting class- no straining for at least three wks, water and air- 1 wk
neomycin, gelatin, or eggs
if allergy to these, must not get an MMR.
Ataxia
inability to coordinate voluntary muscle movements
dyssynergia
inability to coordinate voluntary muscle movements
Aricept (donepezil)
is a cholinesterase inhibitor block cholinesterase the enzyme responsible for breakdown of ach in the synaptic cleft.
Which of the followig is an appropriate post op nursing intervention for the pt who has had a partial or total nephrectomy?
label and secur all caths, tubes, and drains
What is worn under the prosthesis?
limb sock
Nutrition for GB patient
may need enteral or TPN due to dysphagia. Need to positive nitrogen balance, hydrated, electrolytes balanced and sufficient calories
Hashimoto's thyroiditis
most common cause of hypothyroidism. an autoimmune disorder, causes wt gain, decreased appetite, constipation, lethargy, dry cool skin, brittle nails, coarse hair, muscle cramps, weakness and sleep apnea
during pregnancy, immuno compromised
must avoid MMR vaccine if patient has either of these
"A client visits the physician's office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves' disease. Based on history and physical findings, the nurse suspects hyperthyroidism. Exophthalmos is characterized by:
protruding eyes and a fixed stare.
Glycosylated hemoglobin level
provides information about blood glucose levels during the previous 3 months
High-risk immunosuppressed pt
pt w/ hx of malignancy or premature malignancy have increased risk of malignancy when immunosuppressed; pt w/ recent infection or exposure to TB, chicken pox, have high risk for severe generalized disease
Early S&S of HD
restlessness, fidgety, minor gait changes, freq falls, postural differences, protruding tongue, Slurred speech, decreased ability for ADL's, irritability, rage followed by euphoria, depression, suicide
A client with diabetes mellitus has had a R BKA (right below knee amputation). The nurse should monitor for what?
separtion of wound edges. Client's with diabetes mellitus are more prone to wound infection and delayed healing because of the disease
anaphylaxis
serious and immediate hypersensitivity rxn with the release of histamine from the damaged cells; can be systemic or localized
Kaposi's Sarcoma
skin lesions that primarily occur in individuals w/ compromised immune system; slow growing tumor that appears as a raised, oblong, purplish-reddish-brown lesion that may or may not be tender
how are genital warts contracted
skin to skin contact of the oral or vaginal regions
what are the symptoms of trich
slight discharge, burning during urination, pain in lower stomach, pain during sex
Processed fruit juice has lots of?
sodium
"The nurse is assigned to care for a postoperative client who has diabetes mellitus. During data collection, the client reports that he's impotent and says he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
suggest referral to a sex counselor or other appropriate professional.
treatment of Cushings syndrome
surgery, radiation, or chemotherapy Monitor weight ,I&O,Encourage turn cough & deep breathing
s/s thyroid storm
tachycardia, agitation, coma, hypotension Sweating, Hyperactivity, Tachycardia High temperature, tachypnea, Dehydration, GI disturbances, Delerium, coma
S&S of myasthenic crisis
tachycardia, tachypnea, severe resp distress, dysphagia, restlessness, impaired speech and anxiety.
rotavirus
this infection is leading cause of gastroenteritis (vomit and diarrhea) among children
haemophilus influenzae type B
this is the most common cause of meningitis in children over one month of age
pregnant or blleding disorder
what are contraindications to HPV
pregnant, immunocompromised, active TB, allergy to neomycin or gelatin
what are contraindications to varicella vaccine
siezure, pneumonia, fever UTI
what are some severe side effects for rotavirus vaccine
immuno globulin
what blood product can be given at the same time but in different sites
eggs
what food allergy causes the denial of the flu shot
stimulate immunity
what is the purpose of a live attenuated vaccine
killed or inactivated vaccine
what kind of vaccine is the Hep A vaccine
Tx Hyperthyroid:
with PTU and Methimazole and Iodine compounds and Beta Blockers (lols)-decreases anxiety, radioactive iodine
Prevalence
young adults and individuals in their 50's and 80's, more males than females, more Caucasians than African Americans
Wernicke Encephalopathy
•Confusion, ataxia, nystagmus leading to ophthalmoplegia (LR) •+/- Peripheral neuropathy •Due to Thiamine deficiency •Occurs in alcoholics (AIDS, hyperemesis, bariatric surgery) •If suspected, do not delay treatment waiting for confirmatory labs •Thiamine 50mg IV, then IM daily until improvement •IV glucose prior to supplement -> worsen pt
"Which instruction about insulin administration should the nurse give to a client?
"Always follow the same order when drawing the different insulins into the syringe.
"The nurse is caring for a patient whose blood glucose level is 55mg/dL. What is the likely nursing response? "A. Administer a glucagon injection B. Give a small meal C. Administer 10-15 g of a carbohydrate D. Give a small snack of high protein food"
"C The client has low hypoglycemia. This is generally treated with a small snack."
A client with diabetes melllitus has a blood glucose of 644mg/dl. The nurse intreprets that this client is most at risk of developing which type of acid base imbalance? "A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory Acidosis D. Respiratory Alkalosis"
"Correct Answer: A, Metabolic Acidosis Rationale: DM can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis."
The nurse is conducting the admission assessment for the client who is to undergo an arthrogram. What is the priority question the nurse should ask? a) "Are you claustrophobic?" b) "When did you last eat?" c) "When did you last urinate?" d) "Do you have any allergies?"
"Do you have any allergies?" Explanation: Many contrast dyes contain iodine. Therefore, it is essential for the nurse to determine whether the client has any allergies, especially to iodine, shellfish, and other seafood.
A client diagnosed with human immunodeficiency virus (HIV) infection states, "I'm afraid of gaining weight, so I always supplement my diet with vitamins." Which response by the nurse is appropriate?
"Eating a variety of healthy foods is the best source of vitamins."
Blood sugar is well controlled when Hemoglobin A1C is... "a. Below 7% b. Between 12%-15% c. Less than 180 mg/dL d. Between 90 and 130 mg/dL"
"a. Below 7% A1c measures the percentage of hemoglobin that is glycated and determines average blood glucose during the 2 to 3 months prior to testing. Used as a diagnostic tool, A1C levels of 6.5% or higher on two tests indicate diabetes. A1C of 6% to 6.5% is considered prediabetes."
"A client who is started on metformin and glyburide would have initially presented with which symptoms? "a. Polydispisa, polyuria, and weight loss b. weight gain, tiredness, & bradycardia c. irritability, diaphoresis, and tachycardia d. diarrhea, abdominal pain, and weight loss
"a. Polydispisa, polyuria, and weight loss"Symptoms of hyperglycemia include polydipsia, polyuria, and weight loss. Metformin and sulfonylureas are commonly ordered medications. Weight gain, tiredness, and bradycardia are symptoms of hypothyroidism. Irritability, diaphoresis, and tachycardia are symptoms of hypoglycemia. Symptoms of Crohn's disease include diarrhea, abdominal pain, and weight loss."
"(SELECT ALL THAT APPLY) A client with type 2 diabetes mellitus needs instruction on proper foot care. Which instructions should the nurse include in client teaching?
(2) Wear cotton socks. (3) Apply foot powder after bathing. (5) See a podiatrist regularly to have your feet checked.
What question would the nurse ask a pt prior to an IVP?
***1. Are you allergic to shellfish? 2. do you have burning on urination? 3. have you ever had kidney stones? 4. why are you having this test?
632. The nurse is reviewing the laboratory results in a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client?
***1. Low-protein diet 2. High-protein diet 3. Moderate-fat diet 4. High-carbohydrate diet
629. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence?
***1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain
A 58-year old woman presents at her primary care provider's office w/ symptoms of frequency, urgency, nocturia, dysuria, and cloudy, rust-colored urine for the thrid time in the past 2 years. Th nurse shold plan to include which of the following in her teaching for this patinet? Select all that paply.
***1. return to the office in 10 days for follow-up culture 2. preprocedure insturction for an IVP ***3. the potential benefits of estrogen vaginal cream ***4. recommendations for perineal cleansing 5. recommendations for screening cystoscopy
Steroid Hesi Hint**
**Many people take steroids for a variety of conditions, questions often focus on the need to teach clients the importance of following the prescribed regimen precisely. Clients should be cautioned against stopping the medications suddenly and should be informed that it is necessary to taper off the dosage when taking steroids.**
At last measurement, the client's vital signs were as follows: oral temperature 98°F (36.7°C), heart rate 76, respiratory rate 16, and blood pressure (BP) 118/60. Four hours later, the vital signs are as follows: oral temperature 103.2°F (38.5°C), heart rate 76 beats/minute, respiratory rate 14 breaths/minute, and blood pressure 120/66. Which should the nurse's first intervention be at this time? 1) Ask the client if he has had a warm drink in the last 30 minutes. 2) Notify the primary care provider of the client's temperature. 3) Ask the client if he is feeling chilled. 4) Take the temperature by a different route.
*1) Ask the client if he has had a warm drink in the last 30 minutes.*
The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider? 1) Decreased blood pressure (BP) after standing up 2) Decreased temperature after a period of diaphoresis 3) Increased heart rate after walking down the hall 4) Increased respiratory rate when the heart rate increases
*1) Decreased blood pressure (BP) after standing up* Orthostatic Hypotension
A patient tells you that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to: 1) Increased exercise. 2) Nicotine withdrawal. 3) Caffeine intake. 4) Environmental changes.
*1) Increased exercise.*
How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patient's room. 2) Place the tray in a special isolation bag held by a second healthcare worker at the patient's door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal. 4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.
*1) Place the tray in a specially marked trash can inside the patient's room.*
When should the nurse assess pain? 1) Whenever a full set of vital signs is taken 2) During the admission interview 3) Every 4 hours for the first 2 days after surgery 4) Only when the patient complains of pain
*1) Whenever a full set of vital signs is taken*
The nurse is discussing a middle-age adult male client's report of nocturia. The client has diabetes that is managed with diet and exercise as well as hypertension that is currently well-controlled with medication. The nurse should include which of the following as possible causes for his frequent urination at night? (Select all that apply.) 1. An enlarged prostate gland 2. Poorly controlled blood glucose 3. Drinking a cup of tea before bed 4. Possible side effect of his medication 5. Taking his diuretic too close to bedtime 6. Consuming too many liquids during the day
*1. An enlarged prostate gland* *2. Poorly controlled blood glucose* *3. Drinking a cup of tea before bed* *5. Taking his diuretic too close to bedtime*
Which of the following symptomatology is reflective of a lower urinary tract infection? (Select all that apply.) 1. Chills and fever 2. Nausea and vomiting 3. Frequency or urgency 4. Cloudy or blood-tinged urine 5. Pelvic tenderness or flank pain 6. Burning or pain when voiding
*1. Chills and fever* *2. Nausea and vomiting* *3. Frequency or urgency* *4. Cloudy or blood-tinged urine* *6. Burning or pain when voiding*
The nurse instructs the client that before the fecal occult blood test (FOBT) she may eat: 1. Whole wheat bread 2. A lean, T-bone steak 3. Veal 4. Salmon
*1. Whole wheat bread*
The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum? Choose all that apply. 1) 2 inches 2) 3 inches 3) 4 inches 4) 5 inches
*2) 3 inches* *3) 4 inches* When administering an enema, the nurse should insert the tubing about 3 to 4 inches into the patient's rectum. Two inches would not be effective because it would not place the fluid high enough in the rectum. Five inches is too much.
An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client: 1) Experiences less pain than in earlier stages of cancer. 2) Cannot communicate the character of his pain effectively. 3) Recalls pain at a later time than when it occurs. 4) Relies on caregiver to provide pain relief without asking.
*2) Cannot communicate the character of his pain effectively.*
In which situation would using standard precautions be adequate? (Select all that apply.) 1) While interviewing a client with a productive cough 2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter
*2) While helping a client to perform his own hygiene care* *3) While aiding a client to ambulate after surgery* *4) While inserting a peripheral intravenous catheter*
Which of the following statements made by a nurse discussing the effect of an antibiotic on the gastrointestinal system reflects the best understanding of the possible occurrence of diarrhea? 1. "The GI tract naturally rids itself of bacterial toxins by increasing peristalsis, and that causes diarrhea." 2. "The antibiotic is responsible for killing off the GI tract's normal bacterial, and diarrhea is the result." 3. "For some, antibiotics irritate the mucous lining of the intestines, causing decreased absorption and diarrhea." 4. "When you are taking an antibiotic, your body is fighting off an infection, and peristalsis is faster and so diarrhea occurs."
*2. "The antibiotic is responsible for killing off the GI tract's normal bacterial, and diarrhea is the result."*
The nurse knows that which of the following habits may interfere with a client's sleep? 1. Listening to classical music 2. Finishing office work 3. Reading novels 4. Drinking warm milk
*2. Finishing office work* At home a client should not try to finish office work or resolve family problems before bedtime. Noise should be kept to a minimum. Soft music may be used to mask noise if necessary. Reading a light novel, watching an enjoyable television program, or listening to music helps a person to relax. Relaxation exercises can be useful at bedtime. A dairy product snack such as warm milk or cocoa that contains L-tryptophan may be helpful in promoting sleep.
While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should: 1. Immediately stop the infusion 2. Lower the height of the enema container 3. Advance the enema tubing 2 to 3 inches 4. Clamp the tubing
*2. Lower the height of the enema container*
Optic neuritis
inflammation of the optic nerve
Hypoparathyroidism
Hyposecretion of calcitonin resulting in hypocalcemia and hyperphosphatemia
Conjunctivitis Pt Education
Use of meds, washing hands, not touching eyes
What is a fasciculation
fine muscle twitches that are not normally present
Insulin
Stimulates protein synthesis
Nursing interventions for fatigue
Assess, arrange for rest periods, Prioritize activities, avoid temp extremes (hot showers), relieve pain. referrals to groups as needed
Nursing interventions for self-care deficit
Assess, suggest adaptive devices, teach intervetions r/t altered bowel/bladder function
what are symptoms of HIV
flulike symptoms, but after those go away there is no sign
Later Nursing care of HD
focuses on immobility, altered nutrition, impaired communication and self-care deficits.
what long term damage can a yeast infection lead to
food allergies, mood swings, spreading of the infection
Recovery stage of GB
may take months to 2 years. generally muscle strength and function return in descending order.
How can a nurse best protect herself after she experiences a minor allergic reaction to latex?
Avoid use of all latex products.
wait 3 - 11 months
wait this long after a immune serum globulin or blood products before giving an MMR vaccine
how do you prevent crabs
wash sheets often
relapsing- remitting MS
characterized by periodic remissions and exacerbation of symptoms. Most common
what can you NOT do if on your period while you have a yeast infection
wear a tampon
Hypothyroid is aka:
Myxedema
1-2 hr
Onset of action of intermediate insulins
Most common cause of Cushing's syndrome
a corticotropin-secreting pituitary adenoma
addisonian crisis
caused by deficiencies of cortisol and aldosterone
medication for gonorrhea only
cures symptoms, but not the long- term damage
tx for spasticity, neurogenic bladder, and fatigue?
symptomatic therapy
Immunosupressants that help with MS?
-cyclophosphamide -azathioprine -methotrexate -cladribine -mitoxantrone
What percent of ALS is familial?
10%
"Every morning a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?
70% NPH insulin and 30% regular insulin
Which of the following blood types would the nurse identify as the rarest?
AB
Identify specific medications and usage for various sign/symptoms of MS.
ABC+R - Avonex, Betaseron, Copaxone. All for relapsing and/or reducing lesions.
3
A nurse is planning a workshop on health promotion for older adults. Which topic will be included? 1. prevention of falls 2. cardiovascular risk factors 3. adequate sleep 4. how to stop smoking
"The nurse understands that for the parathyroid hormone to exert its effect, what must be present?
Adequate vitamin D level
What is the priority nursing intervention used with clients taking NSAIDs?
Administer or teach client to take drugs with food or milk.
"The nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?
An irregular apical pulse
fatigue
Antdepressants, Ritalin, Antiviral agents (Symmetral)
Describe the phases of a tonic-clonic seizure.
Aura: bright light Tonic phase: muscles are rigid with the arms extended and jaws clenched Clonic phase: movements are jerky as the muscles alternately contract and relax Postictal phase: the pt is unconscious for 30 minutes and then regains conciousness slowly
Which nursing intervention takes priority for a client infected with Pneumocystis carinii pneumonia?
Auscultating breath sounds
spasticity
Baclofen, Dantrium, Vallium, Zanaflex, Klonopin
The nurse is teaching the parent of a diabetic child how to recognize the signs and symptoms of hypoglycemia. Which signs and symptoms should the nurse discuss with the parent?
Behavioral changes, increased heart rate, sweating and tremors
The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction?
Bronchospasm
What is the most famous type of skin traction?
Buck's (used most often with hip and femoral fractures) Must do a good skin assessment with these
ADH-Antidiuretic hormone
Desmopressin (DDAVP) -Acts on kidneys & blood vessels, helps prevent the loss of water from the body by reducing urine output, raises BP by constricting blood vessels Tx-DI Vasopressin (Pitressin) -Helps prevent the loss of water from the body by reducing urine ouput.
A client in the recovery room after a thyroidectomy is asked frequentlyh by the nurse to speak. The rationale for the nurse continuing to evaluate the client's voice is to.
Detect spasms or edema in the area of the vocal cords.
"An obese Hispanic client, age 65, is diagnosed with type 2 diabetes mellitus. Which statement about diabetes mellitus is true?
Diabetes mellitus is three times more common in Hispanics than in Blacks or Whites.
Since the client has too much aldosterone in Cushing's, the serum K+ will go ______.
Down.
Grave's disease
Form of hyperthyroidism causing exophthalmos
Osteoporosis: risk for ____________
Fractures
How long will hypothyroid patients be taking meds such as Levothyroxine (Synthroid), Thyroglobulin (Proloid), & Liothyronin (Cytomel)?
FOR LIFE!
PTU
GI irritation, skin rash, pruritis, agranulocytosis (report s/s of sore throat or fever) Results achieved in several weeks
What are the common side effects of salicylates?
GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation.
Glucagon Hydrochloride
Given to type 1 DM
Diagnosis of MG
H&P, tensilon tests, nerve stimulation studies and analysis of antiacetycholine receptor antibodies.
trich can lead to what is exposed
HIV
what is the most common STD
HPV
which virus has warts
HPV
human papillomavirus infection
HPV stands for
"A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion?
Hydrocortisone
Which immunoglobulin is specific to an allergic response?
IgE
Type 1 Diabetes Treatment
Insulin, diet
thyroid storm
LIFE THREATENING crisis of uncontrolled hyperthyroidism caused by the release into the bloodstream of increased amount of thyroid hormone; , associated with: .
Which of the following is an inaccurate clinical manifestation of a fracture? a) Lengthening b) Deformity c) Pain d) Crepitus
Lengthening Explanation: Clinical manifestations of a fracture include crepitus, deformity pain, shortening, and loss of function.
The client presents with an exaggeration of the lumbar spine curve. The nurse interprets these findings as indicative of: a) Dowager's hump b) Scoliosis c) Lordosis d) Kyphosis
Lordosis Explanation: Lordosis is an exaggeration of the lumbar spine curve.
Hyperthyroid s/sx mimic what other d/o?
Manic
"Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
Neck vein distention
UMN symptoms
Occur due to loss of inhibition of mm - Spasticity, clonus, (+) Babinski, Dysarthria, dysphagia, emotional lability. Fatigue, Oral motor impairment, Fasciculations, spasticity, motor paralysis, Respiratory paralysis, Bowel and bladder remain untouched
With sex hormone overload you may see
Oily skin/acne, women with male traits and poor sex drives or labido
5-15 min
Onset of action of rapid acting insulins
"A nurse administers glucagon to her diabetic client and then monitors the client for adverse drug reactions and interactions. Which type of drug interacts adversely with glucagon?
Oral anticoagulants
Type 2 Diabetes Treatment
Oral meds, insulin, diet, exercise
1-2 hr
Peak of action of rapid acting insulins
What measures should the nurse encourage female clients to take to prevent osteoporosis?
Possible estrogen replacement after menopause; high calcium and vitamin D intake beginning in early adulthood; calcium supplements after menopause; and weight-bearing exercise.
Pemphigus
Potentially fatal; a group of related d/o including vulgarism, vegetans, foliaceus, and erythematosus; rare autoimmune disease that occurs b/w middle and old age; cause unknown
Estrogens
Premarin (cream)-used to treat the vag. symptoms of menapause such as dryness, burning, irritation & painful sex. Estradiol-used to treat symptoms of menopaus, prevention of osteoporosin in post menopausal, replacement with ovarian failure.
Discuss the nursing care for the patient with increased ICP.
Prevent IICP, and avoid the complications of IICP (ie; ineffective breathing patterns, cerebral edema, IICP, coma, brain herniation)
Osteoarthritis
Progressive loss of joint function characterized by pain
aldosterone
promotes Na conservation and K excretion.
Insulin
Promotes conversion of glucose to glycogen for storage
A nurse is caring for a client who is experiencing the end-stage of acquired immunodeficiency syndrome (AIDS) . What is the goal of treatment for this client?
Promoting client comfort
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
Reduced sneezing
Only kind of insulin can be given IV
Regular
mineralocorticoids
Regulate sodium and electrolyte balance (aldosterone, corticosterone, deoxycorticosterone)
fluids
Replacing ________ is the first treatment of hyperglycemic hyperosmolar nonketotic coma
An older adult P/T has limited immobility as a result of a surgical repair of a fracture hip. During assessment you note that the P/T cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)
Respiration's 26 per minute on room air; HR 114; Crackles heard on auscultation.
AIDS interventions
Respiratory support; psychosocial support; Fluid/electrolyte balance; Prevent and monitor infection; Standard precautions; Meticulous skin care; Nutritional support
Liver biopsy:
Right side position post procedure to prevent patient from bleeding.
Pharmacolgocial intervention For ALS
Rilutek (stop progression) Anti-depressants Antispasticity
medcations of ALS
Riluzole: antiglutamate. Inhibits presynaptic release of glutamic acid in CNS and protect neurons. Monitor for liver function, blood count, alkaline phosphatase.
"Which nursing diagnosis is most appropriate for a client with Addison's disease?
Risk for infection
After an extensive diagnostic workup, a client is diagnosed with systemic lupus erythematosus (SLE). Which statement about the incidence of SLE is true?
SLE tends to occur in families.
symptoms of CAD are:
SOB, chest pain and increased pulse.
List three symptoms which may be present in CP.
Seizures, poor sucking, difficulty feeding.
MS Gait Problems
Staggering, Wide BOS, Poor foot placement, Slow uncoordinated progression of LE, Poor ability to produce reciprocal movement
Types of Skeletal traction
Steinman pins Crutchfield Gardner-Wells tongs Halo vest
catecholamines
Stimulate the "fight or flight" response to danger; sympathetic nervous system response (epinephrine, norepinephrine)
Androgens
Testosterone-used in men & boys to treat conditions caused by lack of hormone Virilon-stimulate growth in many tissues especally bone and muscle.
A P/T of any age can develop a contracture of a joint when:
The muscle fibers become shortened because of disuse.
The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour
"A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by:
a corticotropin-secreting pituitary adenoma.
B
Which of the following statements accurately describes mild cognitive impairment. (select all that apply) a. always progresses to AD b. Caused by variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that if treated will delay progression to AD c. Patient is usually not aware that there is a problem with his or her memory.
2
While hospitalized a client is very worried aboiut business activities. The client spends a great deal opf time on the phone and with collegues instead of resting. Which principle of need therapy applies to this client? 1. his higher level need cannot be met unless the lower level physicological need is met 2. His lower level physiological needs are being deferred while higher need are addressed. 3. The higher need takes precedence and the lower need no longer must be met. 4. It is necessary for someone else to meet his higher level needs so he can focus on the lower level needs.
"A client with type 1 diabetes tells a nurse in the clinic, ""I sometimes skip my insulin dose in the morning so I won't gain back any of the weight I've lost."" Which of the following would be an appropriate response for the nurse to make to this client?
You are worried about your weight? There are safer ways to prevent weight gain.
allergy
abnormal, individual response to certain substances that normally do not trigger such an exaggerated rxn
Dyesthesias
abnormal, unpleasant sensation [burning, numbness, pins and needles, tingling]
Exacerbation
action that makes a problem or a disease (or its symptoms) worse
Scleroderma interventions
activity as tolerated, constant room temp, small frequent meals, with no spicy food, if esophagus involved, remain sitting for 1-2hrs after eating, corticosteroids for inflammation, emotional support
Cortisol is a hormone of the __________
adrenal cortex
What glands help you handle stress?
adrenal glands. The adrenal medulla secretes epi and norepi
Epi and nor epi mean:
adrenaline and noradrenaline :)
Patients with type 1 diabetes mellitus may require which of the following changes to their daily routine during times of infection? "a. no change b. less insulin c. more insulin d. oral diabetic agents"
answer C: during times of infection and illness diabetic patients may need even more insulin to compensate for increased blood glucose levels.
Patho of Myasthenia Gravis
antibiodies destroy or block neuromuscular junction receptor sites, decreasing the number of acetylcholine receptors. Net result is decrease in muscles ability to contract.
what can be clamyida be treated with
antibiotics
what is known as the silent disease
clamydia
which of the follow should be immediately reported to hcp
curtain-like shadow across visual field- detached retina surgical emergency
Skin Test: Preprocedure
d/c corticosteroids/antihistamines 5 days before test; Obtain Informed Consent; Be prepared for anaphylactic shock for scratch test
Plasmapheresis
filtration of the plasma to remove some of the proteins
secondary progressive MS
gradual deterioration w/ or w/o relapses.
progressive- relapsing
gradual progression of neurological deterioration w/ super-imposes relapses.
hyperthyroidism
grave's disease and thyrotoxicosis
older than 5 years old
if healthy, pt might not need the HIB vaccine who is older than __
within 3-5 days
if pt. is exposed to varicella can the vaccine be given after.
Secondary Progressive MS
initial relapsing-remitting disease course followed by disease progression at varying rates - minor remissions and plateaus may occur during this progression
Nystagmus
involuntary movements of the eyeballs
Cerebral Arteriography
is a form of medical imaging that visualizes the arterial and venous supply of the brain. It was pioneered by Dr Egas Moniz in 1927, and is now the gold standard for detecting vascular problems of the brain.
diabetes insipidus
is a result of ADH defeicency may result from a brain tumor or infections pituitary surgery, CVA or renal or organ failure
how do you contract herpes
it can only be contracted during an outbreak on the person infected
diabetic ketoacidosis
kussmaul's respirations, dry skin, hypotension, bradycardia
will addison's be gaining or losing weight?
losing - not keeping their water
The edges of a cast can be petaled with tape to do what
minimize skin iritation
What is nursing care after bone biopsy
mointoy site for swelling, bleeding, and hematoma formation elevate site for 24 hours to reduce edem monitor vitals every four hourse for 24 hours. The client usually requires mild analgesics, more sever pain usually indicates that complication are arising
Addisons disease care
monitor I&Os, weight, electrolytes levels
"A client with diabetes mellitus has just been prescribed insulin. When teaching the client about hypoglycemia, the nurse should mention that this reaction may cause:
nervousness, diaphoresis, and confusion.
decerebrate posturing
posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe.
other meds for MG
prednisone, immunosupressants (cyclosporine/Imuran)
Recognize patient's response to SC injury (anger, grief, hopeless or suicidal) .
preventions: allow the client time to grieve or to express denial, depression, and anger over the changes in social, financial, and personal roles - the patient needs time to adjust to lifestyle changes. provide accurate information based on the physician's prognosis. include family and significant others to treat the client as normally as possible. refer the client and family to support groups.
active acquired immunity
produced from immunization
What to do with open fractures
sterile-dressing covering
thyroid scan
stop ingestion of iodine (iodized salt, seafood), do not take prescribed thyroid medication because it may interfere with the scan
A client has slight weakness in the right leg. Based on this information, teh nurse determines that the client would benifit most from the use of a
straight-leg cane is useful for the client with slight weakness in one leg
meds for HD: antidpressants
supplement counseling, but doesn't replace.
Dysdiadicokinesia
the inability to switch on and switch off antagonising muscle groups
Dysarthria
the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system
steriods decrease serum calcium how?
they exrete it through the GI tract.
hypercortisolism is just another word for
too many steriods
how are crabs treated
topical treatments and soaps
After being admitted to the hospital with sickle cell crisis, a client asks a nurse how he can prevent another crisis. Which response by the nurse is best?
"Make sure that you drink plenty of fluids."
Compare and contrast the different types of seizures in children.
...
Compare the symptoms of PDD, Autism and Down syndrome.
...
633. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom(s) of duodenal ulcer?
1. Weight loss 2. Nausea and vomiting ***3. Pain relieved by food intake 4. Pain radiating down the right arm
645. The client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times?
1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime ***4. One hour before meals and at bedtime
Retinal detachment assessment findings
19. Assessment findings are flashes of light, floaters, increase in blurred vision, sense of a curtain coming over eye, loss of portion of visual field, painless loss of central or peripheral vision.
SIADH
Continued release of antidiuretic hormone resulting in water intoxication
Rheumatoid Arthritis
DESCRIPTION: Chronic, systematic, progressive deterioration of the connective tissue (synovioum) of the joints; characterized by inflammation. The exact cause is unknown but it is classified as an immune complex disorder, autoimmune. Joint involvement is bilateral and symmetrical. Severe cases may require joint replacement. NURSING ASSESSMENT: Fatigue; Generalized weakness; Weight loss; Anorexia; Morning stiffness; Bilateral inflammation of joints with: decreased ROM, joint pain, warmth, edema, erythema (rash). Joint deformity. DIAGNOSIS: Elevated erythrocyte sedimentation rate (ESR); Positive rheumatoid factor (RF). Presence of antinuclear antibody, positive (ANA). Joint-space narrowing indicated by arthroscopic examination, (provides joint visualization). **Spongy and boggy joints** Abnormal synovial fluid (fluid in joint) indicated by arthrocentesis. C-reactive protein (CRP) indicated by active inflammation. NANDA: Chronic pain r/t..... ** antidepressants usually ordered.** NURSING INTERVENTIONS: A. Pain relief measures: 1. Use moist heat. Warm, moist compresses, Whirlpool baths, Hot shower in the morning. 2. Use diversionary activities. Imaging, Distraction, Self-hypnosis, Biofeedback. 3. Administer meds and teach client about meds. B. Provide periods of rest after periods of activity: 1. Encourage self-care to maximal level. 2. Allow adequate time for the client to perform activities. 3. Perform activities during time of day when client feels most energetic. C. Encourage the client to avoid overexertion and to maintain proper posture and joint position. D. Encourage use of assistive devices to promote funtional ADL's: 1. Elevated toilet seat. 2. Shower chair. 3. Cane, walker, wheelchair. 4. Reachers. 5. Adaptive clothing and shoes with velcro closures. 6. Straight-backed chair with elevated seat. (remember you can build up a chair with pillows if needed). Develop a teaching plan to include the following: 1.Medication regimen. 2. Need for routine follow-up for evaluation of possible side effects. 3. ROM and stretching exercies tailored to specific client needs. 4. Safety tips and precaustions about equipment use and environment. ***Early diagnosis is better because DMAR's can be given to prevent joint deformity***
Amputation
DESCRIPTION: Surgical removal of a diseased part or organ. Causes for amputation include the following: Peripheral vascular disease, 80% (75% ar diabetics). Trauma. Congenital deformities. Malignant tumors Infection. Amputation necessitates major lifestyle and body-image adjustments. NURSING ASSESSMENT: Prior to amputation, symptoms of peripheral vascular disease include: Cool extremity. Absent peripheral pulses. Hair loss on affected extremity. Necrotic tissue or wounds: blue or blue-gray, turning black. Drainage possible with or without odor. Leathery skin on affected extremity. Decrease of pain sensation in affected extremity. Inadequate circulation is determined by: Arteriogram and Doppler flow studies. NURSING PLANS AND INTERVENTIONS:Provide wound care: Mark dressing for bleeding, and check marking at least every 8 hours. Measure suction drainage every shift. Change dressing as needed (physician usually performs initial dressing change): ****large tourniqiet at bedside for frank hemorrhage**** Maintain aseptic technique. Observe wound color and warmth. Observe for wound healing. Monitor for signs of infection: fever, tachycardia, redness of incision area. Maintain proper body alignment in and out of bed. Position client to relieve edema and spasms at residual limb (stump) site. ***Elevate stump for the first 24 hours postop*** Do not continually elevate stump after 48 hrs postop. (can cause contracture). Keep stump in extended position, and turn client to prone position three times a day to prevent hip flexion contracture. Be aware that phantom pain is real; it will eventually diappear, and it responds to pain meds. Handle affected ody part gently and with smooth movements. Provide passive ROM until client is able to perform active ROM. Collaborate with rehab team members for mobility improvement. Encourage independence in self-care, allowing sufficient time for client to complete care and to have input into care.
"A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, which test should be performed?
Glycosylated hemoglobin level
don't give varicella vaccine
If pt. is HIV can they get the varicella vaccine
Elevated sedimention rate, morning stiffness occure in
RA
what can occur with clamydia and gonorrhea
ecoptic pregnancy
"A nurse administers bromocriptine (Parlodel) to a client diagnosed with acromegaly. After administering the medication, the nurse realizes that she gave the medication to the wrong client. What could have been done to prevent this error?
Verifying the client's identity on the identification band and medication administration record before providing the medication
Fractures Hesi Hint #2
What type of fracture is more difficult to heal: an extracapsular fracture (below the neck of the femur) or an intracapsular fracture (in the neck of the femur)? The blood supply enters the femur below the neck of the femur. Therefore, an intracapsular fracture heals with greater difficulty, and there is a greater likelihood that necrosis will occur because the fracture is cut off from the blood supply.
Mineralocorticoids are:
aldosterone
Causes of SLE
cause unknown; thought to be due to a defect in the immunological mechanisms, possibly genetic origin
cholinergic crisis
caused by overdose of anticholinesterase meds.
Diplopia
double vision, occurs when the mm that control the eyes are not well coordinated
increased ACTH = __________ cortisol level.
increased
tetanus
lock jaw msucle spasms and rigidity causing possible death
For pts with relapsing-remitting disease or secondary progressive, what helps to reduce the frequency of exacerbations?
long term beta-interferon or SQ glatiramer acetate
which herpes simplex IS a STD
simplex 2
stool
where can the Hep A virus be found
neomycin
what antibiotic causes the Hep A vaccine to be contraindicated
Which is the most commonly reported "incident" in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4) Treatment delays
*2) Patient falls* Patient falls, usually in an attempt to go to the bathroom
A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The nurse's most appropriate response to her would be:
"You seem angry. Would you like to talk about it?"
Which urine specific gravity would be expected in a patient admitted with dehydration? 1) 1.002 2) 1.010 3) 1.025 4) 1.030
*4) 1.030* Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity less than 1.010 indicates fluid volume excess, such as when the patient has fluid overload (too much IV fluid) or when the kidneys fail to concentrate urine. Specific gravity greater than 1.025 is a sign of deficient fluid volume that occurs, for example, as a result of blood loss or dehydration.
The nurse is visiting the client who has a nursing diagnosis of urinary retention. Upon assessment the nurse anticipates that this client will exhibit: 1. Severe flank pain and hematuria 2. Pain and burning on urination 3. A loss of the urge to void 4. A feeling of pressure and voiding of small amounts
*4. A feeling of pressure and voiding of small amounts*
The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen? 1. Apply sterile gloves for the procedure. 2. Restrict fluids before the specimen collection. 3. Place the specimen in a clean urinalysis container. 4. Collect the specimen after the initial stream of urine has passed.
*4. Collect the specimen after the initial stream of urine has passed.*
The nurse determines that the nursing diagnosis stress urinary incontinence related to decreased pelvic muscle tone is the most appropriate for an oriented adult female client. A therapeutic nursing intervention based on this diagnosis is to: 1. Apply adult diapers 2. Catheterize the client 3. Administer Urecholine 4. Teach Kegel exercises
*4. Teach Kegel exercises*
The nurse recognizes that a client recovering from anesthesia required for surgical repair of a fractured ulna is likely to experience difficulty urinating primarily because of: 1. The impaired cognitive state the client will experience as the effects of the anesthesia wear off 2. The decreased volume of orally ingested fluids before, during, and after the surgical procedure 3. The length of time the client was under the effects of general anesthesia required for the surgical procedure 4. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder
*4. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder*
Discuss safety measures for a patient in status epilepticus.
...
The client at greatest risk for developing adverse effects of immobility is a: 1. 3-year-old child with a fractured femur 2. 78-year-old man in traction for a broken hip 3. 48-year-old woman following a thyroidectomy 4. 38-year-old woman undergoing a hysterectomy
2. 78-year-old man in traction for a broken hip
"The client diagnosed with type 1 diabetse is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (6 units); >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to thenurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client?
3 unitsThe client's result is 189, which is between 151 and 200, so the nurse should administer 3 units of Humalog insulin subcutaneously.
The post-amputation client is seen by the home health nurse. One client outcome included preventing exposure to infection. Which finding would indicate to the nurse that this outcome was met? a) Decreased need for pain medication b) Absence of fever c) Decreased activity tolerance d) Increased participation in self- care
Absence of fever Explanation: Fever would be an indication of infection.
Which of the following statements made by a family member of a client recently diagnosed with early stages of Alzheimer's disease is most reflective of an understanding of this disease process? A. "Dad has always been a fighter; he'll fight this too. He won't give up." B. "We have an appointment with his care provider to see about medication therapy." C. "Good thing we found out about this early so we can prevent this from getting worse." D. "We have a made arrangements to discuss nursing home placement for dad."
B. "We have an appointment with his care provider to see about medication therapy."
4
Based on the life changes index which individual would have an increased possibility of illness in the near future? 1. A 25 year old man who recently married his high school sweetheart 2. 1 35 year old man fired from his job 3. a 40 year old woman beginning a nursing program 4. 50 year old woman whos husband died a month ago
Explain the use of emergency equipment for patients with a seizure disorder.
Bite stick Suction O2
The client tells the nurse that the client really misses having sugar with tea in the morning. What is an alternative that the nurse could advise them to help sweeten their drink. a. Oatrim c. sucralose b. Olestra d. tannin
C Aspartame is the generic name for a sweetener composed of two amino acids, phenylalanine and aspartic acid. Olestra and Oatrim are fat replacers and tannin is an acid found in some foods such as tea.
A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
Compatible blood and tissue types
When caring for a patient admitted post-stroke (CVA) who has altered consciousness, the nurse should place the patient in which position? 1. side-lying 2. supine 3. prone 4. semi-Fowler's
Correct Answer: 1 Rationale: The side-lying position is the safest position to allow adequate drainage of fluids without aspiration.
"A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
Exercise and a weight reduction diet
Describe symptoms that may indicate a change in LOC.
Irritability Restlessness Personality changes Short-term memory changes Disorientation to place, time, and person
Name two signs of hypocalcemia?
Muscle and abd cramps, positive chvostek's and trousseau's sign
Identify the categories of drugs commonly used to threat arthritis.
NSAIDs, of which salicylates are the cornerstone of treatment, and corticosteroids (used when arthritic symptoms are severe).
anti-dsDNA antibody results
Negative: <70units by ELISA; Borderline: 70-200units; Positive: >200units
Before transferring a P/T from the bed to a stretcher, which assessment data does the RN need to gather? (Select all that apply."
P/T weight, P/T level of cooperation; P/T ability to assist; Presence of medical equipment.
Long Acting Insulin
PM Lantus -onset: 1-1.5 hours -peak: none -duration: 20-24 hours
4-8 hr
Peak action of intermediate insulins
Calcium
Postoperatively for thyroidectomy, check for _____________ deficiency due to removal of parathyroid
Primary Lateral Sclerosis
Purely an upper motor neuron deficit in the limbs -the tract involved is the Lateral Corticospinal Tract
Joint Replacement Hesi Hint #2
Questions about joint replacement focus on complications. A big problem after joint replacement is infection.
"A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
Restricting fluids
Pedi HH #4
Skeletal disorders affect the infant's or child's physical mobility and typical questions focus on appropriate toys and activities for the child who is confined to bed rest and is immobilized.
Pedi HH #2
Skin traction for fx reduction should not be removed unless HCP prescibes its removal.
Insulin
Stimulates active transport of glucose into muscle and adipose tissue Stimulates protein synthesis Promotes conversion of glucose to glycogen for storage Promotes conversion of fatty acids into fat
Insulin
Stimulating active transport of glucose into muscle and adipose tissue
Hypothyroidism
Weight gain Bradycardia Fatigue Cold intolerance Constipation Cool skin Dyspnea Muscle weakness Non-pitting edema Slow response & speech
hyperthyroidism
causes goiter, nervousness, heat intolerance and weight loss despite increased appetite
hypocalcemia
causes muscle twitching, numbness or thingling of the lips, fingers and toes (signs of hyperirritability of the nervous system)
what can HPV lead to
cervical and penile cancers
what are complications of gonorrhea
infertility, meningitis, joint infections
A client with allergic rhinitis is prescribed loratadine (Claritin). On a follow-up visit, the client tells the nurse, "I take one 10-mg tablet of Claritin with a glass of water two times daily." The nurse concludes that the client requires additional teaching about this medication because:
loratadine should be taken once daily for allergic rhinitis.
What is Huntington's disease
progressive, degenerative, inherited neurological disease= progressive dementia, and jerky, rapid involuntary movements. Onset is in 30's.
"The nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will prescribe daily supplements of calcium and:
vitamin D.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
"Client will exhibit no signs or symptoms of aspiration."
Polydipsia and poly uria related to diabetes mellitus are primarily due to: "a.The release of ketones from cells during fat metabolism b. Fluid shifts resulting from exposure to high levels of hyperglycemia c. Damage to the kidneys from exposure to high levels of glucose d. changes in RBCs resulting from attachemnt of excessibe glucose to hemoglobin"
"Coorect answer: d. Rationale: The osmotic effect of glucose produces the manifesatiaions of polydispsia and poly uria."
"(SELECT ALL THAT APPLY) A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms?
(1) Numbness (3) Tingling (4) Muscle twitching and spasms
The physicain has ordered omeprazole 20 mg twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 g daiy for a pt w/ PUD. It is most important for the nurse to instruct the pt to do which of the following?
***1. stop the drugs immediately and notify the physician if a rash, hives, or itching develop. 2. consume 8 oz of yogurt or buttermilk daily while taking these drugs 3. take drugs on empty stomach, 1 hour before breakfast and at least 2 hours after dinner. 4. take drugs w/ full glass of water
Common areas for compartment syndrome
-quads -forearms
"Which of the following is accurate pertaining to physical exercise and type 1 diabetes mellitus? "1. Physical exercise can slow the progression of diabetes mellitus. 2. Strenuous exercise is beneficial when the blood glucose is high. 3. Patients who take insulin and engage in strenuous physical exercise might experience hyperglycemia. 4. Adjusting insulin regimen allows for safe participation in all forms of exercise."
1) physical exercise can slow the progression of diabetes mellitusRationale: Physical exercise slows the progression of diabetes mellitus, because exercise has beneficial effects on carbohydrate metabolism and insulin sensitivity. Strenuous exercise can cause retinal damage, and can cause hypoglycemia. Insulin and foods both must be adjusted to allow safe participation in exercise.
A pt admitted w/ possible kidney stones develops sudden complaints of acute crampy pain on the left side that radiates into the groin. He is nauseated, and vomits clear fluid. On voiding, his urine is pink. The most appropriate response by the nurse is which of the following?
1. obtain a bladder scan to assess for residual urine 2. adminster the rpescribed narcotic analgesic ***3. notify the physician 4. strain all urine
The nurse caring for a pt preparing to under gemodialysis includes which of the following in the plan of care? select all that apply
1. obtain wt and orthostatic vital signs 3. monitor serum creatinine, BUN, and hematocrit levels
Which of the following nursing interventions are of highest priority when caring for a pt w/ small bowel obstruction?
1. placing the pt in semi-Fowler's position ***2. maintaining NG sunction 3. keeping strict I&O records 4. administering prescribed analgesics
Your patient assigned to you has pneumonia. You are reviewing the age-related changed involved with the older adult. Select all age-related changes of the respiratory system that apply. 1. Decreased in residual lung volume 2. Decreased gas exchange 3. Decreased cough efficiency 4. Increased gas exchange
2. Decreased gas exchange 3. Decreased cough efficiency
One reason for medication problems in the elderly is that 1. Regular use of laxatives increases absorption of medications 2. Decreased renal function slows excretion of drugs 3. Enhanced sense of taste of medications 4. Increased perception of pain from injections
2. Decreased renal function slows excretion of drugs
When caring for an older adult patient, the nurse uses the following interventions to accommodate visual changes with age: A. Eye glasses in the bedside table. B. Adequate lighting and uncluttered walkways. C. Draw drapes in room to prevent glare. D. Keep bedside rails down.
B. Adequate lighting and uncluttered walkways.
The leading cause of injury and preventable source of mortality and morbidity in older adults is 1. presbycusis. 2. car accidents. 3. pneumonia. 4. falls.
4. falls.
When a client learned that the symptoms of diabetes were caused by high levels of blood glucose the client decided to stop eating carbohydrates. In this instance, the nurse would be concerned that the client would develop what complication? a. acidosis b. atherosclerosis c. glycosuria d. retinopathy
A When a client's carbohydrate consumption is inadequate ketones are produced from the breakdown of fat. These ketones lower the pH of the blood, potentially causing acidosis that can lead to a diabetic coma.
Myxedema Coma
Complication of Hypothyroidism Resp depression, reduced cardiac output, and cerebral hypoxia Life-threatening Bradycardia, hypoglycemia, Hypotension, Resp depression, stupor, Hypothermia.
27. A patient recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood. b. when an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products. c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic. d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones.
D Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. The other responses are inaccurate. Cognitive Level: Application Text Reference: pp. 1278-1279 Nursing Process: Implementation NCLEX: Physiological Integrity
The nurse is caring for a client who is 8 hours post thyroid ectomy. What are important nursing interventions for this client?
Have the client speak every 2 hours to determine increasing level of hoarseness. Evaluate behind the neck for the presence of blood from the incision. Maintain the client ot semifowler's position. Check the incision for formation of a hematoma.
Hyperparathyroidism
Hypersecretion of calcitonin resulting in hypercalcemia and hypophosphoremia causing loss of calcium from bones into serum, kidney stones and hyperuricemia, osteoporosis, muscle weakness, polyuria and polydipsia
Discuss the nursing care for patients with Alzheimer's disease.
Nursing care focuses on assisting the client and caregiver to maintain the highest quality of life. Diags: Disturbed Thought Process, Self-Care Deficits, Caregiver Role Strain
Identify support systems available to patient and family.
Teach about psychological support, respite care, community resources such as home health agency, meals on wheels, elder care, sources for special adaptive equipment, support groups and stroke clubs.
Reinforce teaching to patient/family healthy lifestyle choices.
Talk about changing modifiers to prevent future TIAs or CVAs: controlling hypertension (stress, meds), reinforcing the benefits of anticoagulant therapy and other info about medications, low-cholesterol and low-fat diet to reduce arteriosclerosis, etc. when to seek medical care; complications such as aspiration, pneumonia, UTI, skin breakdown; safety measures to prevent falls; psychologic support.
S/S hypothyroidism
a lowered basal metabolism rate with obesity, dry itchy skin, slow pulse, fluid retention and edema hoareness, sluggishness, and goiter, decreased b/p ,slowed heart rate, respiratory rate, fatigue, cold intolerance and weight gain.
A nurse cares for a client following a liver biopsy. Which nursing care plan reflects proper care? a. Position in a dorsal recumbent position, with one pillow under the head b. Bed rest for 24 hours, with a pressure dressing over the biopsy site c. Position to a right side-lying position, with a pillow under the biopsy site d. Neurological checks of lower extremities every hour
c. Position to a right side-lying position, with a pillow under the biopsy site Positioning the client in a right side-lying position with a pillow under the biopsy site reflects proper care. Answer 1 does not permit the necessary pressure applied to the biopsy site. B ed rest is only required for several hours. There is no reason to do neurological checks.
Early Nursing care of HD
centered on teaching about disease, psych support, genetic counseling,
autumn
what time of year is the flu shot to be given
A 54-year-old patient admitted with type 2 diabetes, asks the nurse what "type 2" means. Which of the following is the most appropriate response by the nurse? "1. ""With type 2 diabetes, the body of the pancreas becomes inflamed." 2. "With type 2 diabetes, insulin secretion is decreased and insulin resistance is increased." 3. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." 4. "With type 2 diabetes, the body produces autoantibodies that destroy b-cells in the pancreas.""
"Right Answer: 2 Rationale: In type 2 diabetes mellitus, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin"
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [Retrovir]), 200 mg by mouth every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
"Take zidovudine every 4 hours around the clock."
A 40-year-old client with mild dementia related to end-stage acquired immunodeficiency syndrome (AIDS) is preparing for discharge. She has decided against further curative treatment. Before discharge, she develops ocular cytomegalovirus (CMV). Her physician recommends treatment with a ganciclovir-impregnated implant (Vitrasert), which requires a surgical procedure. The client's husband feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which response best answers the husband's question while promoting client advocacy?
"The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult."
How should a nurse respond when asked by a family member of a client with human immunodeficiency virus (HIV) infection why she's performing passive range-of-motion (ROM) exercises on the client?
"These exercises help prevent contractures by keeping his joints mobile."
Post-Op care for the hip replacement patient
-Neurovascular checks -Monitor drains (don't want fluid to accumulate in tissue) -Firm mattress (joints need support) -Over-bed trapeze to build upper body strength -isometric exercises while in bed -no weight bearing until ordered -hydrate! -stresses to the new hip joint should be minimal in the first 3-6 months -no sleeping on the operative side -do not give pain meds in the operative hip
Should you relieve traction?
-Never relieve traction unless you've got a physician's order
Phantom Pain
-Seen more with AKA (above knee) -Diversional activity is the first thing to do -Usually subsides in 3 months
Patho of Compartment Syndrome
-fluid accumulates in the tissue and impairs tissue perfusion -The muscle becomes swollen and hard and the client complains of severe pain that is not relieved with pain meds -Pain is unpredictable -Pain is disproportionate to the injury, if undetected, it may result in nerve damage and possible amputation
factors that precipitate relapse
-infx -stress -post-partum (relapse less common during pregnancy)
Brain stem includes
-mesencephalon, pons and medulla oblongata (extend from the base of the brain to the foramen magnum)
Things to remember post knee surgery
-never hyper extend or hyperflex the knee -neurovascular checks -pain relief
A 23-year old woman presents to the urgency clinic w/ symptoms of a UTI. The nursing hx reveals that the pt was treated 3 months ago for a UTI. What additional question should the nurse ask?
1. Did you complete your antibiotic prescription for your first UTI? ***2. What form of birth control are you using? 3. does your partner have similar symptoms? 4. How much fluid do you drink each day?
How many doses of radioactive iodine can be given? What is the purpose? What precautions should be taken? What complication should be watched for?
1. The purpose is to destroy thyroid cells. Follow radioactive precautions: stay away from babies for 24 hours - don't kiss anyone for24 hrs. watch for thyroid storm.
Rule: When on a medication that fluctuates weight and weight has to be monitored - keep weight within ________ lbs of thier normal weight.
2 - 3 lbs - WEIGHT is very important in adjusting medication
Glaucoma
2 Types: Chronic open-angle glaucoma and Acute closed angle glaucoma. DESCRIPTION: Condition characterized by increased intraocular pressure (IOP). Glaucoma involves gradual, painless vision loss (peripheral lost). Glaucoma may lead to blindness if untreated. Glaucoma usually occurs bilaterally in those who have a family hx of the condition. Aqueous fluid is inadequately drained from the eye. It is generally asymptomatic, especially in early stages. It tends to be dx during routine visual examinations. It cannot be cured but can be treated with success pharacologically and surgically. NURSING ASSESSMENT: Early signs: Decreased accommodation or ability to focus. Late signs: Loss of peripheral vision. Seeing halos ar ound lights. Decreased visual acuity not correctable with glasses. Headache or eye pain that may be so severe as to cause n/v. ***acute closed-angle glaucoma-surgical emergency*** DX Tests: Tonometer, used to measure IOP. Electronic tonometer, used to detect drainage of aqueous humor. Gonioscopy, used to obtain a direct visualization of the lens. RISK FACTORS: Family Hx of glaucoma. Family Hx of diabetes. Hx of previous ocular problems. Medication use, glaucoma is a side effect of many meds eg. antihistamines, anticholinergics. It can also result from the interaction of meds. NURSING PLANS AND INTERVENTIONS: Administer eye drops as prescribed. Orient client to surroundings. Avoid nonverbal communication that requires visual acuity. Develop a teaching plan that includes the following: Careful adherence to eye-drop regimen can prevent blindness. Vision already lost cannot be restored. Eye drops are needed for the rest of life. Proper eye-drop instillation technique: Wash hands and external eye. Tilt head back slightly. Instill drop into lower lid, without touching the lid with the tip of the dropper. Release the lid, and sponage excess fluid from lid and cheek. Close eye gently, and leave closed 3-5 minutes. Apply gentle pressure on inner canthus to decrease systemic absorption. Safety measures to prevent injuries: Remove throw rugs. Adjust lighting to meet needs. Avoid activites that may increase IOP: Emotional upsets. Exertion like pushing, heavy lifting, shoveling. Coughing severely or excessive sneezing (get medical attention before upper respiratory infection worsens.) Wearing constrictive clothing eg tight collar or tie, tight belt or girdle. Straining at stool and constipation.
Diagnosis of MS requires
2 or + exacerbation separated by 1 mo and lasts +24 hrs. OR history of repeated exacerbation & remissions w/ or w/o recovery followed by increase in symptoms for 6 or + months. OR slow increase in symptoms for 6 months
"The nurse administered isophane insulin suspension (NPH) to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?
4 p.m.
Of which of the following symptoms might an older woman with diabetes mellitus complain? wps.prenhall.com 1) anorexia 2)pain intolerance 3) weight loss 4) perineal itching
4) perineal itchingRationale: Older women might complain of perineal itching due to vaginal candidiasis.
hypothyroidism
A condition of hyposecretion of the thyroid gland causing low thyroid levels in the blood that result in sluggishness, slow pulse, and often obesity,
A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements by a newly nurse indicates a need for further teaching? A. My line of gravity should fall outside my base of support. B. The lower my center of gravity, the more stability I have. C. To broaden my base of support, I should spread my feet apart. D. When I lift an object, I should hold it as close to my body as possible.
A. My line of gravity should fall outside my base of support. (Not correct, line of gravity will fall with IN base of support )
A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? A. S B. O C. L D. E E. R
ANS: B The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the "O" in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), open posture when interacting with the client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).
"A client brings her food journal containing her dietary intake for the past 3 days to the diabetic clinic. A nurse notes that despite dietary teaching about carbohydrate intake, the client consumed 3 servings of bread each day. What should the nurse do with this information?
Ask the diabetes educator to review with the client ways to decrease carbohydrate intake.
Which of the following interventions should be taken to help an older client to prevent osteoporosis? A. Decrease dietary calcium intake. B. Increase sedentary lifestyles C. Increase dietary protein intake. D. Encourage regular exercise.
D. Encourage regular exercise. Rationale: Key word in question is prevent Weight-bearing exercises helps to fight off degeneration of bone in osteoporosis
Which of the following responses by an older-adult client is most reflective of a need for further education by the nurse regarding the physiological changes associated with the older adult? A. "I call a cab if I want to go out after dark." B. "I can't help worrying about becoming forgetful." C. "I have my eyes checked regularly. Can't afford to fall." D. "I really enjoy eating good vanilla ice cream, but I have cut way down." 0%
B. "I can't help worrying about becoming forgetful."
When caring for the older adult, it is important to: Student Response Value Correct Answer Feedback A. Repeat oneself often because older adults are forgetful. B. Treat the client as an individual with a unique history of his or her own. C. Be aware that older adults are no longer interested in sex. D. Disregard the older adult's experiences because older people are too old-fashioned to be of value today.
B. Treat the client as an individual with a unique history of his or her own.
A 76-year-old adult female is brought to a neighborhood client after being found wandering around the local park. The client appears disheveled and reports being hungry. Which of the following assessment and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.) A. Falls asleep in the examination room B. Repeatedly states, "Don't hurt me." C. Chafing around wrists and ankles D. Bruises in various stages of healing
B. Repeatedly states, "Don't hurt me." C. Chafing around wrists and ankles D. Bruises in various stages of healing
The three common conditions affecting cognition in the older adults are: A. Stroke, MI, Cancer B. Cancer, Alzheimer's disease, Stroke C. Delirium, Depression, Dementia D. Blindness, Hearing loss, Stroke
C. Delirium, Depression, Dementia
The nurse is caring for a client postthyroidectomy. Which of the follwoing observations sould cause the nurse the most concern?
Client's wrist spontaneously flexes whent he blood pressure cuff is tightened.
Fracture Hesi Hint #5
Clients with fractures or edema in or casts on the extremities need frequent neurovascular assessment distal to the injury. Skin, color, temp, sensation, capillary refill, mobility, pain, and pulses should be assessed. (CMS)
Cataracts
Clouding and blurring of the lens Opacity Visual acuity is restricted No pain is assoc. with it
In a patient with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which of the following complications do the assessments help the nurse to monitor in the patient? a) Compartment syndrome b) GI bleeding c) Ganglion cysts d) Carpal tunnel syndrome
Compartment syndrome Explanation: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a patient with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A patient with a dislocation does not experience an increased risk of complications such as GI bleeding, carpal tunnel syndrome, or ganglion cysts.
A 13-year-old client is brought to the emergency department. The client's mother reports that the client was struck with a baseball bat on his upper arm while diving for a pitched ball. After diagnostic tests are completed, the physician reassures the mother that her son's humerus is not broken but he has suffered another type of injury. What type of injury would you expect the physician to diagnose? a) Sprain b) Strain c) Contusion d) Subluxation
Contusion Explanation: A contusion is a soft tissue injury resulting from a blow or blunt trauma.
Which of the following is the priority nursing diagnosis for the patient who has undergone surgery for a spinal fusion? 1. Acute Pain 2. Impaired Mobility 3. Risk for Infection 4. Risk for Injury
Correct Answer: 2 Rationale: The priority nursing diagnosis for a patient who has undergone a spinal fusion is Impaired Mobility, due to the assessment of the ABCs (airway, circulation, breathing). Impaired mobility can affect the patient's circulation, therefore affecting tissue perfusion and causing a risk for skin breakdown. Acute Pain is the next priority since it is an active diagnosis. Diagnoses with "risk for" do not take priority over active diagnoses.
A client is admitted to the medical-surgical floor with a diagnosis of acute pancreatitis. His blood pressure is 136/76 mm Hg, pulse 96 beats/minute, respirations 22 breaths/minute, temperature 99°F (38.3°C), and he has been experiencing severe vomiting for 24 hours. His past medical history reveals hyperlipidemia and alcohol abuse. The physician prescribes a nasogastric (NG) tube for the client. Which of the following is the primary purpose for insertion of the NG tube? A. Empty the stomach of fluids and gas to relieve vomiting. B. Prevent spasms at the sphincter of Oddi. C. Prevent air from forming in the small and large intestines. D. Remove bile from the gallbladder.
Correct answer: A An NG tube is no longer routinely inserted to treat pancreatitis, but if the client has protracted vomiting, the NG tube is inserted to drain fluids and gas and relieve vomiting. An NG tube doesn't prevent spasms at the sphincter of Oddi (a valve in the duodenum that controls the flow of digestive enzymes) or prevent air from forming in the small and large intestine. The common bile duct connects to the pancreas and the gall bladder, and a T tube rather than an NG tube would be used to collect bile drainage from the common bile duct.
During a teaching session, the nurse tells the client that 50% to 60% of daily calories should come from carbohydrates. What should the nurse say about the types of carbohydrates that can be eaten? a. Simple carbohydrates are absorbed more rapidly than complex carbohydrates. b. Simple sugars cause a rapid spike in glucose levels and should be avoided c. Simple sugars should never be consumed by someone with diabetes. d. Try to limit simple sugars to between 10% and 20% of daily calories.
D It is recommended that carbohydrates provide 50% to 60% of the daily calories. Approximately 40% to 50% should be from complex carbohydrates. The remaining 10% to 20% of carbohydrates could be from simple sugars. Research provides no evidence that carbohydrates from simple sugars are digested and absorbed more rapidly than are complex carbohydrates, and they do not appear to affect blood sugar control.
A RN is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education?
I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill.
The nurse is caring for a client with cirrhosis of the liver. The client has developed ascites and requires a paracentesis. Which of the following symptoms is associated with ascites and should be relieved by the paracentesis? A. Pruritus. B. Dyspnea. C. Jaundice. D. Peripheral neuropathy.
Correct answer: B Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm, resulting in difficulty breathing and dyspnea. Paracentesis (surgical puncture of the abdominal cavity to aspirate fluid) is done to remove fluid from the abdominal cavity and thus reduce pressure on the diaphragm in order to relieve the dyspnea. Pruritus, jaundice, and peripheral neuropathy are signs of cirrhosis that aren't relieved or treated by paracentesis.
A major symptom of Meniere's Disease is
Incapacitating vertigo
Anti-Thyroid
Increase effect on anticoagulant, antidepressant, decrease glucose meds, dijoxin, and dilantin. Methimazole (Tapazole)-hyper, sudden withdrawl cuase thyroid crisis, don't increase K PTU (propythiouracil)-hyper, thyrotoxic crisis, watch for iodine, alter effectivness Radioactive Iodine-hyper Potassium Iodide
glucagon
Increases blood glucose by converting glycogen to glucose
Which factor is most important when providing care for a client with hemophilia?
Ensuring client safety
Neuro s/s of anaphylaxis
Headache, dizziness, paresthesia, feeling of impending doom
calcium
Hydration and diuretics can enhance excretion of ______________ in patients with hyperparathyroidism
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?
Infection
sex hormones
Influence development of sexual characteristics (androgens, estrogens)
"The nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy?
Levothyroxine (Synthroid)
Synthroid
Medication to treat hypothyroidism
1-4 hr
Onset of long-lasting insulins
Risk factors for Osteoporosis
Over 60 Postmenopausal women Family History Thin body build Low calcium and Vit D Smoker Immobile
Hearing Loss Hesi Hint #2
Questions often focus on communicating with older adults who are hearing impaired. Speak in a low-pitched voice, slowly and distinclty. Stand in front of the person, with the light source behind the client. Use visual aids if available.
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
Western blot test with ELISA.
hyperkalemia
What condition can cause a peaked T wave?
3
Which one of the followin is an example of the emotional component of wellness? 1. the client chooses healthy foods 2. a new father decides to take parenting classes 3. A client expressess frustration with her partner's substance abuse 4. A widow with no family decides to join a bowling league
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide?
Take ferrous sulfate and the antacid at least 2 hours apart."
"A diabetic client develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect may these findings have on his need for insulin?
They will increase the need for insulin.
what is a yeast infection caused by
a fungus
what is trich caused by
a parasite
Paresis
a slight or partial paralysis. Use Light resistance training to treat.
Immune deficiency
absence or inadequate production of immune bodies; congenital or acquired; tx depends on inadequacy and primary cause
The guidelines for Carbohydrate Counting as medical nutrition therapy for diabetes mellitus includes all of the following EXCEPT: a. Flexibility in types and amounts of foods consumed b. Unlimited intake of total fat, saturated fat and cholesterol c. Including adequate servings of fruits, vegetables and the dairy group d. Applicable to with either Type 1 or Type 2 diabetes mellitus
b. Unlimited intake of total fat, saturated fat and cholesterol
S&S of MG
based on which muscle group involved
A patient with DI is treated with nasal desmopression. The nurse recognize that the drug is not having an adequate therapeutic effect the the patient experiences a. headache and weight gain b. nasal irritation and nausea c. a urine specific gravity of 1.002 d. an oral intake greater than urinary output
c. a urine specific gravity of 1.002 (rationale- normal urine specific gravity is 1.003 to 1.030, and urine with a specific gravity of 1.002 is very dilute, indicating that there continues to be excessive loss of water and that treatment of DI is inadequate. H/A, weight gain, and oral intake greater the urinary output are signs of volume excess that occur with overmedication. Nasal irritation & nausea may also indicate overmedication.)
A patient is scheduled for bilateral adrenalectomy. During the postoperative period, the nurse would expect administration of corticosteroids to be a. reduced to promote wound healing b. withheld until symptoms of hypocortisolism appear c. increased to promote an adequate response to the stress of surgery d. reduced because excessive hormones are released during surgical manipulation of the glands
c. increased to promote an adequate response to the stress of surgery (rationale- although the patient with Cushing syndrome has excess corticosteroids, removal of the glands and the stress of surgery require that high doses of cortisone be administered postoperatively for several days. The nurse should monitor the patient postoperatively to detect whether large amounts of hormones were released during surgical manipulation and to ensure the healing is satisfactory.)
Describe nursing measures in response to unexpected negative response (bleeding).
hold next dose immediately, call PHP if bleeding will not stop after 10min of pressure if external, be prepared to administer antidote, FFP, or other drugs as ordered by PHP.
dysphagia
condition in which swallowing is difficult or painful
thymus gland w/ MG
cont to produce antibodies . Possible source of autoantigen that triggers MG
Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer? a. Abdominal CT scan b. Abdominal x-ray c. Colonoscopy d. Fecal occult blood test
d. Fecal occult blood test Surface blood vessels of polyps and cancers are fragile and often bleed with the passage of stools. Abdominal x-ray and CT scan can help establish tumor size and metastasis. A colonoscopy can help locate a tumor as well as polyps, which can be removed before they become malignant.
The nurse is collecting data on a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find:
deposits of adipose tissue in the trunk and dorsocervical area.
vomitting and or diarrhea
delay rotavirus vaccine if infant is experiencing these two problems
"The client is being evaluated for hypothyroidism. The nurse should stay alert for:
decreased body temperature and cold intolerance.
s/s of addisons disease
decreased sodium,& blood volume postural hypotention and syncope,possible hypovolemic shock, tachycardia,arrhythmias,tremors confusion hypoglycemia hyponatremia, diarrhea & hyperkalemia
patho of Guillain-Barre syndrome
destruction of meylin sheaths in axons of PNS= poor conduction of nerve impulses=sudden muscle weakness, loss of reflex response. result of humoral and cell-mediated immunologic responses.
Glaucoma assessment findings
diminished accommodation, increased IOP
Hyperpathia
exaggerated subjective response to a painful stimuli, w/ a continuing sensation of pain after the stimulation has ceased.
s/s diabetes insipidus
excretion of laerge amounts of fluid (polyuria) extreme thirst(polydipsia)low specific gravity occur 3-6 days after a head injury
A client seeks tx in er department for a lower leg injury. There is visible deformity to the lower aspect of the leg and injured leg appears shorte than the other. The area is painful, swollen, and beginnin to become ecchymotic. The nurse interprets that this cliet has experienced a
fracture
Immunomodulators given to who?
given to relasping/remitting. Prolongs onset of disability.
"Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
heat intolerance and systolic hypertension.
trigeminal Neuralgia
intense paroxysmal neuralgia along the trigeminal nerve. results from demyelination of the sensory division of the trigeminal nerve and is characterized by stabbing short attacks of severe facial pain Eating, shaving or simply touching the face may elicit the response
third stage of lyme disease
large joints become involved; arthritis progresses
type 2 diabetes
only type of diabetes where oral antidiabetic agent are effective
nursing care of GB is focused on
pain control and risk for impaired skin integrity.
later S&S of ALS
paralysis, muscle mass decrease, progressive fatigue, atrophy of tongue & facial muscles= dysphagia/dysarthria. Emotional libility & loss of control. eventually patient will need total care and ventilatory support.
"During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:
phosphorus.
Lyme disease interventions
remove tick, clean with antiseptic; after 4-6wks, blood test to check for presence of disease; if confirmed, ATBs;
observe the nursing assistant performing all of these interventions for the pt with CTS
replace the pts splint in hyperextension
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
For the patient in Buck's extension traction which is applied to a leg, the nurse can provide counteraction by:
slighltly elevating the foot of the bed
weakness and fatigue exacerbated by....
stress, fever, overexertion, and exposure to heat. relieved by rest.
Interventions for postransplant immunosuppressed pt
strict aseptic technique; teaching re asepsis and s/s of infection/rejection; psychosocial support; pt teaching re immunosuppressants
Goodpasture's syndrome interventions
suppression of the immune system and plasmapheresis to remove autoantibodies; supportive tx for pulmonary/renal involvement
what STD's are testing by a swabbing of discharge
trich, gonorrhea, clamydia
antinuclear antibody (ANA) Titer
used in the differential dx of rheumatic diseases and to detect antinucleoprotein factors and patterns associated with certain autoimmune d/o
resp S&S of MD
weakening of intercostal muscles. decrease in diaphra movement, dyspnea, poor gas exchange complications: decreased ability to walk, eat and ADL's, pneumonia
Choice Multiple question - Select all answer choices that apply. A bone graft may be used for which of the following reasons? Select all that apply. a) Improvement of motion b) Defect filling c) Stimulation of bone healing d) Joint stabilization e) Reduction of a fracture
• Joint stabilization • Defect filling • Stimulation of bone healing Explanation: A bone graft is used for joint stabilization, defect filling, or stimulation of bone healing. Tendon transfer is used for improving motion. Either closed or open reduction may be used to reduce a fracture.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
"I will receive parenteral vitamin B12 therapy for the rest of my life."
The majority of the S/S in Addison's disease are a result of ___________ initially. What are these symptoms again (think of progression)?
Hyperkalemia. Muscle twitching > muscle weakness > muscle paralysis.
Aldosteronism
Hypersecretion of aldosterone from adrenal cortex causing hypokalemia, hypernatremia, hypertension
Cushing's disease
Hypersecretion of glucocorticoids causing upper body obesity, moon face, poor skin integrity, osteoporosis, hyperglycemia, hypernatremia,hypokalemia, hirsutism, amenorrhea, elevated triglycerides, hypertension, and immunosuppression
Hyperthyroidism
Hypersecretion of thyroxine from immune system attacking thyroid gland causing anxiety, irritability, insomnia, tachycardia, tremors, diaphoresis, sensitivity to heat, weight loss, exophthalmos and photosensitivity, diarrhea,
Describe assessment findings: nuchal rigidity, photophobia, opisthotonus, Kerning's sign, and Brudzinksi's sign.
Nuchal rigidity: neck stiffness Photophobia: intolerance of bright light Opisthotnus: A type of spasm in which the head and heels arch backward in extreme hyperextension and the body forms a reverse bow Kerning's sign: is positive when the leg is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful Brudzinski's sign: is the appearance of involuntary lifting of the legs when lifting a patient's head.
"A client with primary diabetes insipidus is prescribed desmopressin (DDAVP). Which instruction should the nurse provide before the client is discharged?
You may not be able to use desmopressin nasally if you have nasal discharge or blockage.
a
A major goal of treament for the patient with AD is to: a. maintain patient safety b. maintain or increase body weight c. return to a higher level of self care d. enhance functional ability over time
5. When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately?" b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic?" d. "Is your urine unusually dark-colored?"
A Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar- containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. Cognitive Level: Application Text Reference: pp. 1255, 1258 Nursing Process: Assessment NCLEX: Physiological Integrity
What is the purpose of a nurse providing appropriate feedback? A. To give the client good advice B. To advise the client on appropriate behaviors C. To evaluate the client's behavior D. To give the client critical information
ANS: D The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors.
Hypothyroid s/sx mimic what other d/o?
Depression
"The nurse should expect a client with hypothyroidism to report which health concerns?
Puffiness of the face and hands
The nurse is caring for a client who has normal glucose levels at bedtime, hypoglycemia at 2am and hyperglycemia in the morning. What is this client likely experiencing? "A. Dawn phenomenon B. Somogyi effect C. An insulin spike D. Excessive corticosteroids"
"1. B The Somogyi effect is when blood sugar drops too low in the morning causing rebound hyperglycemia in the morning. The hypoglycemia at 2am is highly indicative. The Dawn phenomenon is similar but would not have the hypoglycemia at 2am."
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
"Avoid sharing such articles as toothbrushes and razors."
"A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, "a. ""I may have an occasional alcoholic drink if I include it in my meal plan."" b. ""I will need a bedtime snack because I take an evening dose of NPH insulin."" c. ""I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia."" d. ""I may eat whatever I want, as long as I use enough insulin to cover the calories.
"D. ""I may eat whatever I want, as long as I use enough insulin to cover the calories."" Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction."
Which is a major factor regulating sleep? 1) Electrical impulses transmitted to the cerebellum 2) Level of sympathetic nervous system stimulation 3) Amount of sleep a person has become accustomed 4) Amount of light received through the eyes
*3) Amount of sleep a person has become accustomed to*
A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? (Select all that apply.) 1) Question the order because the patient must remain in isolation. 2) Place an N-95 respirator mask on the patient and transport him to the test. 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport.
*3) Place a surgical mask on the patient and transport him to CT lab.* *4) Notify the computed tomography department about precautions prior to transport.*
Light sleep and slowing brain and body processes are associated with which stage of NREM sleep? a. I b. II c. III d. IV
*b. II* These are characteristics of a person in Stage II of NREM sleep.
Treatment of compartment syndrome
-Elevate extremity (get fluid away) -soft cast then rigid cast -Loosen the cast to restore circulation -Be careful in picking the answer to "remove the cast" -fasciotomy -cast cutters to remove the case (instruct them the cast saw does not touch the skin, but it does vibrate)
Explain the nursing care for the patient receiving anticoagulant therapy.
-Monitor labs, monitor VS, monitor for signs of bleeding, reduce risk factors such as shaving (electric), etc. -Patients should be given the NPSA booklet (see guidance and resources) -On discharge, nurses should ensure patients know their drug dosage and arrange follow-up care -There is no evidence to suggest grapefruit juice should be avoided but cranberry juice can affect INR results. Foods rich in vitamin K can affect INR results if eaten in large quantities -Almost any drug can interact with oral anticoagulants, including herbal remedies. Most increase the effect but some reduce it. The INR should be closely monitored when a new drug is started or dose altered -Patients must know to seek medical attention for injuries, particularly head injuries, due to haemorrhage risk
Tx for degenerative motor neuron diseases
-Riluzole 50mg BID reduces the presynaptic release of glutamate, may slow progression of ALS -Monoclonal gammopathy (increased IgG) - may benefit from plasmapheresis or immunosuppression -Symptomatic treatment with anticholinergic drugs dries up oral secretions -Spasticity may be helped by Baclofen or Valium
Complications with Fractures include:
-Shock (hypovolemic) -Fat embolism -compartment syndrome
Which of the following laboratory values would you expect in a client experiencing prolonged immobility? 1. Elevated calcium 2. Decreased sodium 3. Elevated hemoglobin 4. Elevated potassium
1. Elevated calcium
646. The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if which of the following is noted?
1. Resolved diarrhea ***2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count
Before transferring a client from the bed to a stretcher, which assessment data does the nurse need to gather? (choose all that apply) 1. The client's weight 2. How cooperative the client is 3. The client's nutritional status 4. The presence of intravenous (IV) tubes
1. The client's weight 2. How cooperative the client is 4. The presence of intravenous (IV) tubes
types of spinal muscular atrophies:
1. Werdnig-Hoffman dz 2. late childhood 3. Kugelberg-Welander syndrome 4. adult onset
Recognizing the risk for urolithiasis in the immobilized pt, the nurse apprpriately plans to do which of the following?
1. administer a Ca supplement 2. regularly monitor urine pH 3. maintain an indwelling urinary cath ***4. increase fluid intake to 3000 mL per day
A nurse is caring for a man who has returned to the unit from the recovery room following a TURP. His urinary drainage bad is filled with dark red fluid w/ obvious clots. He is having painful bladder spasms. What would the nurse do first?
1. assess his I&O since surgery 2. administer pain medication in the form of a B&O suppository ***3. report your assessments to his urologist 4. nothing, because these manifestations are espected following a TURP
The nurse caring for a pt scheduled for an abdominal paracentesis instructs the pt to do which of the following?
1. avoid eating or drinking fluid for 6 hrs prior to the procedure 2. scrub the abd w/ antiseptic soap before the procedure ***3. empty the bladder before the procedure 4. report excess flatus following the procedure to the physician
The nurse evaluates his teaching of a pt w/ acute stress gastritis as effective when the pt states that sh will do which of the following?
1. avoid using aspirin or NSAIDs for routine pain reliefe
The enlarging prostate in BPH typically is manifested by assessment of problems w/ which of the following?
1. bowel eleimination ***2. urinary eliminatin 3. peripheral vascular function 4. skin integrity
During a health hx interview, a pt tells the nurse that she has to get up to void several times a night. This finding is documented as which of the following?
1. polyuria ***2. nocturia 3. dysuria 4. hematuria
What diagnostic test can be used to determine GFR as well as glomerular damage?
1. routine urinalysis 2. renal scan ***3. creatinine clearance 4. renal biopsy
Why should a trach be set up after a thyroidectomy (3)?
1.) Hypocalcemia - no PTH > serum Ca decreases > decreased sedative properties > check chovsteks/trosseaus 2.) swallowing problems 3.) laryngeal nerve damage
What are the 4 functions of glucocorticoids?
1.) change your mood 2.) Alter defense mechanisms (by decreases immune system) 3.) breaksdown protein/fat 4.) inhibits insulin (start doing accuchecks even if not diabetic).
Normal intraocular pressure
10-21 mm Hg
"A nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose of 120 mg/dL, temp of 101 F, pulse of 88 bpm, respirations of 22, and blood pressure of 100/72. Which finding would be of most concern to the nurse? "1. Pulse 2. Respiration 3. Temperature 4. Blood pressure"
3) temp. An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis. The other findings noted in the question are within normal limits.
"After a 3-month trial of dietary therapy, a client with type 2 diabetes still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:
30 minutes before breakfast.
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? 1. Encourage isometric exercises. 2. Suction every 8 hours. 3. Give low-dose heparin 4. Promote incentive spirometer use.
4. Promote incentive spirometer use. -- helps keep the airways open and prevents atelectasis.
11. The nurse has been teaching the patient to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. The statement by the patient that indicates a need for additional instruction is, a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I will buy the 0.5-ml syringes because the line markings will be easier to see." c. "I should draw up the regular insulin first after injecting air into the NPH bottle." d. "I do not need to aspirate the plunger to check for blood before I inject the insulin."
A Rationale: Rotating sites is no longer necessary because all insulin is now purified human insulin, and the risk for lipodystrophy is low. The other patient statements are accurate and indicate that no additional instruction is needed. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
Teaching that the nurse will plan for the patient with SLE includes a. ways to avoid exposure to sunlight b. increasing dietary protein and carbohydrate intake c. the necessity of genetic counseling before planning a family d. the use of no pharmacologic pain interventions instead of analgesics
A. ways to avoid exposure to sunlight
"The risk factors for type 1 diabetes include all of the following except: "a. Diet b. Genetic c. Autoimmune d. Environmental"
A: Type 1 diabetes is a primary failure of pancreatic beta cells to produce insulin. It primarily affects children and young adults and is unrelated to diet.
Adenocorticosteriod therapy in MS
ACTH, Prednisone, Methylprednisolone. Used to sustain remission and treat exacerbation. used to suppress immune system.
Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process? A. "We've discussed past coping skills. Let's see if these coping skills can be effective now." B. "Please tell me in your own words what brought you to the hospital." C. "This new approach worked for you. Keep it up." D. "I notice that you seem to be responding to voices that I do not hear."
ANS: A This is an example of the therapeutic communication technique of formulating a plan of action. By the use of this technique, the nurse can help the client plan in advance to deal with a stressful situation which may prevent anger and/or anxiety from escalating to an unmanageable level.
A student nurse tells the instructor, "I'm concerned that when a client asks me for advice I won't have a good solution." Which should be the nursing instructor's best response? A. "It's scary to feel put on the spot by a client. Nurses don't always have the answer." B. "Remember, clients, not nurses, are responsible for their own choices and decisions." C. "Just keep the client's best interests in mind and do the best that you can." D. "Set a goal to continue to work on this aspect of your practice."
ANS: B Giving advice tells the client what to do or how to behave. It implies that the nurse knows what is best and that the client is incapable of any self-direction. It discourages independent thinking.
A client slammed a door on the unit several times. The nurse responds, "You seem angry." The client states, "I'm not angry." What therapeutic communication technique has the nurse employed and what defense mechanism is the client unconsciously demonstrating? A. Making observations and the defense mechanism of suppression B. Verbalizing the implied and the defense mechanism of denial C. Reflection and the defense mechanism of projection D. Encouraging descriptions of perceptions and the defense mechanism of displacement
ANS: B This is an example of the therapeutic communication technique of verbalizing the implied. The nurse is putting into words what the client has only implied by words or actions. Denial is the refusal of the client to acknowledge the existence of a real situation, the feelings associated with it, or both.
Which nursing statement is a good example of the therapeutic communication technique of focusing? A. "Describe one of the best things that happened to you this week." B. "I'm having a difficult time understanding what you mean." C. "Your counseling session is in 30 minutes. I'll stay with you until then." D. "You mentioned your relationship with your father. Let's discuss that further."
ANS: D This is an example of the therapeutic communication technique of focusing. Focusing takes notice of a single idea or even a single word and works especially well with a client who is moving rapidly from one thought to another.
"A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which gland?
Adrenal cortex
Joint Replacement Hesi Hint #4
After hip replacement, instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting. This upward motion can pop the prosthesis out of the socket.
A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient's lab results would expect which of the following changes in laboratory findings? A. Elevated serum calcium. B. Low serum parathyroid hormone (PTH). C. Elevated serum vitamin D. D. Low urine calcium.
Answer: A The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. Parathyroid hormone levels may be high or normal but not low. The body will lower the level of vitamin D in an attempt to lower calcium. Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones.
If a dislocation is not treated promptly, tissue death due to anoxia can occur. This would be documented as which of the following? a) Heterotopic ossification b) Osteomyelitis c) Subluxation d) Avascular necrosis (AVN)
Avascular necrosis (AVN) Explanation: If a dislocation is not treated promptly, AVN, tissue death due to anoxia and diminished blood supply, and nerve palsy may occur. Subluxation is a partial dislocation of the articulating surfaces. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Osteomyelitis is an acute or chronic inflammation of the bone caused by infection.
A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. The nurse teaches the patient that a. the feet should be soaked in warm water on a daily basis. b. flat-soled leather shoes are the best choice to protect the feet from injury. c. heating pads should always be set at a very low temperature. d. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure.
B Rationale: The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided; the patient should see a specialist to treat these problems.
The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs. An appropriate nursing intervention for this problem is to a. restrict dietary protein intake. b. arrange for a pressure-relieving mattress. c. perform passive range of motion QID. d. turn the patient every 4 hours.
B Rationale: The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Dietary protein intake may be increased in patients with ascites to improve oncotic pressure. Turning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown.
If the patient was instructed to avoid foods that may have a laxative effect, the nurse would advise the patient to avoid which of the following foods? A) Chinese B) Alcohol C) Eggs D) Pasta
B) Alcohol All the foods listed as such alcohol have a constipating effect
Mr. T is nervous about a colonoscopy scheduled for tomorrow. The nurse describes the test by explaining that it allows which of the following? A) Visual examination of the esophagus and stomach B) Visual examination of the large intestine C) Radiographic examination of the large intestine D) Fluoroscopic examination of the small intestine
B) Visual examination of the large intestine An esophagogastroduodenoscopy Allows visual examination of the esophagus and stomach. The radiographic examination of the large intestine refers to a barium enema, and a fluoroscopic Examination of the small intestines refers to an upper gastrointestinal series
Which of the following statements made by a nurse reflects the best understanding of the health value of conducting a blood pressure (BP) screening at a senior citizens centers health fair? A. "This is a high risk group, so assessing BP allows us to identify clients at risk and send them for treatment." B. "Older adults enjoy health fairs, so it's a good place to screen substantial numbers of clients for hypertension." C. "Hypertension doesn't present symptoms early on, so screening elder adults is a wonderful preventive measure." D. "Blood pressure problems are common among this group, so it's a good way to monitor the effectiveness of their medications."
B. "Older adults enjoy health fairs, so it's a good place to screen substantial numbers of clients for hypertension."
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
Bluish urine
Pre-op notes about Total Hip Replacement: what type of traction is used?
Buck's is frequently used
Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention Enema by doing which of the following? A) Administering a large volume solution 500 to 1000 ml B) Mixing milk and molasses and equal parts for an enema C) Instructing the patient to retain the enema for at least 30 seconds D) Administering the enema while the patient is sitting on a toilet
C) Instructing the patient to retain the enema for at least 30 seconds The usual amount of solution administered with a retention Enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema That helps to expel flats, As does the Harrison flush procedure
An overall, general assessment of an older adult patient is best performed in which setting? A. During a meal. B. During assessment of vital signs. C. While assisting a patient with a bath. D. When assisting a patient during a walk.
C. While assisting a patient with a bath.
A patient with cirrhosis is being treated with spironolactone (Aldactone) tid and furosemide (Lasix) bid. The patient's most recent laboratory results indicate a serum sodium of 134 mEq/L (134 mmol/L) and a serum potassium of 3.2 mEq/L (3.2 mmol/L). Before notifying the physician, the nurse should A. administer only the furosemide B. administer both drugs as ordered C. administer only the spironolactone D. Withhold the furosemide and spironolactone
C. administer only the spironolactone The potassium level is dangerously low. Lasix is potassium depleting, while spironolactone is potassium sparing. You would hold the Lasix and call the physician. This is a good NCLEX question that integrates this course with pharmacology.
The nurse teaches the patient with RA that one of the most effective methods of aerobic exercise is a. ballet dancing b. casual walking c. aquatic exercises d. low-impact aerobic exercises
C. aquatic exercises
When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should A. use a standardized geriatric nursing care plan. B. plan for likely long-term-care transfer to allow additional time for recovery. C. consider the preadmission functional abilities when setting patient goals. D. minimize activity level during hospitalization.
C. consider the preadmission functional abilities when setting patient goals. Rationale: The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan is unlikely to address individual patient needs and strengths. A patients need for discharge to a long-term-care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.
During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate a. increased RBCs b. decreased ESR c. decreased anti-DNA d. increased complement
C. decreased anti-DNA
A 70-year old patient is being evaluated for symptoms of RA. The nurse recognizes that a major problem in the management of RA in the older adult is that a. RA is usually more severe in older adults b. older patients are not as likely to comply with treatment regimens c. drug interactions and toxicity are more likely to occur with multidrug therapy d. laboratory and other diagnostic tests are not effective in identifying RA in older adults
C. drug interactions and toxicity are more likely to occur with multidrug therapy
A patient with OA uses NSAIDs to decrease pain and inflammation. The nurse teaches the patient that common side effects of these drugs include a. allergic reactions, fever, and oral lesions b. fluid retention, hypertension, and bruising c. skin rashes, gastric irritation, and headache d. prolonged bleeding time, blood dyscrasias, and hepatic damage
C. skin rashes, gastric irritation, and headacche
During the physical assessment of the patient with moderate RA, the nurse would expect to find a. hepatomegaly b. Heberden's nodes c. spindle-shaped fingers d. crepitus on joint movement
C. spindle-shaped fingers
A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect? A: Atherosclerosis B: Diabetic nephropathy C: Autonomic neuropathy D: Somatic neuropathy
C: Autonomic neuropathy
Identify two types of hearing loss.
Conductive (transmission of sound to inner ear is blocked) and sensorineural (damage to 8th cranial nerve).
A client is admitted to the medical-surgical floor with a suspected diagnosis of acute myeloid leukemia. A nurse discusses the client's condition in the hallway. This action by the nurse jeopardizes which of the following principles?
Confidentiality
"Which of the following would indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?
Confusion and seizures
Glaucoma Drug Therapy
Constrict the pupil. Reduce aqueous humor Beta-blockers Prostaglandin-agonist Adrenergic-agonist Cholinergic-agonist Carbonic inhibitors
Radioactive Iodine (sodium 1131)
Contraindicated for pregnant women Destroys thyroid Fast the night before Benefits may not be seen for 4-6 weeks Avoid contact with other ppl for 2-4 days Increase fluid intake to flush body Expect tenderness in neck Wash clothes, oral care, bathing separately.
A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure
Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.
The nurse recognizes that the most common type of brain attack (CVA) is related to which of the following? 1. ischemia 2. hemorrhage 3. headache 4. vomiting
Correct Answer: 1 Rationale: Eighty percent of all strokes are caused by ischemia. Hemorrhagic strokes are less common than ischemic strokes. Headache and vomiting may be symptoms associated with CVA, but not common causes.
A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? 1. "I will stop taking this medicine if I notice any bruising." 2. "I will not eat spinach while I'm taking this medicine." 3. "It will be OK for me to eat anything, as long as it is low fat." 4. "I'll check my blood pressure frequently while taking this medication."
Correct Answer: 2 Rationale: Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless by prescriber order. Low-fat foods do not interfere with warfarin therapy, which is not prescribed to affect the blood pressure.
A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which of the following? 1. increased episodes of hypoglycemia 2. possible episodes of hyperglycemia 3. no change in the patient's glycemic parameters 4. both hyper- and hypoglycemic episodes
Correct Answer: 2 Rationale: A common side effect of corticosteroids is hyperglycemia. Stress as well as the medication could cause this person to have periods of elevated blood sugars.
Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury? 1. Fluid Volume Deficit 2. Impaired Physical Mobility 3. Ineffective Airway Clearance 4. Altered Tissue Perfusion
Correct Answer: 3 Rationale: Ineffective Airway Clearance is the priority nursing diagnosis for this patient. The nurse utilizes the ABCs (airway, breathing, circulation) to determine priority. With Ineffective Airway Clearance, the patient is at risk for aspiration and therefore, impaired gas exchange. Fluid Volume Deficit is the nurse's next priority (circulation), and then Altered Tissue Perfusion. If the patient does not have enough volume to circulate, then tissue perfusion cannot be adequately addressed. The last priority for this patient is Impaired Physical Mobility.
Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy? 1. Provide the patient with an air mattress. 2. Place pillows under patient to help patient turn. 3. Teach the patient to grasp the side rail to turn. 4. Use the log roll to turn the patient to the side.
Correct Answer: 4 Rationale: A patient who has undergone a laminectomy needs to be turned by log rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.
The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is which of the following? 1. diabetes 2. heart disease 3. renal insufficiency 4. hypertension
Correct Answer: 4 Rationale: Hypertension is the greatest risk factor for stroke, and should be controlled. Diabetes, heart disease, and renal insufficiency can all lead to stroke, however hypertension is the greatest risk.
A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia
Correct Answer: 4 Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.
The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient that the most beneficial measure to protect the joints is to do which of the following? A. Use a wheelchair to avoid walking as much as possible. B. Eat a well-balanced diet to maintain a healthy body weight. C. Incorrect Use a walker for ambulation to relieve the pressure on her hips. D. Sit in chairs that do not cause her hips to be lower than her knees.
Correct answer: B. Eat a well-balanced diet to maintain a healthy body weight. Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight.
The nurse is reinforcing general health teaching with a 64-year-old patient with osteoarthritis (OA) of the hip. Which of the following points would the nurse include in this review of the disorder (select all that apply)? A. OA cannot be successfully treated with any current therapy options. B. OA is an inflammatory disease of the joints that may present symptoms at any age. C.Joint degeneration with pain and disability occurs in the majority of people by the age of 60. D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling. E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.
Correct answer: D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling. E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication. Rationale: OA occurs with greater frequency with increasing age, but it usually remains confined to a few joints and can be managed with a combination of exercise, diet, and medication. OA can lead to significant disability.
"Which of the following factors are risks for the development of diabetes mellitus? (Select all that apply.) "a) Age over 45 years b) Overweight with a waist/hip ratio >1 c) Having a consistent HDL level above 40 mg/dl d) Maintaining a sedentary lifestyle
Correct: a,b,d"Rationale: Aging results in reduced ability of beta cells to respond with insulin effectively. Overweight with waist/hip ratio increase is part of the metabolic syndrome of DM II. There is an increase in atherosclerosis with DM due to the metabolic syndrome and sedentary lifestyle.
acute exacerbations
Corticosteroids - methylprednisilone, prednisone, dexamethasone
GI s/s of anaphylaxis
Cramping, abdominal pain, n/v/d
When Hypothyroid is present at birth it's called:
Cretinism
A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). When teaching the patient about the reason for these lifestyle changes, the nurse will tell the patient that a. the high insulin levels associated with this syndrome damage the lining of blood vessels, leading to vascular disease. b. although the fasting plasma glucose levels do not currently indicate diabetes, the glycosylated hemoglobin will be elevated. c. the liver is producing excessive glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production. d. the onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise.
D Rationale: The patient with IFG is at risk for developing type 2 diabetes, but this risk can be decreased with lifestyle changes. Glycosylated hemoglobin levels will not be elevated in IFG and the Hb A1C test is not included in prediabetes testing. Elevated insulin levels do not cause the damage to blood vessels that can occur with IFG. The liver does not produce increased levels of glucose in IFG
Which of the following statements made by an older-adult client poses the greatest concern for the nurse conducting an assessment regarding the clients adjustment to the aging process? A. "I use to enjoy dancing and jogging so much, but now I have arthritis in my knees so that it's hard to even walk." B. "I've given my grandchildren money for college so they can live a better life than I had." C. "Growing old certainly presents all sorts of challenges. I wish I knew then what I know now." D. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."
D. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."
A patient is taking delayed-release omeprazole (Prilosec) capsules for the treatment of gastroesophageal reflux disease (GERD). Which statement will the nurse include in the teaching plan about this medication? A. "Take this medication once a day after breakfast." B. "You will only have to be on this medication for 2 weeks for a life long treatment of the reflux disease." C. "The medication may be dissolved in a liquid for better absorption." D. "The entire capsule should be taken whole, not crushed, chewed, or opened."
D. "The entire capsule should be taken whole, not crushed, chewed, or opened."
A 70-year-old client asks the nurse to explain to her about hypertension. An appropriate response by the nurse as to why older clients often have hypertension is due to: A. Myocardial muscle damage B. Reduction in physical activity C. Ingestion of foods high in sodium D. Accumulation of plaque on arterial walls
D. Accumulation of plaque on arterial walls
When taking a health history, the nurse screens for manifestations suggestive of diabetes type I. Which of the following manifestations are considered the primary manifestations of diabetes type I and would be most suggestive of diabetes type I and require follow-up investigation? a. Excessive intake of calories, rapid weight gain, and difficulty losing weight b. Poor circulation, wound healing, and leg ulcers, c. Lack of energy, weight gain, and depression d. An increase in three areas: thirst, intake of fluids, and hunger
D. An increase in three areas: thirst, intake of fluids, and hunger The primary manifestations of diabetes type I are polyuria (increased urine output), polydipsia (increased thirst), polyphagia (increased hunger).
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer.
D. Assess the client's ability to help with the transfer. The first action the nurse would take using the nursing process is to assess/collect data from the client. The nurse should assess the client's ability to help with the transfers (balance, muscle strength & endurance). Then the nurse can proceed with a safe transfer of the client.
Characteristics of spondyloarthritides associated with HLA-B27 antigen include a. symmetric polyarticular arthritis b. an absence of extraarticular disease c. presence of rheumatoid factor and autoantibodies d. high level of involvement of sacroiliac joints and the spine
D. high level of involvement is sacroiliac joints and the spine
An important nursing intervention for the patient with ankylosing spondylitis is to teach the patient to a. wear roomy shoes with good orthotic support b. sleep on the side with the knees and hips flexed c. keep the spine slightly flexed while sitting, standing, or walking d. perform back, neck, and chest stretches and deep breathing exercises
D. perform back, neck and chest stretches and deep breathing exercises
A patient is seen at the outpatient clinic for a sudden onset of inflammation and severe pain in the great toe. A diagnosis of gout is made on the basis of a. a family history of gout b. elevated urine uric acid levels c. elevated serum uric acid levels d. the presence of sodium urate crystals in synovial fluid
D. the presence of sodium urate cystals in synovial fluid
After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when the patient says, a. heat treatments should not be used if muscle spasms are present b. cold applications can be applied for 15-20 minutes to relieve joint stiffness c. I should use heat applications for 20 minutes to relieve the symptoms of an acute flare d. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain
D. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relive the pain
"A frail elderly patient with a diagnosis of type 2 diabetes mellitus has been ill with pneumonia. The cliet's intake has been very poor, and she is admitted to the hospital for observation and management as needed. What is the most likely problem with this patient? "A. Insulin resistance has developed. B. Diabetic ketoacidosis is occuring. C. Hypoglycemia unawareness is developing. D. Hyperglycemic hyperosmolar non-ketotic coma.
D.Illness, especially with the frail elderly patient whose appetite is poor, can result in dehydration and HHNC. Insulin resisitance is inidcated by a daily insulin requirement of 200 units or more. Diabetic ketoacidosis, an acute metabolic condition, usually is caused by absent or markedly decreased amounts of insulin.
Osteoarthritis (OA) AKA Degenerative Joint Disease (DJD)
DESCRIPTION: Noninflammatory arthritis. OA is characterized by a degeneration of cartilage, a wear-and-tear process. It usually affects on or two joints. It occurs asymmetrically. Obesity and overuse are predisposing factors. NURSING ASSESSMENT:Joint pain that increases with activity and improves with rest. Morning stiffness. Asymmetry of affected joints. **Crepitus (grating sound in the joint).** Limited movement. Visible joint abnormalities indicated on radiographs. Joint enlargement and bony nodules. NURSING INTERVENTIONS:(same as RF) Instruct in weight-reduction diet. Remind client that excessive use of the involved joint aggravates pain and may accelerate degeneration. Teach client to: Use correct posture and body mechanics. Sleep with rolled terry cloth towel under cervical spine if neck pain is a problem. Relieve pain in fingers and hands by wearing stretch gloves at night. Keep joints in functional position. Tylenol or NSAIDs
meds for TN
DOC=tricyclic anticonvulsant- carbamazepine (tegretol). other Dilantin, gabapentin or muscle relaxers- baclofen. SE= dizziness, N, Drowsiness. need to assess liver function, bone marrow and blood levels of meds.
What is compartment syndrome?
Damage to nerves and vasculature of an extremity due to compression.
What is the cause of sensoneural hearing loss?
Damage to the cochlear or vestibular nerves
"A client with type 2 diabetes tells a nurse that he stopped walking at the mall because of his ""bad leg pain."" How should the nurse respond to this client?
Did you notify your physician when you started to have the leg pains?
long-lasting
Do not mix ___________- insulins with any other insulin or solution
The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly determined need for this age-group? A. Suggest that he purchase an emergency in-home alert system. B. Arrange for the client to receive meals delivered to his home daily. C. Encourage the client to use a compartmentalized pill storage container for his daily medications. D. Provide only written document describing the medications the client is currently prescribed.
Encourage the client to use a compartmentalized pill storage container for his daily medications.
Meneire's Disease
Episodic/incapacitating vertigo, tinnitus, fluctuating sensorineural hearing loss, aural fullness.
"Which outcome indicates that treatment of a client with diabetes insipidus has been effective?
Fluid intake is less than 2,500 ml/day.
Copaxone
Glatiramer (MS, immunomodulator)
Addisonian crisis involves severe _________ and ________ collapse.
Hypotension & Vascular
Immunomodulators for MS
Interferon beta-1a (Avonex=IM weekly)/ (Rebif= subq 3x week) Interferon beta-1b (Betaseron= subq every other day) Glatiramer acetate (copaxone, copolymer-1= subq daily) Natalizumab (tysabri= IV monthy)
What does Potassium Iodide (SSKI) & Strong iodine solution (Lugol's solution) do for hyperthyroid patients? What should be given with these iodine compounds? What about antithyroids?
Iodine compounds decrease the size and the vascularity of the gland - this is especially good for preop patient to decrease bleeding. Give iodine compounds in milk, juice, and use a straw - because iodine stains the teeth. ----Antithyroids inhibit the production of TH, therefore making the client euthyroid (aka normal thyroid).
What is the somogyi phenomenon? What is the treatment (2)?
It is when the patient has normal BG levels at night, but drops in the early morning hrs (2-3am), client's body attempts to compensate by producing counter-regulatory hormones to increase BG resulting in hyperglycemia. Decrease intermediate acting insulin (NPH insulin, Lente insulin) and increase bedtime snack.
steroids
Large doses of ________ should be given at 0800 to simulate normal excretion by the body (2/3 morning and 1/3 night)
Thyroid
Levothyroxine (synthroid)-hyper, hormone replacement Liothyronine (cytomenl)t3-hypo Liotrix (thyrolar)-hypo
A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
Listen and show interest as the client expresses feelings.
(Florinef) Fludocortisone Acetate
Long lasting oral med with mineralcorcoid & mod glucorticoid activity. -prescribed for long term tx addisons disease -help restore electrolyte balance
Would you expect the TSH level to be high or low in someone with hyperthyroidism
Low
Tests for MS
MRI= lesions seen CT= atrophy & white matter lesions CFS analysis= increase of T lymphocytes w/ antigens Also increase in IgG
Myxedema Coma Interventions
Maintain airway Hourly vitals Monitor body temp Cardiac monitoring continuously Hypertonic saline fluids, glucose Aspiration precautions
Tx for hypothyroid:
Meds: All have thyroid in a form in the name: Levothyroxine (Synthroid), Thyroglobulin (Proloid), Liothyronine (cytomel)... They will take these forever... watch for CAD
The adrenal medulla and cortex synthesizes what hormones?
Medulla = the catecholamines, epinephrine and norepinephrine. Adrenal cortex = glucocorticoids, mineral corticoids, & sex hormones
"When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which possible adverse effect of the drug?
Menstrual irregularities
transsphenoidal hypophysectomy
Microsurgery in which an incision is made at the junction of the gums and upper lip. A surgical microscope is advanced and a special surgical instrument is used to excise all or part of the pituitary gland.
Cataract Post-Op Care
Mild itching is normal, pain is a problem. Reduce IOP Prevent infection Assess for bleeding Teach pt to report any changes in vision to dr Avoid activities that can increase IOP Proper eye drop admin
Discuss the community resources available to the patient with a neuromuscular disorder.
Muscular Dystrophy Association (MDA) Outpatient Therapy Support Groups
is there a cure for genital warts
NO
A client is brought to the ED in an unresponsive state, and a dx of HHNS Is made. The nurse would immediately prepare to initiate which of the following in anticipation of the MD order?
Normal Saline
"A nurse is caring for a client with type 1 diabetes, who underwent a right hemicolectomy for colon cancer the day before. A physician prescribes the following sliding scale of regular insulin coverage every 6 hours for the client. Which action should the nurse take if the client's glucose level is 181 mg/dl?
Notify the physician.
A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone (Deltasone) daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
Osteoporosis
2-4 hr
Peak of action of short acting insulins
"Which of the following is an adverse reaction to glipizide (Glucotrol)?
Photosensitivity
"After undergoing a subtotal thyroidectomy, a client develops hypothyroidism. The physician prescribes levothyroxine (Synthroid), 25 mcg P.O. daily. For which condition is levothyroxine the preferred agent?
Primary hypothyroidism
"A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
Rapid, thready pulse
Thyroid Storm
Rare, but fatal complication of hyperthyroidism Reduce body temp and heart rate Fever 100-106 Tachycardia >140 bpm Hot, flushed skin Anxious Diarrhea, nausea
"Which of the following would the nurse expect to assess in an elderly client with Hashimoto's thyroiditis?
Weight gain, decreased appetite, and constipation
Hyperthyroidism
Weight loss Tachycardia Insomnia Heat intolerance Diarrhea Finger clubbing Nervousness Tachypnea Flushed skin Exopthalmos
RF Hesi Hint #4
What activity recommendations should the nurse provide a client with rheumatoid arthritis? Do not exercise painful, swollen joints. Do not exercise any joint ot the point of pain. Perform exercises slowly and smoothly; avoid jerky movements.
Cataract Hesi Hint #2
When the cataract is removed, the lens is gone, making prevention of falls important. When the lens is replaced with an implant, vision is better.
Explain the difference between a TIA and a CVA.
While transient ischemic attack (TIA) is often labeled "mini-stroke," it is more accurately characterized as a "warning stroke," a warning you should take very seriously. TIA is caused by a clot; the only difference between a stroke and TIA is that with TIA the blockage is transient (temporary). TIA symptoms occur rapidly and last a relatively short time. Most TIAs last less than five minutes; the average is about a minute. Unlike a stroke, when a TIA is over, there's no permanent injury to the brain.
"A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
You must avoid coughing, sneezing, and blowing your nose.
Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? Activity Intolerance. Risk for Activity Intolerance. Impaired Physical Mobility. Risk for Disuse Syndrome.
Your Answer: Activity Intolerance. Rationale: Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not "at risk for," as in option 2. There is no evidence that the client requires assistance (impaired mobility, option 3), or is immobile (disuse syndrome, option 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Diagnosis.
Multiple Sclerosis
a chronic progressive nervous disorder involving loss of myelin sheath around certain nerve fibers. Onset 15-50 yrs old
A client has just had surgery for colon cancer. Which of the following disorders might the client develop? a. Peritonitis b. Diverticulosis c. Partial bowel obstruction d. Complete bowel obstruction
a. Peritonitis Bowel spillage could occur during surgery, resulting in peritonitis. Complete or partial bowel obstruction may occur before bowel resection. Diverticulosis doesn't result from surgery or colon cancer.
diptheria
acute contagious infection tha can cause repiratory obstruction
addison's disease
aldosterone secretion is reduced
clamydia is caused by a
bacteria
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
bilateral hearing loss.
Which of the following persons would most likely be diagnosed with diabetes mellitus? A 44-year-old: a. Caucasian woman. b. Asian woman. c. African-American woman. d. Hispanic male.
c. African-American woman. Age-specific prevalence of diagnosed diabetes mellitus (DM) is higher for African-Americans and Hispanics than for Caucasians. Among those younger than 75, black women had the highest incidence.
Which of the following diabetes drugs acts by decreasing the amount of glucose produced by the liver? a. Sulfonylureas b. Meglitinides c. Biguanides d. Alpha-glucosidase inhibitors
c. Biguanides Biguanides, such as metformin, lower blood glucose by reducing the amount of glucose produced by the liver. Sulfonylureas and Meglitinides stimulate the beta cells of the pancreas to produce more insulin. Alpha-glucosidase inhibitors block the breakdown of starches and some sugars, which helps to reduce blood glucose levels
To prevent complications in the patient with Cushing syndrome, the nurse monitors the patient for a. hypotension b. hypoglycemia c. cardiac arrhythmias d. decreased cardiac output
c. cardiac arrhythmias (rationale- electrolyte changes that occur in Cushing syndrome include sodium retention and potassium excretion by the kidney, resulting in hypokalemia, which may lead to cardiac arrhythmias or arrest. Hypotension, hypoglycemia, and decreased cardiac strength and output are characteristic of adrenal insufficiency.)
The nurse is performing discharge teaching for a patient with Addison's disease. It is MOST important for the nurse to instruct the patient about: a. signs and symptoms of infection b. fluid and electrolyte balance c. seizure precautions d. steroid replacement
d. steroid replacement steroid replacement is the most important information the client needs to know.
how do genital warts grow
in clusters
patient/family teaching for GB
paralysis isn't permanent, rationals for interventions to increase compliance
Nikolsky's sign
separation of the epidermis caused by rubbing the skin; present in pemphigus
Skin Testing
the admin of an allergen to the surface of the skin or into the dermis; admin by patch, scratch, or intradermally
A client who is learning to use a can if afraid it will slip with ambulations causing a fall. the nurse provides the client with the greatest reassurance by telling the client that:
the cane has a flared tip with concentric rings to provide stability
A client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the can by holding it with the
the client is taught to hold the cane on the opposite side of the weakness. This will be the patient's left hand. The cane is placed 6 inches lateral to the fithe toe
which STD's cause pelvic inflammatory disorder
trich, gonorrhea, clamydia
characteristics of degenerative motor neuron diseases
•Weakness •No sensory Loss or sphincter disturbance •Progressive course •No identifiable cause other than genetic in familial cases (usually sporadic) •Onset between age 30 and 60
symptoms of underactive bladder?
-Bladder becomes too full and you may leak urine -Problems starting to urinate or emptying all the urine from the bladder -Unable to tell when the bladder is full -Urinary retention
Continuous Passive Motion (CPM)
-Continuously flexes and extends the knee to prevent scar tissue from forming and increasing gradually
symptoms of overactive bladder?
-Having to urinate too often in small amounts -Problems emptying all the urine from the bladder -Loss of bladder control
Treatment of Fractures
-Immobilize the bone ends plus the adjacent joints -support fracture above and below the site -move extremity as little as possible -splints help prevent fat emboli and muscle spasm
Immediate Post Op care for amputations
-Keep a tournaquette at the bedside -Extension to prevent hip/knee contractions -Inspect the residual limb daily to be sure that it lies completely flat on the bed
Discuss the adaptions the nurse makes to provide care in the home environment.
...
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, "You are incompetent!" Which is the nurse's best response? A. "Do you believe that I was the cause of your blood test being canceled?" B. "I see that you are upset, but I feel uncomfortable when you swear at me." C. "Have you ever thought about ways to express anger appropriately?" D. "I'll give you some space. Let me know if you need anything."
ANS: B This is an example of the appropriate use of feedback. Feedback should be directed toward behavior that the client has the capacity to modify.
A client diagnosed with dependant personality disorder states, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate? A. "It would be best to do that in order to increase independence." B. "Why would you want to leave a secure home?" C. "Let's discuss and explore all of your options." D. "I'm afraid you would feel very guilty leaving your parents."
ANS: C The most appropriate response by the nurse is, "Let's discuss and explore all of your options." In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.
The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a "general lead"? A. "Do you know why you are here?" B. "Are you feeling depressed or anxious?" C. "Yes, I see. Go on." D. "Can you chronologically order the events that led to your admission?"
ANS: C The nurse's statement, "Yes, I see. Go on." is an example of the therapeutic communication technique of a general lead. Offering a general lead encourages the client to continue sharing information.
A client's younger daughter is ignoring curfew. The client states, "I'm afraid she will get pregnant." The nurse responds, "Hang in there. Don't you think she has a lot to learn about life?" This is an example of which communication block? A. Requesting an explanation B. Belittling the client C. Making stereotyped comments D. Probing
ANS: C This is an example of the nontherapeutic communication block of making stereotyped comments. Clichés and trite expressions are meaningless in a therapeutic nurse-client relationship.
The nurse asks a newly admitted client, "What can we do to help you?" What is the purpose of this therapeutic communication technique? A. To reframe the client's thoughts about mental health treatment B. To put the client at ease C. To explore a subject, idea, experience, or relationship D. To communicate that the nurse is listening to the conversation
ANS: C This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.
Which nursing statement is a good example of the therapeutic communication technique of giving recognition? A. "You did not attend group today. Can we talk about that?" B. "I'll sit with you until it is time for your family session." C. "I notice you are wearing a new dress and you have washed your hair." D. "I'm happy that you are now taking your medications. They will really help."
ANS: C This is an example of the therapeutic communication technique of giving recognition. Giving recognition acknowledges and indicates awareness. This technique is more appropriate than complimenting the client which reflects the nurse's judgment.
A client on an inpatient psychiatric unit tells the nurse, "I should have died because I am totally worthless." In order to encourage the client to continue talking about feelings, which should be the nurse's initial response? A. "How would your family feel if you died?" B. "You feel worthless now, but that can change with time." C. "You've been feeling sad and alone for some time now?" D. "It is great that you have come in for help."
ANS: C This nursing statement is an example of the therapeutic communication technique of reflection. When reflection is used, questions and feelings are referred back to the client so that they may be recognized and accepted.
A client tells the nurse, "I feel bad because my mother does not want me to return home after I leave the hospital." Which nursing response is therapeutic? A. "It's quite common for clients to feel that way after a lengthy hospitalization." B. "Why don't you talk to your mother? You may find out she doesn't feel that way." C. "Your mother seems like an understanding person. I'll help you approach her." D. "You feel that your mother does not want you to come back home?"
ANS: D This is an example of the therapeutic communication technique of restatement. Restatement is the repeating of the main idea that the client has verbalized. This lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue, or clarify if necessary.
Which of the following terms refers to moving away from midline? a) Inversion b) Adduction c) Abduction d) Eversion
Abduction Explanation: Abduction is moving away from midline. Adduction is moving toward midline. Inversion is turning inward. Eversion is turning outward.
What are the signs and symptoms of compartment syndrome?
Abnormal neurovascular assessment: cold extremity, severe pain, inability to move the extremity, and poor capillary refill.
Hypothyroid interventions
Add fiber to the diet Rest periods Skin moisturizers Low cal diet Increase fluid intake Cough & deep breathe
For a client w/ addison's disease, what should be focused on (what is lost)? Thus, since this is insufficient, what is lost and what is retained? Treatment will involve the mineralocorticoid drug _________ (Florinef)(aldosterone). _____ is very important in adjusting their medication.
Aldosterone. Na/Water is lost, K+ is retained. Fludrocortisone. Weight.
The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
An above-normal anti-deoxyribonucleic acid (DNA) test
"Which of the following is the most common cause of hyperaldosteronism?
An adrenal adenoma
Immunosuppressants for MS
Azathioprine (Imuran) Cyclophosphamide (Cytoxan)
Pituitary Gland
Controlled primarily by the hypothalamus; termed :master gland: as it directly affects the function of other endocrine glands
Performance of activities of daily living (ADLs) and active range of motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. Elbow flexion with eating and bathing. Elbow extension with shaving and eating. Wrist hyperextension with writing. Thumb ROM with eating and writing. Hip flexion with walking.
Correct Answers: Elbow flexion with eating and bathing. Thumb ROM with eating and writing. Hip flexion with walking. Rationale: Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension (option 2). Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint (option 3). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation.
Which of the following patient statements most clearly suggests a need to assess the patient for ankylosing spondylitis (AS)? A. "My right elbow has become red and swollen over the last few days." B. "I wake up stiff every morning and my knees just don't want to bend." C. "My husband tells me that my posture has become so stooped this winter." D. "My lower back pain seems to be getting worse all the time and nothing seems to help."
Correct answer: D. "My lower back pain seems to be getting worse all the time and nothing seems to help." Rationale: AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.
Of the following options, which is the greatest barrier to providing quality health care to the older-adult client? A. Poor client compliance resulting from generalized diminished capacity B. Inadequate health insurance coverage for the group as a whole C. Insufficient research to provide a basis for effective geriatric health care D. Preconceived assumptions regarding the lifestyles and attitudes of this group
D. Preconceived assumptions regarding the lifestyles and attitudes of this group
"When teaching a client about insulin administration, the nurse should include which instruction?
Draw up clear insulin first when mixing two types of insulin in one syringe.
Other names for hyperparathyroidism would be (2). Other names for hypoparathyroidism would be (2).
Hypercalcemia, hypophosphatemia.---hypocalcemia, hyperphosphatemia.
"What does a positive Chvostek's sign indicate?
Hypocalcemia
"A client is evaluated for type 1 diabetes. Which client comment correlates best with this disorder?
I'm thirsty all the time. I just can't get enough to drink.
Interventions for Diabetic Neuropathy
I/O, monitor BUN/Creatinine, maintain normal blood glucose, restrict dietary protein, sodium, potassium
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
Increased weight, hypertension, and insomnia
"When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which action?
Increasing fluid intake
The nurse should include which intervention in the postoperative care plan? a) Keeping a pillow between the client's legs at all times b) Turning the client from side to side every 2 hours c) Maintaining the client in semi-Fowler's position d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift
Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.
Which nursing intervention is appropriate for minimizing muscle spasms in the client with a hip fracture? a) Assist the client with use of a trapeze. b) Maintain the internal fixator. c) Apply a soft compression dressing. d) Maintain Buck's traction.
Maintain Buck's traction. Explanation: Buck's traction decreases pain, muscle spasm, and external rotation by immobilizing the hip fracture.
A 17-year-old high school junior was involved in a motor-vehicle collision and brought to the ED via squad. His left arm was severely traumatized in the accident and he was taken immediately to surgery. He is admitted to the ICU where you practice nursing and the physician has ordered close monitoring for compartment syndrome. What musculoskeletal structure does compartment syndrome affect? a) Nerve b) All options are correct c) Bone d) Ligament
Nerve Correct Explanation: Compartment syndrome affects nerve innervation, leading to subsequent palsy (decreased sensation and movement).
What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition?
Notify physician stat, draw blood gases, administer O2 according to blood gas results, assist with endotracheal intubation and treatment of respiratory failure.
30-60 min
Onset of action of short acting insulins
A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? a) Prevent internal rotation of the affected leg. b) Keep the hip flexed by placing pillows under the client's knee. c) Use measures other than turning to prevent pressure ulcers. d) Keep the affected leg in a position of adduction.
Prevent internal rotation of the affected leg. Explanation: The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.
Insulin
Promotes conversion of fatty acids into fat
Hyperthyroid Drugs
Propranolol (beta-blocker) Radioactive Iodine PTU Tapazole Lithium
Skin s/s of anaphylaxis
Pruritus, angioedema, erythema, urticaria
Which nursing intervention is essential in caring for a client with compartment syndrome? a) Wrapping the affected extremity with a compression dressing to help decrease the swelling b) Starting an I.V. line in the affected extremity in anticipation of venogram studies c) Keeping the affected extremity below the level of the heart d) Removing all external sources of pressure, such as clothing and jewelry
Removing all external sources of pressure, such as clothing and jewelry Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.
A client is admitted to an acute care facility with a myocardial infarction. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to assist in formulating which nursing diagnosis?
Risk for impaired skin integrity
"A client is transferred to a rehabilitation center after being treated in the hospital for a stroke. Because the client has a history of Cushing's syndrome (hypercortisolism) and chronic obstructive pulmonary disease (COPD), the nurse helps formulate a nursing diagnosis of:
Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion.
Addison's disease
Symptoms include fatigue, anorexia, weight loss, hyperpigmentation, hypotension, hypoglycemia, hyponatremia, hyperkalemia
What 3 hormones do the thyroid produce? What product is needed to make these hormones?
T3, T4, & Calcitonin. Iodide.
A client with type 1 diabetes calls the nurse because he is nauseous and does not feel well. The client asks if he should take his medication. What would be important for the nurse to tell the client?
Take his regular dose of insulin, replace food with fruit juices, and monitor the blood glucose level.
List the three symptoms of hyperglycemia?
Think three P's: polyuria (urine loss due to hypertonic vascular fluid and accompanying weight loss), polydipsia , polyphagia (breakdown of fat/protein).
"A client has type 1 diabetes. Her husband finds her unconscious at home and administers glucagon, 0.5 mg subQ. She awakens in 5 minutes. Why should her husband offer a complex carbohydrate snack to her as soon as possible?
To restore liver glycogen and prevent secondary hypoglycemia
graves disease treatment
Treated by surgical removal of the thyroid or partial destruction of thyroid with radioactive iodine
pemphigus tx goal
aimed at suppressing the immune response that causes blister formation
Imuran
an immunosuppressive drug (trade name Imuran) used to prevent rejection of a transplanted organ
SE of immunosuppressant for MS
bone marrow depression, increase risk of cancer. Hepatitis W/ Imuran. Cytoxan SE= hemorrhagic cystitis, sterility, stomatitis.
Of which of the following symptoms might an older woman with diabetes mellitus complain? a. Anorexia b. Pain intolerance c. Weight loss d. Perineal itching
d. Perineal itching
Expressive Aphasia
damage to Broca's area can cause this condition in which person cannot talk, though understand speech
what are the symptoms of crabs
itching or a gray/blue patch in genital area
Aldosterone makes you retain: and makes you lose:
sodium and water / potassium
there are no tests that can be done to see if you have HPV
true
what can you do to prevent a yeast infection
wear cotton underwear, quickly change out of wet swimsuits, avoid tight clothing, change pads/tampons often
9-26
what ages are recommended for HPV vaccine
Osteoporosis Hesi Hint #1
Postmenopausal, thin white women are at highest risk for development of osteoporosis. Encourage exercise, a diet high in calcium and supplemental calcium. Tums are an excellent source of calcium, but they are also high in sodium, so hypertensive or edematous individuals should seek another souce of supplemental calcium.
Which electrolyte replacement should the nurse anticipate being ordered by thehealth-care provider in the client diagnosed with DKA who has just been admitted tothe ICD? 1.Glucose. 2.)Potassium. 3.Calcium. 4.Sodium
Potassium"1.Glucose is elevated in DKA; therefore, theHCP would not be replacing glucose. 2.(CORRECT)-->The client in DKA loses potassium from increased urinary output, acidosis, cata-bolic state, and vomiting. Replacement isessential for preventing cardiac dysrhyth-mias secondary to hypokalemia. 3.Calcium is not affected in the client with DKA.4.The IV that is prescribed 0.9% normal salinehas sodium, but it is not specifically orderedfor sodium replacement. This is an isotonicsolution. TEST-TAKING HINT: Option "1" should be elim-inated because the problem with DKA iselevated glucose so the HCP would not bereplacing it. The test taker should use physiol-ogy knowledge and realize potassium is in thecell."
Discuss the precautions to teach when instructing a patient on anticoagulants.
Precautions: in pts with fever, heart failure, diarrhea, diabetes, malignancy, HTN, renal/hepatic disease, psychoses, depression, or spinal procedures. Interactions: aspirin, acetaminophen, NSAIDS, penicillin, aminoglycosides, tetracyclines, cephalosporins, beta blockers, loop diuretics, oral contraceptives, vitamin-K, barbiturates Contraindicated: hemorrhagic diseases, TB, leukemia, uncontrolled HTN, GI ulcers, recent surgery of eye or CNS, aneurysm. Use during pregnancy can cause fetal death. May be contraindicated with a hypersensitivity to pork products.
"A client with type 1 diabetes takes 15 units of isophane insulin suspension (Humulin N) before breakfast and 8 units before dinner. During a follow-up visit, the nurse reevaluates the client's knowledge about insulin therapy and self-administration skills and learns that the client is unaware that certain over-the-counter (OTC) preparations and other medications may interact with insulin. The nurse should advise the client to avoid which OTC preparations?
Preparations containing salicylates
What care is indicated for a child with juvenile rheumatoid arthritis?
Prescribed exercise to maintain mobility; splinting of affected joints; and teaching about medication management and side effects of drugs.
Describe the use of clinical pathway/care map to guide the care of the patient with a CVA.
Purpose: To reduce unnecessary utilization of hospital resources, to give the most efficient care possible (because time is of the essence). Clinical pathways are multidisciplinary plans (or blueprint for a plan of care) of best clinical practice for specified groups of patients with a particular diagnosis that aid in the coordination and delivery of high quality care.
Fracture Hesi Hint #1
Questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a nonwheeled walker, the client should lift an dmove the walker forward and then take a step into it. The client should avoid scooting the walker or shuffling forward into it; these movements take more energy and provide less stability than does a single movement.
Differentiate between RF and osteoarthritis in terms of joint involvement.
RF occurs bilaterally, Osteoarthritis occurs asymmetrically.
"The nurse is teaching a community class to peole with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes? 1. The islet cells in the pancreas stop producing insulin. 2. The client eats too many foods that are high in sugar. 3 The pituitary gland does not produce vasopression. 4. The cells become resistant to the circulating insulin.
"1. This is the cause of Type 1 diabetes mellitus. 2. This may be a reason for obesity, which may lead to Type 2 diabetes, but eating too much sugar does not cause diabetes. 3. This is the explanation for diabetes insipidus, which should not be confused with diabetes mellitus. 4. (CORRECT) Normally insulin binds to special receptor sites on the cells and initiates a series of reactions involved in metabolism. In Type 2 diabetes these reactions are diminished primarily as a result of obesity and aging."
Discuss nursing care for the child with CP.
ROM exercises to prevent contractures, use special appliances to help the child perform ADLs, provide protective head gear and bed pads to prevent injury, provide a high-calorie diet because the child will have a high metabolism rate due to high motor function, explain the disorder and treatment to the family and that efforts should be made to ensure that the child reaches the optimal developmental level possible.
iodine
Radioactive __________ treatment shrinks thyroid gland prior to surgery
Skin Test: Postprocedure
Record site, date, and time of test; Record date, time of follow-up; inspect site for erythema, papules, vesicles, edema, or wheal; measure wheal if present
Two days after a client undergoes splenectomy, a nurse changes his abdominal dressings according to the physician's order. How should the nurse proceed with the dressing change?
Remove the soiled dressings using clean gloves.
A nurse is preparing a teaching plan for a client with sickle cell disease. She includes periods of rest in her plan. Why is this point important to include?
Rest relieves stress, which may precipitate sickle cell crisis.
An older adult who was in a car accident and FX his femur has been immobilized for 5 days. Which nursing DX is related to P/T safety when nurse assists the P/T out of bed for the first time?
Risk for activity intolerance.
"A client with type 1 diabetes must learn how to self-administer insulin. The physician has prescribed 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
Rotate injection sites within the same anatomic region, not among different regions.
Recognize signs and symptoms of client's impaired cognition.
STAGE 1: 2-4 years after onset short term memeory loss; forgets locations and names of objects attempts to cover up memory loss has difficulty learning new information or making decisions decreased attention span can be angry or depressed antidementia meds are trying to prolong this stage. STAGE 2: 2-10 years after end of stage 1 unable to remember names of family members and gets lost in familiar locations easily agitated and irritable has difficulty using objects; reading, writing, and speaking cannot follow a conversation personal hygiene declines unable to make decisions (choose clothing) walks and unsteady gait, head down, shoulders bent, shuffles exhibits "sundowning" and wandering behavior STAGE 3: 1-3 years after stage 2 cannot recognize self or others inability to communicate has delusions and hallucinations bowel and bladder incontinence
Thyroidectomy:
Semi Fowler and avoid hyperflexion and hyperextension of the neck
"A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes, which is controlled by tolazamide (Tolinase). What is the most important laboratory test for confirming HHNS?
Serum osmolarity
Which type of gait correlates with Parkinson's disease? a) Shuffling b) Scissors c) Steppage d) Spastic hemiparesis
Shuffling Explanation: A variety of neurologic conditions are associated with abnormal gaits, such as spastic hemiparesis gait (stroke), steppage gait (lower motor neuron disease), and shuffling gait (Parkinson's disease). Scissors gait is seen in cerebral palsy.
Hypoparathyroidism
Signs of __________________ include paresthesia, muscle creamps and tetany, Chvostek's and Trousseau's signs, alopecia, dry skin, and painful menstruation
What is the pathophysiology for DKA?
Since there is no insulin, glucose builds up in the vascular space > the blood becomes hypertonic and pulls fluid into the vascular space > the kidneys filter excess glucose and fluids (polyuria, polydipsia) and the cells are astarving so they break down protein and fat for energy (polyphagia) > when you breakdown fat you get ketones > now the client becomes metabolically acidotic.
Discuss the common drugs, side effects, and precautions when administering drugs prescribed for extra-pyramidal disorders.
Sinemet: Dopaminergics - carbidoma-levodopa mixture. Levodopa is converted to doapaimine in the brain and carbidopa prevents levodopa from being destroyed. Comtan is used in adjunct to Sinemet sometimes. Enhances Tasmar: last resort Dry mouth/difficulty swallowing, anorexia, nausea, diskinesia vomiting, abdm pain and constipation, increased hand tremor, headache and dizziness. Caution should be used in combination with opioids, antacids, anticonvulsantsm and tricyclic antidepressants. Choreiform movements and dystonic movements are the most adverse reaction to levodopa.
how is skeletal traction applied?
Skeletal traction is maintained by pins or wires applied to the distal fragment of the fracture.
a,b,c,d,e
Social effects of a chronic neurologic disease include (select all that apply) a. divorce b. job loss c. depression d. role changes. e. loss of self esteem
Discuss drugs used to treat seizures by: name, action, adverse reactions and special precautions.
Sodium Luminal (Phenobarbital) Diphenylhdantin (Dilantin) Mephenytoin (Mesantoin) Valproic Acid (Depakene) Carbamazine (Tegretol)
Mineralocorticoids/Aldosterone: makes you retain ______, but inversely makes you lose _________. Too much aldosterone ______ vascular space and _____ serum potassium.
Sodium, Potassium. Increases. Decreases.
Gluco-corticosteroids
Solumedrol-used for decrease adrenal ftn, modifying the body's immune response to various conditions & decrease inflammation. Decadron (dexamethezone)-treat certain conditions associated with decrease adrenal ftn, works by decreasing or preventing tissue from responding to inflammation. Prednizone
"A client who has had type 2 diabetes for 20 years tells the nurse that sometimes she has diarrhea and other times constipation. In addition, she sometimes feels ""full"" after eating small amounts. Which of the following would be an appropriate response for the nurse to make?
Sometimes people with diabetes have problems with their digestion. Did you tell your physician about this?
A client sustains an injury to the ligaments surrounding a joint. The nurse identifies this as which of the following? a) Fracture b) Strain c) Sprain d) Contusion
Sprain Explanation: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.
A 45-year-old softball player arrives at the emergency department following his injury while sliding into a base during a game. After his examination and radiographs, the physician diagnoses muscle strain and prescribes appropriate treatment. What does the physician mean with the term "strain"? a) Stretched or pulled beyond capacity b) Subluxation of a joint c) Injuries to ligaments surrounding a joint d) Injury resulting from a blow or blunt trauma
Stretched or pulled beyond capacity Explanation: A strain is an injury to a muscle when it is stretched or pulled beyond its capacity.
glucocorticoids
Substances that affect carb, fat, and protein metabolism; affect stress reactions and the inhibition of the inflammatory process (cortisol, cortisone, corticosterone)
Addisonian Crisis
Sudden extreme weakness, severe abdominal, back, and leg pain; hyperpyrexia; coma; and death secondary to physical stress or trauma
"A client with type 2 diabetes comes to the clinic with a diabetic foot ulcer on his left heel that hasn't responded to treatment. Which action should a nurse take after assessing the ulcer?
Suggest a consult with a wound care specialist.
Skull sutures are an example of which type of joint? a) Amphiarthrosis b) Synarthrosis c) Diarthrosis d) Aponeuroses
Synarthrosis Explanation: Skull sutures are considered synarthrosis joints and are immovable. Amphiarthrosis joints allow limited movement, such as a vertebral joint. Diarthrosis joints are freely movable joints such as the hip and shoulder. Aponeuroses are broad, flat sheets of connective tissue.
RF Hesi Hint #3
Synovial tissues line the bones of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction. Often the disease goes into remission. Decreasing the amount of bone and joint destruction reduces the amount of disability.
"The nurse explains to a client with thyroid disease that the thyroid gland normally produces:
T3, T4, and calcitonin.
what is trich short for
TRICHONOMIASIS
"A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse drug effect?
Tachycardia
Pt Education for hypothyroid Meds
Take early morning on empty stomach Take at least 4 hrs apart from other drugs: antacids, and iron. Take at the same time every day. Measure pulse twice weekly report if >100.
The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
Take piroxicam with food or an antacid.
"Which instruction concerning the administration of levothyroxine (Synthroid) should the nurse teach a client?
Take the drug on an empty stomach.
SLE data collection
butterfly rash on face; dry, scaly, raised rash on upper body or face; fever, weakness, malaise, fatigue; anorexia and wt loss; photosensitivity; joint pain; erythema of the palms; anemia; + ANA test; Elevated sedimentation rate and C-reactive protein
A client is brought to the emergency room in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician's orders? a) endotracheal intubation b) 100 units of NPH insulin c) intravenous infusion of normal saline d) intravenous infusion of sodium bicarbonate
c) intravenous infusion of normal saline The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHNS.
The nurse is caring for the client diagnosed with ascites from hepatic cirrhosis. What information should the nurse report to the health-care provider? a. A decrease in the client's daily weight of one (1) pound. b. An increase in urine output after administration of a diuretic. c. An increase in abdominal girth of two (2) inches. d. A decrease in the serum direct bilirubin to 0.6 mg/dL.
c. An increase in abdominal girth of two (2) inches. Rationale: An increase in abdominal girth would indicate that the ascites is increasing, meaning that the client's condition is becoming more serious and should be reported to the health-care provider.
The nurse is caring for a patient with a diagnosis of hypothyroidism. Which nursing diagnosis should the nurse most seriously consider when analyzing the needs of the patient? a. High risk for aspiration related to severe vomiting b. Diarrhea related to increased peristalsis c. Hypothermia related to slowed metabolic rate d. Oral mucous membrane, altered related to disease process
c. Hypothermia related to slowed metabolic rate Thyroid hormone deficiency results in reduction in the metabolic rate, resulting in hypothermia, and does predispose the older adult to a host of other health-related issues. One quarter of affected elderly experience constipation.
A patient with Addison's disease comes to the emergency department with complaints of N/V/D, and fever. The nurse would expect collaborative care to include a. parenteral injections of ACTH b. IV administration of vasopressors c. IV administration of hydrocortisone d. IV administration of D5W with 20mEq of KCl
c. IV administration of hydrocortisone (rationale- vomiting and diarrhea are early indicators of addisonian crisis and fever indicates an infection, which s causing additional stress for the patient. treatment of a crisis requires immediate glucocorticoid replacement, and IV hydrocortisone, fluids, sodium and glucose are necessary for 24hours. Addison's disease is a primary insufficiency of the adrenal gland, and ACTH is not effective, nor would vasopressors be effective with the fluid deficiency of Addison's. Potassium levels are increased in Addison's dz, and KCl would be contraindicated.)
Polyarteritis nodosa
collagen disease and a form of systemic vasculitis that causes inflammation of the arteries in visceral organs, brain, and skin; middle-aged men affected; poor prognosis; renal d/o & cardiac involvement are most common cause of death
Dysphagia
condition in which swallowing is difficult or painful
"The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:
consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Should contraction be intermittent or continuous?
continuous! Never relieve traction without a doc's order
clonus
convulsion characterized by alternating contractions and relaxations
"An adolescent client with type I diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? "a) sweating and tremors b) hunger and hypertension c) cold, clammy skin and irritability d) fruity breath and decreasing level of consciousness
d) fruity breath and decreasing level of consciousness"Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Instead, hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold, clammy skin, irritability, sweating, and tremors are all signs of hypoglycemia."
Discuss the nursing implications for medications ordered for a patients with a head injury.
osmotic diuretics (Mannitol) expel large amount of h2o and electrolytes - may have to switch to loop diuretic. Corticosteroids reduce inflammation. Zantac, Protonix, or antacids are given to prevent GI irritation. Antemetics are used to prevent vomiting. Anticonvulsants (Dilantin, Valium, phenobarbital). Barbituates are given to induce coma, last resort, reduces metabolism and slows brain death. Nursing Implications:
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse's suspicions are:
drop in blood pressure and rise in heart rate.
UMN lesion
paresis, spasticity, brisk tendon reflexes, involuntary flexor or extensor spasms, clonus,a babinski sign
A client with a sprain but not fracture should be told to do what before being sent home
patien should be taughts to rest, ice, compress, and elevate SPRIAN=RICE
Pre-op care for t. hypophysectomy
perform capillary glucose testing q4h because excess cortisol may cause insulin resistance, placing the pt at risk for hyperglycemia
"A client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by:
performing capillary glucose testing frequently.
Identify community care and resources to assist patient and family with chronic and long-term disabilities.
physical therapy will demonstrate assistive devices, social services can arrange referral to home health agency, transfer to rehab center, or job retraining program.
Explain interventions to prevent patient aspiration and assist with feeding a patient with a swallowing disorder.
place client in upright positon for meals and 30 minutes afterward. tild head slightly forward. do not feed client who does not have functioning gag reflex or has altered LOC. provide oral care before meals. serve thickened liquids and pureed or soft food and place foods on unaffected side of mouth. limit distractions at meal time. have suction equipment available during mealtimes.
Food high in calcium include what
plain yougurt, diary products, seafood, sardines, green vegetables, calcium-fortified orange juics, and cereal
what helps with severe relapses that don't respond to corticosteroids?
plasmapheresis
what medicine is used to treat syphilis
prescribed medicine
what is a neurogenic bladder?
problem in which a perosn lacks bladder control d/t brain or nerve condition
"A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:
profound neuromuscular irritability.
Amyotrophic Lateral Sclerosis
progressive muscle atrophy caused by hardening of nerve tissue on the lateral columns of the spinal column (Lou Gehrig disease)Chronic Degenerative Disease UMN and LMN impairments. Rapid degeneration and demyelination of the giant pyramidal cells of the cerebral cortex
thyroid
propylthiouracil blocks _______ hormone production - can cause agranulocytosis
Why is limb shaping important post amputation?
prosthesis -you want the end to be shaped like a cone (smaller and rounded at the bottom)
A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension tractions is primarily:
provides comfort by reducing muscle spasms and provides fracture immobilization
Discuss the local and national community resources available for patients for home care.
psychological support, respite care, meals on wheels, sources for special adaptive equipment, support groups, social services
suffered a fx femr
pt appears confused-fracture of a long bone early manifestiation of fat emboli
contraindications for anticholinesterase
pt w/ obstruction of intestinal/urinary tract. asthma, hyperthyriodism, bradycardia, peptic ulcer disease.
ocular/ facial S&S of MG
ptosis, diplopia, facial weakness, Dysphagia, dysarthria. complications: difficulty closing eyes, aspiration, impaired communication, impaired nutrition.
Goodpasture's syndrome data collection
pulmonary and renal involvement, SOB, hemoptysis, decreased UO, edema and wt gain, HTN and tachycardia
symptoms of latex allergy
range from mild contact dermatitis to moderately severe sx of rhinitis, conjunctivitis, urticaria, and bronchospasm; possible anaphylaxis
What is ALS's?
rapidly progressive, degenerative neurological disease defined by weakness, wasting of voluntary muscles w/o sensory changes. Fatal
glipzide (glucotrol) adverse reaction
rash, pruritus and photosensitivity
10 to 15 g of simple carbohydrates
recommended to reverse hypoglycemia. 3-5 pieces of hard candy, 2-3 packets of sugar or 4oz of fruit juice. if necessary, can be repeated in 15 min
Lumbar Puncture
removal by centesis of fluid from the subarachnoid space of the lumbar region of the spinal cord for diagnostic or therapeutic purposes
goal of plasmapheresis for MG
remove antiacetylcholine receptor antibodies. decreases muscle weakness, fatigue etc
Surgery for TN
rhizotomy- surgically severing nerve root. residual pain/numbness from surgery. can lose sensations on affected side of face, lose corneal reflex.
Why must you study the foramen magnum?
rule out possibility of Arnold Chiari malformation (parts of cerebellum and lower brainstem are displaced inferiorly causing mixed pyramidal and cerebellar deficits in the limbs).
first stage of Lyme disease
s/s several days-months following bite; small red pimple develops, spreads to ring-shaped rash; rash may be large, small, or not occur at all; flu-like s/s occur
S&S of MS
sensory loss, visual deficits (blurring, diplopis, dimished visual fields, altered reaction to light, red-green color distortion), weakness, paresthesias, ataxia, vertigo. Fatigue.
A nurse is evaluating the pin sites of a client in skeletal traction. THe nurse is least concerned with 1. inflammation 2.serous drainage 3.pain at pin site 4.purulent drainage
serous drainage. A small amount of serous oozing is expected at pin insertion sites.
"In a 28-year-old female client who is being successfully treated for Cushing's syndrome, the nurse would expect a decline in:
serum glucose level.
second stage of Lyme disease
several weeks following the bite; joint pain, neuro complications, cardiac complications
Acute stage of GB
severe/rapid weakness, loss of muscle strength, progresses to quadriplegia & resp failure. decrease in DTRs, paresthesias, numbness, pain esp at night, facial muscle involvement. Involvement of Autonomic nervous=bradycardia, sweating, fluctuating BP. LAST 2 WEEKs
Late S&S of HD
severely altered gait, uncontrolled movements, facial grimacing, dysphagia, unintelligible speech, impaired diaphragm, immobility, aspirations, poor O2 sats, cachexia, loss of memory and cognitive skills, total dependence of care
"The physician diagnoses type 1 diabetes in a client who has classic manifestations of the disease and a random blood glucose level of 350 mg/dl. In addition to dietary modifications, the physician prescribes insulin. Initially, most clients receive the least antigenic form of insulin. Therefore, the nurse expects the physician to prescribe:
human insulin.
hypersensitivity and allergy data collection
hx of exposure to allergen; itching, tearing, and burning of eyes and skin, rashes, nose twitching and nasal stuffiness
Interventions for individual with latex allergy
hx of latex allergy upon assessment; ID latex allergy risk factors; Use non-latex gloves, supplies; Keep latex-free cart in pt room; cloth barrier under BP cuff; Educate pt to always inform HCPs of allergy
Signs and symptoms of addisons disease are innitally those of _______________, which are:
hyperkalemia / beginning with muscle twitching, then proceeds to weakness and then flaccid paralysis. (remember if don't get that bannanna from not enough k, then will have muscle rigidity and cramping)
"A 68-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these findings, the nurse would suspect:
hyperparathyroidism.
diseases associated w/ MG
hyperthryoidism, rheumatoid arthritis, lupus erythematosus,
"Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for:
hypocortisolism
Cretinism
hyposecretion of thyroid hormone in fetus or neonate causing severe, irreversible mental retardation if not treated - requires lifelong HRT
two doses 4-8 weeks apart
if pt. older than 13 has not had chickenpox require this dosage and frequency of vaccine
A nurse witnesses a client sustain a fall and suspects that the client's lef may be fractures. Which action is the priotiry
immobilize the leg before moving the client
passive immunity
immune globulins are used so antibodies are already formed and conferred from breastmilk
Apraxia
impaired ability to carry out motor activities despite intact motor function
"Before undergoing a subtotal thyroidectomy, a client receives potassium iodide (Lugol's solution) and propylthiouracil (PTU). The nurse would expect the client's symptoms to subside:
in 1 to 2 weeks.
nutritional S&S of MD
inability to chew and swallow, decreased ability to move tongue, impairment of fine motor movements= inability to eat. complications: weight loss, dehydration, skin breakdown, aspiration,
A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include: a) body-wide decrease in bone mass. b) inability to perform active movement and pain with passive movement. c) a growth in and around the bone tissue. d) inability to perform passive movement and pain with active movement.
inability to perform active movement and pain with passive movement. Explanation: With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor.
subQ
inactivated polio virus vaccine IPV is given via this route
Also with too many glucocorticoids, you may see increased risk of __________, ______glycemia, __________ to depression, ______-faced, _______-obesity and __________ hump.
infection / hyperglycemia / psychosis to depression / moon faced - fat redistribution or fluid retention / truncal obesity and buffalo hump also all from fat redistribution
Lyme Disease
infection caused by Borrelia brugdorferi, acquired from a tick bite; stimulates inflammatory cytokines and autoimmune mechanisms
Glucocorticoids are also known as anti___________
inflammatories... this is why cortisol cream is for anti itch cream... they stop the fighters in the body... the reaction.
avoid pregnancy for at least 3 months
inform adolescent girls to avoid this after immunization of MMR
SIADH (syndrome of inappropriate antidiuretic hormone)
is characterized by high levels of ADH in the absence of serum hypo-osmolality. caused by the etopic production of ADH by malignant tumors,( oat cell carcinoma of the lungs ,pancreatic carcinoma, leukemia, or hodgkins disease)
Addisons Disease
is disorder resulting from distruction or disfunction of the adrenal cortex resulting in a defeciency in cortisol, aldosterone, adrenal androgens and skin pigmentation
During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
joint abnormalities.
A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Include what instructions for patien
keep cast and extremity elevate the cast needs to be kept clean and dry allow the wet cast 24 hours to 72 hours to dry
Distinguish the characteristics of right and left hemiplegia.
left hemisphere lesion: right hemiplegia, right visual field deficits, aphasia both expressive and receptive, agrahia - difficulty writing, alexia - reading problems, aware of deficits, impaired intellectual ability, no memory deficits, no hearing deficits, deficits in the right visual field as reading, problems and inability to discriminate words and letters, behavior slow cautious and disorganized, anxious when attempting new task, depression, sense of guilt, quick anger and frustration, feeling of worthlessness, worries over the future right hemisphere lesion: left hemiplegia, left visual deficits, disoriented to time place and person, cannot recognize faces, spatial - perception deficits, neglect of left side, patient unaware of paralyzed side, loss of depth perception, impulsive - easily distracted, unaware of neurological deficits, confabulates, euphoric impaired sense of humor, constantly smiles, denies illness, poor judgement, overestimates ability, loss of ability to hear tonal variations
B cells
lie dormant until specific antigen enters the body, then they multiple for defense
Drug therapy of hypothyroidism is usually...
lifelong
anesthesia
loss of bodily sensation with or without loss of consciousness
Important nursing interventions to prevent acute renal railure in the critically ill pt include which of the follwing?
maintain fluid voluem and cardiac output
Describe a therapeutic environment for a patient with Alzheimer's disease.
make schedule of the client's daily activities, label drawers containing client's clothes and label rooms, use communication techniques to the client's level of ability, when the client is agitated re-direct attention, if pt wanders they need a MedicAlert, schedule rest periods or quite times throughout the day, set boundaries by placing red or yellow tape on the floor, assign the same caregivers as much as possible, music/art therapy, orient to person place and time if needed.
Polyarteritis nodosa data collection
malaise, low fever, severe abd. pain, bloody diarrhea, wt loss, elevated sedimentation rate
Single lesions may be...
malignant or congenital
false negetive TB result
measles vaccine may cause this type of result
SLE precipitating factors
medications, stress, genetics, UV/sunlight, pregnancy
Cushing's syndrome/disease clients have too many __________, _________, and ______ hormones.
mineralcorticoids, glucocorticoids, and sex hormones
In an individual with Sjögren's syndrome, nursing care should focus on:
moisture replacement.
what happens if herpes is left untreated
more outbreaks can occur and there is a higher risk of HIV
adrenal adenoma
most common cause of hyperaldosteronism
Goodpasture's syndrome etiology
most common in males and young adults that smoke; exact cause unknown
"An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of:
myxedema coma.
What assessment is most important with fractures?
neuro-vascular checks -Pulse, Color, Movement, Sensation, Cap refill, and temp
is a yeast infection an STD
no
is there a cure for HIV/AIDS
no
s/sx of hypothyroid:
no energy (thyroid hormone gives us energy), fatigue, GI system is slow, weight is up, they are cold, speech is slow and no expression
A clietn has had a bone scan procedure. What is the after care
no specific aftercare. Encourage client to drink large amounts of water for 24-48 hours to flush the radiosotope from the system. There are no hazards to the clietn or staff from the minimal amount of radioactivity of the isotope
symptoms of HPV
no symptoms except the warts
Can you dx MS based on one lesion?
no.
with addison's disease we have ___________ aldosterone which is a mineralocorticoid... so, we have how much fluid? what do they retain?
not enough / losing water and sodium / fluid deficit / pt retains potassium becuase aldosterone usually gets rid of potassium and keeps na and h20.
Medications for GB
nothing to treat specifically GB, treat other sysmptoms ie) UTI due to stasis in bladder, morphine for muscle pain, anticoags to prevent DVTs.
a client who sustained a crush injury to right lower leg c/o numbness and tingling of the affected extremity. right leg appears pale and pedal pulse is weak.
notify the hcp- this is signs of compartment syndrome
skin around pin site is swollen red and crusty with dried drainage
notify the hcp-indicates osteomalitis
Stabilizing stage of GB
occurs 2 to 3 weeks after initial onset. symptoms "level off", labile autonomic functions stabilize.
"Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 units of regular insulin. The nurse should expect the dose's:
onset to be at 2:30 p.m. and its peak to be at 4 p.m.
what is herpes simplex 1
oral herpes caused by kissing, sharing drinks, foods and chapstick
Pemphigus Interventions
oral hygiene, soothe oral lesions; increased fluids; soothing (oatmeal) baths as ordered; ATBs for secondary infections; corticosteroids and cytotoxic agents
"A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use of:
short-acting insulin only.
What is a gallium scan
similar to a bone scan, but with an injection of gallium isotope instead of technetium-99m. Gallium is injected 2-3 hours before the procedure, which takes 30-60 minutes to perform. The client must lie still during procedure and there is no special aftercare
Scleroderma Data collection
skin is taught, hard, thick, and shiny, with a loss of elasticity and it adheres to underlying structures; decreased ROM, joint contractors; Stiffness and muscle weakness
"A client with Addison's disease comes to the clinic for a follow-up visit. When collecting data on this client, the nurse should stay alert for signs and symptoms of:
sodium and potassium abnormalities.
what are the symptoms of herpes simplex 2
sores around the genital/rectum, tired achy muscles
Latex Allergy
source of the allergic rxn is thought to be due to the proteins in the natural rubber latex or the various chemicals used in the manufacturing process of latex gloves
Describe four types of CP.
spastic (most common): the cortex is affected resulting in the child having a scissor-like gait where one foot crosses in front of the other foot. other s&s: underdeveloped limbs, increased deep tendon reflexes, contractures, involuntary muscle contraction and relaxation, flexion. athetoid: the basal ganglia are affected resulting in uncoordinated involuntary motion. other s&s: uncontrolled involuntary movements, drooling writhing, all extremities move with voluntary movement, difficulty swallowing, facial grimacing. ataxic: the cerebellum is affected resulting in poor balance and difficulty with muscle coordination. other s&s: wide-based gait, unsteadiness, clumsiness, poor balance, unnatural muscle coordination.
Kaposi Sarcoma interventions
standard precautions; protective isolation if immune system depressed; prep pt for chemo or radiation; admin immunotherapy to stabilize immune system
An appropriate goal of nursing care for a pt with end-stage renal disease is the pt will be able to do which of the following?
state the advantages and disadvantages of types of renal replacement therapies
myasthenic crisis
sudden exacerbation of motor weakness= resp failure/ aspiration. caused by undermedication/ infection.
hypoglycemia
sweating, tremor, tachycardia, palpitations, nervousness, light-headedness, hunger, cool skin, seizures, irritability, confusion, coma
which two STD's can be tested with a blood test
syphilis and HIV
Levothyroxine (Synthroid)
the agent of choice for thyroid hormone replacement because its standard hormone content gives it predictable results
which clinical manifest on a leg from which a cast has just been removed is abnormal finding
the bony prominences are excoriated; (restricted motion, smaller, atrophy, skin peeling wrinkled and dry are all normal findings)
dysarthria
the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system
Graves disease
the most common form of hyperthyroidism; caused by an autoimmune defect that creates antibodies that stimulate the overproduction of thyroid hormones; ,
List common signs and symptoms of head injury.
the most common general symptoms: Impulsive behavior Loss of memory Impaired perception Personality changes Loss of taste and smell Diminished concentration Hearing and balance disorders Cognitive fatigue Concussion Coma Epilepsy open head injury: open wound on head, no nerves receptors so patient might not even realize the extent of injuries. Most open head injuries expose the brain to the outside environment, leaving victims extremely susceptible to infection (meningitis). closed head injury: Loss of consciousness Dilated pupils Respiratory issues Convulsions Headache Dizziness Nausea and vomiting Cerebrospinal fluid leaking from nose or ears Speech and language problems Vision issues scalp injury: concussion: immediate loss of consciousness for <5min. drowsiness, confusion, dizziness, HA, blurred or double vision. contusion: varies with the size and location of injury. initial loss of consciousness;if LOC remmains altered, client may become combative. During unconsciousness, lies motionless; has pale, clammy skin; faint pulse; hypotension; shallow resps; altered motor responses. epidural hematoma: brief loss of consciousness followed by a short period of alterntess. the client rapidly progresses into coma with decorticate or decerebate posturing, ipsilateral pupil dilation, and seizures. subdural hematoma: acute - rapid deterioration from drowsiness and confusion to coma, ipsilateral pupil dilation and contralateral hemiparesis subacute - appear 48 hours - 2 weeks later; alert period followed by slow progression to coma chronic - develops within weeks/months after initial injury. slowed thinking, confusion, drowsiness; may progress to pupil changes and motor deficits intracerebral hematoma: decreased LOC; pupil changes and motor deficits.
A nurse is evaluating the client's use of a cane for left sided weakness. The nurse would interven if the client moves the cane with witch side as the right leg is moved?
the nurse would interven and correct if the patient moves the cane when the righ leg is moved. The cane is held 6 inches lateral to the fifth great tow. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through
A nurse is planning to teach the client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion would the nurse include in the teaching plan
the shoulder of a casted arm should be lifeted over the head perodically as a prevenetive meausre.
how is a yeast infection contracted
the vagina already has healthy yeast, but it occurs when there becomes too much yeast -which can be caused by hormonal changes
What should a yeast infection look like
the vagina may swell and be red, there may be a white lumpy discharge with no smell
Explain the use of thrombolytic drugs in the treatment of a CVA.
thrombolytic drugs dissolve blood clots that have already formed within the walls of a blood vessel. is prescribed after an ischemic stroke has occurred, within 3 hours of onset this therapy is given. 0.9mg/kg, 10% given IV bolus over one minute, the rest given over 60 minutes. criteria for receiving thrombolytic drugs: • Age 18 years or older • Clinical diagnosis of ischemic stroke • Time of onset of stroke known and is 3 hours or less • Systolic blood pressure <185 mm Hg; diastolic <110 mm Hg • Not a minor stroke or rapidly resolving stroke • No seizure at onset of stroke • Not taking warfarin (Coumadin) • Prothrombin time <15 seconds or INR <1.7 • Not receiving heparin during the past 48 hours with elevated partial thromboplastin time • Platelet count >100,000/mm3 • No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm • No major surgical procedures within 14 days • No stroke, serious head injury, or intracranial surgery within 3 months • No gastrointestinal or urinary bleeding within 21 days assess q 15min for first hour, then every 15-30 minutes for the next 8 hours, then at least q4hrs. bleeding and IICP are side effects to monitor for. draw CBC before starting thrombolytics patients is critical and cared for in ICU for 48 hours used as soon as possible after formulation of clot
two injections at same time in different extremities
to reduce pain and anxiety associated with injections - use correct needle, distract child, pressure on site for 10 seconds before injection, and if you have two injections to give -
medications for HD: tetrabenzine
treat chorea (jerky movements). increased depression/suicide. DO NOT take w/ levodopa
treatmentof thyroid storm
treated with iodine, PTU, beta blocker for tachycardia, cooling, sedation, glucocorticoids to decrease swelling, and IV fluids
s/s Cushings syndrome
truncal obesity, round moon face, supraclavicular fat pads (buffalo hump, edema, hypertension, muscular weakness and wasting, skin infection.. Decreased potassium increased soduim, , BUN and glucose .
cognex
used in treatment of mild to moderate dementia associated with Alzheimer's disease. Increases level f ACH in the CNS by inhibiting its breakdown
ca gluconate
used to reverse a negative ca balance and relieve muscle cramps
Late S/S
varying neurological deficits, typically severe in nature
Causes of trigeminal neuralgia
vascular compression and demeylination of nerve caused by trauma, infection of jaw/teeth, aneurysm, tumor, MS.
AIDS
viral disease caused by HIV that destroys T cells, increasing susceptibility to infection and malignancy; clinically manifests by opportunistic infection and unusual neoplasms; incubation period is long, up to 10+yrs;
Early S/S
visual disturbances, paresthesias, incontinence, weakness and fatigability
hypocortisolism
vomiting, weakness, dehydration and hypotension. steroids should be given before surgery (hypophysectomy) to prevent hypocortisolism from occuring
"The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
wash and inspect his feet daily.
S/S SIADH
water retention, hyponatremia, & seurm hypo-osmlality; blood volume expands, but plasma diluted brain cells swell causing headache ;change in mental status or personality lethragy and irritability weight gain occurs without edema
musculoskeletal S&S of MD
weakness, fatigue, decreased function, comlplications; decrease ability to preform ADL's, immobility, myasthenic and cholinergic crisis
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:
wear gloves when providing mouth care.
Cushing's syndrome
weight gain, facial hair, amenorrhea, frequent bruising and acne. affects women ages 20 to 40. causes changes in fat distribution, adipose tissue accumulates in the trunk, face (moonfaace) and dorsocervical areas (buffalo hump)
Polyarteritis nodusa interventions
well-balanced diet; corticosteroids/analgesics; emotional support; initiate support services
2-23 months
what age should the pneumococcal conjugate vaccine be given
HA, photophobia, >liver enzymes, fever
what are 4 side effects to Hep B Vaccine
seizures, crying for 3 hours, or >105* temp
what are contraindications or side effects to DTaP or Tdap
allergy to baker's yeast, or liver abnormalities
what are contraindications to the use of the 3 injections to Hep B vaccine
bacterial meningitis
what illness is caused by the pneumocoocal infection
genital warts
what is HPV
.01 ml/kg
what is epi 1:1,000 dose for anaphylaxis reaction to vaccine
gardisil or cervarix
what is name of the HPV vaccine
aspirin free pain reliever
what pain reliever is given to DTaP if fever or pain at injection site occured
meningitis, epiglottitis, pneumonia, sepsis and septic arthritis
what serious diseases are vaccinated for with HIB vaccine
day care, immunosuppressed, cardiopulmonary illnesses, diabetes, SCA, asplenia pt.
what type of pt. are recommended for the pneumonia vaccine
Tdap
what vaccine is recommended for those who go to college and live in crowded conditions or work with infants less than 12 months old.
wait until they recover
when should an severely ill person receive a Tdap or DTaP vaccine if they are sick
after 6 weeks and finish by 32 weeks
when should rotavirus be given to an infant and end the series of oral dose
4
which is the best response by the nurse if the client fails to follow the information or teaching provided? 1. give up because the client doesnt want to change 2. develop a tough approach 3. guide the client to create a plan of action 4. Remind the client of previous successes.
paresthesias
which is the feeling of pins and needles or numbness of the face, body and extremities.
what is vitiligo?
white pachy area of depigmented skin (caused by addisons)
pertussis
whooping cough respiratory distress, pneumonia, seizures, brain damage or death
avoid pregnancy for 3 months after vacine
how long should childbearer women avoid pregnancy after vaccine
2 under age of 12, one older than 12.
how many doses of flu vaccine be given for under 12 and over 12.
What is MS?
chronic demyelination of CNS. onset 20-40 yrs old. Mostly Northern European ancestry, those living in Northern Climates.theory= immune response to protein in CNS
what is trigeminal neuralgia
chronic disease of Cranial Nerve 5 causes unilateral excruciating facial pain.
Dislocation (after hip surgery)
circulatory/nerve damage S/S: shortening of leg, abnormal rotation, can't move extremity, PAIN
what are the symptoms of herpes simplex 1
cold sores and blisters aroung the mouth
Cause of Huntington's disease
dominant autosomal trait causes localized death of neurons in basal ganglia. If parent has it, each kid has 50% chance of having it only need 1 gene for disease expression.
A pt hospitalized w/ sever ascites due to cirrhosis develops a fever and confusion. The nurse should do which of the following?
***1. auscultate bowel sounds and palpate for abdominal tenderness 2. Inquire about headache and check for nuchal rigidity 3. observe for neck vein distention and auscultate lung sounds 4. measure abdominal girth and percuss for shifting dullness
"The nurse is caring for a woman at 37 weeks gestation. The client was diagnosed with insulin-dependent diabetes mellitis (IDDM) at age 7. The client states, ""I am so thrilled that I will be breastfeeding my baby."" Which of the following responses by the nurse is best? "1. You will probably need less insulin while you are breastfeeding. 2. You will need to initially increase your insulin after the baby is born. 3. You will be able to take an oral hypoglycemic instead of insulin after the baby is born. 4. You will probably require the same dose of insulin that you are now taking."
"1. breastfeeding has an antidiabetogenic effect, less insulin is needed. (correct) 2. insulin needs will decrease due to antidiabetogenic effect of breastfeeding and physiological changes during immediate postpartum period. 3. client has IDDM, insulin required. 4. during third trimester insulin requirements increase due to increased insulin resistance"
"The client diagnosed with Type 1 diabetes has a glycosylated hemoglobin (A1 c) of 8.1%. Which interpretation should the nurse make based on this result? 1.This result is below normal levels.2.This result is within acceptable levels. 3.This result is above recommended levels 4.This result is dangerously high.
"1.The acceptable level for an A1c for a client with diabetes is between 6% and 7%, which corresponds to a 120-140 mg/dL average blood glucose level. 2.This result is not within acceptable levelsfor the client with diabetes, which is 6% to7%. 3.(CORRECT) This result parallels a serum blood glucoselevel of approximately 180 to 200 mg/dL. An A1 c is a blood test that reflects average blood glucose levels over a period of 2-3months; clients with elevated blood glucose levels are at risk for developing long-term complications. 4.An A1c of 13% is dangerously high; it reflects a 300-mg/dL average blood glucose level overthe past 3 months."
"An 18-year-old female client, 5'4'' tall, weighing 113 kg, comes to the clinic for a non-healing wound on her lower leg, which she has had for two weeks. Which disease process should the nurse suspect the client is developing? "A. Type 1 diabetes B. Type 2 diabetes C. Gestational diabetes D. Acanthosis nigricans"
"A: Type 1 diabetes usually occurs in young clients who are underweight. In this disease, there is no production of insulin from the beta cells in the pancreas. People with type 1 diabetes are insulin dependent with a rapid onset of symptoms, including polyuria, polydipsia, and polyphagia. CORRECT -->B. Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Non-healing wounds are a hallmark sign of type 2 diabetes. This client weights 248.6 lbs and is short. C. Gestational diabetes occurs during pregnancy. There is no mention of this. D. Acanthosis nigricans (AN), dark pigmentation and skin creases in the neck, is a sign of hyperinsulinemia. The pancreas is secreting excess amounts of insulin as a result of excessive caloric intake. It is identified in young children and is a precursor to the development of type 2 diabetes."
The nurse is educating a pregnant client who has gestational diabetes. Which of the following statements should the nurse make to the client? Select all that apply. "a. Cakes, candies, cookies, and regular soft drinks should be avoided. b. Gestational diabetes increases the risk that the mother will develop diabetes later in life. c. Gestational diabetes usually resolves after the baby is born. d. Insulin injections may be necessary. e. The baby will likely be born with diabetes f. The mother should strive to gain no more weight during the pregnancy.
"ANS: A, B, C, D Gestational diabetes can occur between the 16th and 28th week of pregnancy. If not responsive to diet and exercise, insulin injections may be necessary. Concentrated sugars should be avoided. Weight gain should continue, but not in excessive amounts. Usually, gestational diabetes disappears after the infant is born. However, diabetes can develop 5 to 10 years after the pregnancy"
"Prediabetes is associated with all of the following except: " a. Increased risk of developing type 2 diabetes b. Impaired glucose tolerance c. Increased risk of heart disease and stroke d. Increased risk of developing type 1 diabetes"
"ANSWER: D Persons with elevated glucose levels that do not yet meet the criteria for diabetes are considered to have prediabetes and are at increased risk of developing type 2 diabetes. Weight loss and increasing physical activity can help people with prediabetes prevent or postpone the onset of type 2 diabetes."
A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? a) "Apply ice packs for the first 24 to 48 hours, then apply heat packs." b) "Apply heat packs for the first 24 to 48 hours." c) "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." d) "Apply ice packs for the first 12 to 18 hours."
"Apply ice packs for the first 24 to 48 hours, then apply heat packs." Explanation: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.
During a diabetes screening program, a patient tells the nurse, "My mother died of complications of type 2 diabetes. Can I inherit diabetes?" The nurse explains that "a.) as long as the patient maintains normal weight and exercises, type 2 diabetes can be prevented. b.) the patient is at a higher than normal risk for type 2 diabetes and should have periodic blood glucose level testing. c.) there is a greater risk for children developing type 2 diabetes when the father has type 2 diabetes. d.) although there is a tendency for children of people with type 2 diabetes to develop diabetes, the risk is higher for those with type 1 diabetes."
"B Rationale: Offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes. The risk can be decreased, but not prevented, by maintenance of normal weight and exercising. The risk for children of a person with type 1 diabetes to develop diabetes is higher when it is the father who has the disease. Offspring of people with type 2 diabetes are more likely to develop diabetes than offspring of those with type 1 diabetes."
Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? A) BP 126/80 B) A1C 9% C)FBG 130mg/dL D) LDL cholesterol 100mg/dL
"B) A1C 9% Rationale: Lowering hemoglobin A1C (to average of 7%) reduces microvascular and neuropathic complications. Tighter glycemic control(normal A1C < 6%) may further reduce complications but increases hypoglycemia risk."
"The client, an 18-year-old female, 5'4'' tall, weighing 113 kg, comes to the clinic for a wound on her lower leg that has not healed for the last two (2) weeks. Which diseaseprocess would the nurse suspect that the client has developed? "1.Type 1 diabetes. 2.Type 2 diabetes. 3.Gestational diabetes. 4.Acanthosis nigricans"
"Correct Answer: 2 Type 2 diabetes is a disorder that usually occurs around the age of 40, but it is now being detected in children and young adultsas a result of obesity and sedentary life-styles. Wounds that do not heal are a hall-mark sign of Type 2 diabetes. This client weighs 248.6 pounds and is short"
Which statement by the patient with type 2 diabetes is accurate. "a. ""I am supposed to have a meal or snak if I drink alcohol"" b. ""I am not allowed to eat any sweets because of my diabetes."" c. I do not need to watch what I eat because my diabetes is not the bad kind."" d. The amunt of fat in my diet is not important; it is just the carbohydrates that raise my blood sugar."""
"Correct Answer: A Alcohol should be consumed with food to reduce the risk of hypoglycemia."
"Which of the following persons would most likely be diagnosed with diabetes mellitus? A 44-year-old.. "A. Caucasian Woman B. Asian Woman C. African-American woman D. Hispanic Male
"Correct answer: African-American woman Rationale: Age-specific prevalence of diagnosed diabetes mellitus (DM) is higher for African-Americans and Hispanics than for Caucasians. Among those younger than 75, black women had the highest incidence."
"Excessive thirst and volume of very dilute urine may be symptoms of: "A. Urinary tract infection B. Diabetes insipidus C. Viral gastroenteritis D.Hypoglycemia"
"Correct answer: B Diabetes insipidus is a condition in which the kidneys are unable to conserve water, often because there is insufficient antidiuretic hormone (ADH) or the kidneys are unable to respond to ADH. Although diabetes mellitus may present with similar symptoms, the disorders are different. Diabetes insipidus does not involve hyperglycemia."
"The principal goals of therapy for older patients who have poor glycemic control are: "A. Enhancing quality of life. B. Decreasing the chance of complications. C. Improving self-care through education. D. All of the above."
"D. All of the above. Rationale: The principal goals of therapy for older persons with diabetes mellitus and poor glycemic control are enhancing quality of life, decreasing the chance of complications, improving self-care through education, and maintaining or improving general health status."
"A nurse shoud recognize which symptom as a cardinal sign of diabetes mellitus? "a. Nausea b. Seizure c. Hyperactivity d. Frequent urination
"D. Frequent Urination Polyphagia, polyuria, polydipsia, and weight loss are cardinal signs of DM. Other signs include irritability, shortened attention span, lowered frustration tolerance, fatigue, dry skin, blurred vision, sores that are slow to heal, and flushed skin."
Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture? a) "Don't flex your hip more than 60 degrees, don't cross your legs, and have someone help you put your shoes on." b) "Don't flex your hip more than 120 degrees, don't cross your legs, and have someone help you put your shoes on." c) "Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." d) "Don't flex your hip more than 30 degrees,
"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." Explanation: Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.
The nurse is teaching the parents of a child with hemophilia about how to provide a safe home environment throughout the child's life. Which nursing instruction is most appropriate?
"Establish a written emergency plan that includes what to do in specific situations and the names and phone numbers of emergency contacts."
A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? a) "The occupational therapist is showing me how to use a sock puller to help me get dressed." b) "I'll need to keep several pillows between my legs at night." c) "I need to remember not to cross my legs. It's such a habit." d) "I don't know if I'll be able to get off that low toilet seat at home by myself."
"I don't know if I'll be able to get off that low toilet seat at home by myself." Explanation: The client requires additional teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
"I won't donate blood because I don't want to get AIDS."
In teaching a female client who is HIV-positive about pregnancy and the human immunodeficiency virus (HIV), the nurse would know more teaching is necessary when the client says:
"I'll need to have a C-section if I become pregnant and have a baby."
Following surgery, a pt has not voided for 12 hours. What assessment should the nurse make?
***1. palpate for bladder distention. 2. ausculatate for bowel sounds. 3. inspect for edema of the urethra 4. percuss for gastric tympany
"When an older adult is admitted to the hospital with a diagnosis of diabetes mellitus and complaints of rapid-onset weight loss, elevated blood glucose levels, and polyphagia, the gerontology nurse should anticipate which of the following secondary medical diagnoses? "1.Impaired glucose tolerance 2.Gestational diabetes mellitus 3.Pituitary tumor 4. Pancreatic tumor
"Pancreatic tumor Rationale: The onset of hyperglycemia in the older adult can occur more slowly. When the older adult reports rapid-onset weight loss, elevated blood glucose levels, and polyphagia, the healthcare provider should consider pancreatic tumor."
A 27-year-old client with end-stage acquired immunodeficiency syndrome (AIDS) is being cared for by his wife at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about advance directives. At the next visit, the client states that since he and his wife filled out the advance directive form he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client 's concerns?
"Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself."
"(SELECT ALL THAT APPLY) A 45-year-old female client is admitted to the hospital with Cushing's syndrome. Which nursing interventions are appropriate for this client?
(1) Assess for peripheral edema (3) Measure intake and output (5) Weigh the client daily
"(SELECT ALL THAT APPLY) A client is seen in the clinic with suspected parathormone (PTH) deficiency. Part of the diagnosis of this condition includes the analysis of serum electrolyte levels. Which electrolyte levels would the nurse expect to be abnormal in a client with PTH deficiency?
(1) Calcium (6) Phosphorous
(SELECT ALL THAT APPLY) The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions should the nurse include in the teaching plan?
(1) Stay out of direct sunlight., (3) Monitor body temperature., (4) Taper the corticosteroid dosage as ordered by the physician when symptoms are under control.
"(SELECT ALL THAT APPLY) A client visiting the clinic is scheduled for an outpatient thyroid scan in 2 weeks. Which instructions should the nurse include in her client teaching to ensure that this client is prepared for the test?
(1) Stop using iodized salt or iodized salt substitutes 1 week before the scan. (2) Stop eating seafood 1 week before the scan. (4) Don't take any prescribed thyroid medication on the day of the scan.
"(SELECT ALL THAT APPLY) A client is diagnosed with a goiter after traveling in a foreign country for 3 months. During her trip, the client wasn't able to tolerate food. Which signs and symptoms would the nurse expect to see in this client?
(2) Dizziness when raising her arms above her head (3) Dysphagia (5) Respiratory distress
"(SELECT ALL THAT APPLY) A 48-year-old female client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan?
(2) High-fiber, low-calorie diet (4) Use of stool softeners (5) Thyroid hormone replacements
"(PUT IN ORDER) A client is ordered to receive 20 units of isophane insulin suspension (Humulin N) and 5 units of regular insulin (Humulin R) by subcutaneous injection. Place in chronological order the steps to take when mixing different types of insulin in a syringe. Use all the options.
(2) Inject 20 units of air into the Humulin N Vile (4) Withdrawl the syringe; don't withdrawl the insulin, (5) Inject 5 units of air into the Humulin R vile (1) Invert the vial and withdrawl the Humulin R Dose (3) Insert the syringe needle into the Humulin N vial (6) Invert the vial and withdral the Humulin N dose.
"(SELECT ALL THAT APPLY) A 56-year-old female client is being discharged after having a thyroidectomy. Which discharge instructions are appropriate for this client?
(2) Take thyroid replacement medication, as ordered. (3) Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin. Report them to the physician.
(SELECT ALL THAT APPLY) A client has undergone total gastrectomy due to stomach cancer. Which nursing interventions are necessary for this client immediately after surgery?
(3) Observe the wound for redness, swelling, and warmth, (4) Encourage incentive spirometry use every hour during the client's waking hours., (5) Administer opioid analgesics as prescribed.
(SELECT ALL THAT APPLY) The nurse is planning care for a client with human immunodeficiency virus (HIV). Which statement by the nurse indicates her understanding of HIV transmission?
(4) "I will wear a mask, gown, and gloves when splashing of bodily fluids is likely.", (5) "I will wash my hands after client care."
634. The client with hiatal hernia chronically experiences heartburn following meals. The nurse plans to teach the client to avoid which action because it is contraindicated with a hiatal hernia?
***1. Lying recumbent following meals 2. Taking in small, frequent, bland meals 3. Raising the head of bed on 6-inch blocks 4. Taking H2-receptor antagonist medication
A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated? 1) Apply an indwelling fecal drainage device. 2) Apply an external fecal collection device. 3) Place an incontinence garment on the patient. 4) Place a waterproof pad under the patient's buttocks.
*1) Apply an indwelling fecal drainage device.* An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive days of use; and for patients who have severe hemorrhoids, recent bowel, rectal, or anal surgery or injury; rectal or anal tumors; or stricture or stenosis. External devices are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. Even with absorbent products or an external collection device, the nurse should place a waterproof pad under the patient to protect the bed linens.
In preventing and controlling the transmission of infections, the single most important technique is: 1) Hand hygiene 2) The use of disposable gloves 3) The use of isolation precautions 4) Sterilization of equipment
*1) Hand hygiene*
The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and: 1) Have the patient void directly into the bedpan. 2) Pour the urine into a graduated container. 3) Read the volume with the bedpan on a flat surface at eye level. 4) Observe color and clarity of the urine in the bedpan.
*1) Have the patient void directly into the bedpan.* First, the nurse should put on gloves and have the patient void directly into the bedpan. Next, she should pour the urine into a graduated container, place the measuring device on a flat surface, and read the amount at eye level. She should observe the urine for color, clarity, and odor. Then, if no specimen is required, she should discard the urine in the toilet and clean the container and bedpan. Finally, she should record the amount of urine voided on the patient's intake and output record.
The surgeon orders hourly urine output measurement for a patient after abdominal surgery. The patient's urine output has been greater than 60 ml/hour for the past 2 hours. Suddenly the patient's urine output drops to almost nothing. What should the nurse do first? 1) Irrigate the catheter with 30 ml of sterile solution. 2) Replace the patient's indwelling urinary catheter. 3) Infuse 500 ml of normal saline solution IV over 1 hour. 4) Notify the surgeon immediately.
*1) Irrigate the catheter with 30 ml of sterile solution.* If the patient's urinary output suddenly ceases, the nurse should irrigate the urinary catheter to assess whether the catheter is blocked. If no blockage is detected, the nurse should notify the surgeon. The surgeon may request that the catheter be changed if irrigation does not help or if the tubing is not kinked. However, the nurse should not change a catheter in the immediate postoperative period without consulting with the surgeon. The surgeon may prescribe an IV fluid bolus if the patient is suspected to have a deficient fluid volume.
What is typically the most reliable indicator of pain? 1) Patient's self-report 2) Past medical history 3) Description by caregiver(s) 4) Behavioral cues
*1) Patient's self-report*
A nurse is teaching a group of mothers about first aid. Should poison come in contact with their child's clothing and skin, which action should the nurse instruct the mothers to take first? 1) Remove the contaminated clothing immediately. 2) Flood the contaminated area with lukewarm water. 3) Wash the contaminated area with soap and water and rinse. 4) Call the nearest poison control center immediately.
*1) Remove the contaminated clothing immediately.* Remove contaminated clothing immediately - then wash with water - irrigate it and contact poison control.
Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning)
*1) Risk for Falls* Risk for Falls due to loss of muscle strength and joint mobility
Which of the following factors has the greatest positive effect on sleep quality? 1) Sleeping hours in synchrony with the person's circadian rhythm 2) Sleeping in a quiet environment 3) Spending additional time in stage IV of the sleep cycle 4) Napping on and off during the daytime
*1) Sleeping hours in synchrony with the person's circadian rhythm*
Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown
*1) Washing hands*
The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient's care plan? "Teach the patient to: 1) use an electric razor for shaving." 2) apply skin moisturizer." 3) use less soap when bathing." 4) floss teeth daily."
*1) use an electric razor for shaving."* The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss.
Which of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function? 1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working." 2. "Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines." 3. "If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain." 4. "Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure."
*1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working."* Except in cases of severe traumatic pain, which sends a person into shock, most people reach a level of adaptation in which physical signs return to normal. Thus clients in pain will not always have changes in their vital signs. Changes in vital signs are more often indicative of problems other than pain. Although the remaining options recognize the phenomena, they are not assuming that no elevation of vital signs means the absence of pain.
A client who is 2 days' postoperative reports feeling "constipated" to the nurse. The client has good bowel sounds in all four quadrants and has tolerated liquids well. Her pain is being controlled with an opioid analgesic. Which of the following interventions should the nurse try initially? 1. "Let me get you some apple juice." 2. "Ambulating may get your bowels moving." 3. "I'll see about getting a different pain medication." 4. "Your health care provider might prescribe an enema if I call."
*1. "Let me get you some apple juice."*
A 74-year-old client has been having sleeping difficulties. To have a better idea of the client's problem, the nurse should respond: 1. "What do you do just before going to bed?" 2. "Let's make sure that your bedroom is completely darkened at night." 3. "Why don't you try napping more during the daytime?" 4. "Do you eat a small snack before going to bed?"
*1. "What do you do just before going to bed?"* To assess the client's sleeping problem, the nurse should inquire about predisposing factors, such as by asking "What do you do just before going to bed?" Assessment is aimed at understanding the characteristics of any sleep problem and the client's usual sleep habits so that ways for promoting sleep can be incorporated into nursing care. Older adults sleep best in softly lit rooms. Napping more during the daytime is often not the best solution. The nurse should first assess the client's sleeping problem. The client does not always have to eat something before going to bed.
Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter? 1. Empty the drainage bag at least every 8 hours. 2. Clean up the length of the catheter to the perineum. 3. Use clean technique to obtain a specimen for culture and sensitivity. 4. Place the drainage bag on the client's lap while transporting the client to testing.
*1. Empty the drainage bag at least every 8 hours.*
Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care? 1. Flex the knees and keep the feet wide apart. 2. Assume a position far enough away from the client. 3. Twist the body in the direction of movement. 4. Use the strong back muscles for lifting or moving.
*1. Flex the knees and keep the feet wide apart.* The correct answer is to flex the knees and keep the feet wide apart. This will create a wide base of support, providing greater stability for the nurse and reducing the risk of back injury. The nurse should be positioned close to the client and use the arms and legs. Dividing balanced activity between arms and legs reduces the risk of back injury. Facing the direction of movement prevents abnormal twisting of the spine, also reducing the risk of back injury.
When a client's husband questions how a patient-controlled analgesia (PCA) pump works, the nurse explains that the client: 1. Has control over the frequency of the intravenous (IV) analgesia 2. Can choose the dosage of the drug received 3. May request the type of medication received 4. Controls the route for administering the medication
*1. Has control over the frequency of the intravenous (IV) analgesia* With a PCA system the client controls medication delivery. The PCA system is designed to deliver no more than a specified number of doses. The client does not choose the dosage. The health care provider prescribes the type of medication to be used. The advantage for the client is that he or she may self-administer opioids with minimal risk for overdose. The client does not control the route for administration. Systemic PCA typically involves IV drug administration but can also be given subcutaneously.
Communication involves both active listening and body language working together. The nurse actively listens to the client and: 1. Sits facing the client 2. Keeps the arms and legs crossed 3. Leans back in the chair away from the client 4. Avoids eye contact as much as is physically possible
*1. Sits facing the client* Active listening means to be attentive to what the client is saying both verbally and nonverbally. A nonverbal skill to facilitate attentive listening is to sit facing the client. This posture gives the message that the nurse is there to listen and is interested in what the client is saying. For active listening, the arms and legs should be uncrossed. This posture suggests that the nurse is "open" to what the client says. For active listening, the nurse should lean toward the client. This posture conveys that the nurse is involved and interested in the interaction. For active listening, the nurse should establish and maintain intermittent eye contact. This conveys the nurse's involvement in and willingness to listen to what the client is saying.
When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.) 1. Stress management 2. Enhanced cardiac output 3. Improved bone integrity 4. Facilitation of weight control 5. Increased cognitive function 6. Increased musculoskeletal flexibility
*1. Stress management* *2. Enhanced cardiac output* *3. Improved bone integrity* *4. Facilitation of weight control* *6. Increased musculoskeletal flexibility* Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Effects on cognitive function are not consistent.
Which of the following clients presents with an increased risk for urinary incontinence? (Select all that apply.) 1. The 74-year-old diagnosed with parkinsonism 5 years ago 2. The 25-year-old with Crohn's disease diagnosed 4 years ago 3. The 62-year-old Alzheimer's disease client diagnosed 8 years ago 4. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago 5. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago 6. The 69-year-old client diagnosed with type 2 diabetes 9 years ago
*1. The 74-year-old diagnosed with parkinsonism 5 years ago* *3. The 62-year-old Alzheimer's disease client diagnosed 8 years ago* *4. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago* *5. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago* *6. The 69-year-old client diagnosed with type 2 diabetes 9 years ago*
A timed urine specimen collection is ordered. The test will need to be restarted if which of the following occurs? 1. The client voids in the toilet. 2. The urine specimen is kept cold . 3. The first voided urine is discarded. 4. The preservative is placed in the collection container.
*1. The client voids in the toilet.*
hypersensitivity and allergy interventions
ID specific allergen; management of sx with antihistamines, anti-inflammatory agents, or corticosteroids; ointments, creams, wet compresses, and soothing baths for local rxns; possible desensitization
A client with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the client to begin putting a little weight on the left foot when walking. Which of the following gaits should the client be taught to use? 1. Two-point 2. Three-point 3. Four-point 4. Swing-through
*1. Two-point* The two-point gait requires at least partial weight bearing on each foot. The client moves a crutch at the same time as the opposing leg, so that the crutch movements are similar to arm motion during normal walking. In a three-point gait, weight is borne on both crutches and then on the uninvolved leg. The four-point gait gives stability to the client but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. This client is only supposed to use partial weight bearing, so this gait would not be appropriate. Paraplegics who wear weight-supporting braces on their legs use the swing-through gait. It would not be appropriate for this client.
The nurse instructs a woman about providing a clean catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure? 1) "I will be sure to urinate into the 'hat' you placed on the toilet seat." 2) "I will cleanse my genital area from front to back before I collect the specimen midstream." 3) "I will need to lie still while you put in a urinary catheter to obtain the specimen." 4) "I will collect my urine each time I urinate for the next 24 hours."
*2) "I will cleanse my genital area from front to back before I collect the specimen midstream."* To obtain a clean catch urine specimen, the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream. This follows the principle of going from "clean" to "dirty." The nurse should have the ambulatory patient void into a "hat" (container for collecting the urine of an ambulatory patient) when monitoring urinary output, but not when obtaining a clean catch urine specimen. A urinary catheter is required for a sterile urine specimen, not a clean catch specimen. A 24-hour urine collection may be necessary to evaluate some disorders but a clean catch specimen is a one-time collection.
The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis? 1) Prepare the patient for an abdominal flat plate. 2) Collect a stool specimen that contains 20 to 30 ml of liquid stool. 3) Administer a laxative to prepare the patient for a colonoscopy. 4) Test the patient's stool using a fecal occult test.
*2) Collect a stool specimen that contains 20 to 30 ml of liquid stool.* To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that contains 20 to 30 ml of liquid stool. An abdominal flat plate and a fecal occult blood test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis.
When changing a diaper, the nurse observes that a 2-day-old infant has had a green black, tarry stool. What should the nurse do? 1) Notify the physician. 2) Do nothing; this is normal. 3) Give the baby sterile water until the mother's milk comes in. 4) Apply a skin barrier cream to the buttocks to prevent irritation.
*2) Do nothing; this is normal.* During the first few days of life, a term newborn passes green black, tarry stools known as meconium. Stools transition to a yellow green color over the next few days. After that, the appearance of stools depends upon the feedings the newborn receives. Sterile water does nothing to alter this progression. Meconium stools are more irritating to the buttocks than other stools because they are so sticky and the skin usually must be rubbed to cleanse it.
Which one of the following clients would probably have a higher than normal respiratory rate? A client who has: 1) Had surgery and is receiving a narcotic analgesic. 2) Had surgery and lost a unit of blood intraoperatively. 3) Lived at a high altitude and then moved to sea level. 4) Been exposed to the cold and is now hypothermic.
*2) Had surgery and lost a unit of blood intraoperatively.* Hypovolemia / shock. BP decreases, respiratory rate increases
After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviate the patient's pain? 1) Encourage the client to ambulate to promote flow of spinal fluid. 2) Offer caffeinated beverages to constrict blood vessels in his head. 3) Encourage coughing and deep breathing to increase CSF pressure. 4) Restrict oral fluid intake to prevent excess spinal pressure.
*2) Offer caffeinated beverages to constrict blood vessels in his head.*
While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patient's bladder. Which statement by the instructor is best? "You should: 1) Try to palpate it again; it takes practice but you will locate it." 2) Palpate the patient's bladder only when it is distended by urine." 3) Document this abnormal finding on the patient's chart." 4) Immediately notify the nurse assigned to your patient."
*2) Palpate the patient's bladder only when it is distended by urine."* The bladder is not palpable unless it is distended by urine. It is not difficult to palpate the bladder when distended. The nurse should document her finding, but it is not an abnormal finding. It is not necessary to notify the nurse assigned to the patient.
A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of: 1) Powerlessness 2) Self-care deficit 3) Tissue integrity impairment 4) Knowledge deficit of hygiene practices
*2) Self-care deficit* The client who is unable to complete bathing and grooming independently has a nursing diagnosis of self-care deficit. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of powerlessness. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of tissue integrity impairment. There is no indication this client has a knowledge deficit of hygiene practices.
A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation? 1) Skin was softened from prolonged exposure to moisture. 2) Superficial layers of skin were absent. 3) Epidermal layer of skin was rubbed away. 4) Lesion caused by tissue compression was present.
*2) Superficial layers of skin were absent.* Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or searing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.
The nurse and a client are discussing possible behaviors that might be interfering with the client's ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the client's sleep routine that possibly are contributing to the difficulty? 1. "When do you usually retire for the night?" 2. "What do you do to help yourself fall asleep?" 3. "How much time does it usually take for you to fall asleep?" 4. "Have you changed anything about your presleep ritual lately?"
*2. "What do you do to help yourself fall asleep?"* As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem.
Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding bowel patterns? 1. "The more fiber I eat, the fewer problems I have with my bowels." 2. "Whole grain cereal and toast for breakfast keeps my bowels moving regularly." 3. "My wife makes whole grain muffins; they are really good and good for me too." 4. "I use to have trouble with constipation until I started taking a fiber supplement."
*2. "Whole grain cereal and toast for breakfast keeps my bowels moving regularly."*
The nurse recognizes that the leading cause of death for the otherwise healthy 1-year-old is: 1. Physical abuse 2. Accidental injury 3. Contagious diseases 4. Stranger abduction
*2. Accidental injury* Injuries are the leading cause of death in children older than 1 year of age and cause more deaths and disabilities than do all diseases combined.
Which of the following symptoms should the nurse assess with a client who is deprived of sleep? 1. Elevated blood pressure and confusion 2. Confusion and irritability 3. Inappropriateness and rapid respirations 4. Decreased temperature and talkativeness
*2. Confusion and irritability* Psychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptom of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative.
The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly? 1. The client keeps the cane on the left side. 2. Two points of support are kept on the floor at all times. 3. There is a slight lean to the right when the client is walking. 4. After advancing the cane, the client moves the right leg forward.
*2. Two points of support are kept on the floor at all times.* Two points of support, such as both feet or one foot and the cane, should be on the floor at all times. The cane should be kept on the stronger side, the client's right side. The client should keep his or her body upright and midline. Leaning can cause the client to lose his or her balance and fall. After advancing the cane, the client should move the weaker leg, the client's left leg, forward to the cane.
The nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, "I don't know what is wrong with me. I have been napping all day and can't seem to think clearly." The nurse's best response is 1) "You are sleep deprived, but that will resolve in a few days." 2) "You are experiencing hypersomnia, so it will be important for you to walk in the hall more often." 3) "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?" 4) "I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep."
*3) "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?"* The data suggests that the patient is used to being awake at night and sleeping during the day. The hospital routine has disrupted this normal pattern.
A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be: 1) "Your vital signs confirm that your infection is resolved; how do you feel?" 2) "I'll let your health care provider know so you can be discharged." 3) "Your vital signs are stable, but there are other things to assess." 4) "We still need to keep monitoring your temperature for a while."
*3) "Your vital signs are stable, but there are other things to assess."*
A nurse is teaching wellness to a women's group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)? 1) 2 to 4 glasses a day 2) 4 to 6 glasses a day 3) 6 to 8 glasses a day 4) 8 to 10 glasses a day
*3) 6 to 8 glasses a day* A minimum of 6 to 8 glasses of fluid should be consumed each day to promote healthy bowel function.
For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated. 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion
*3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago* Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly.
The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is: A. A reduced skin elasticity is common in the older adult B. The attachment between the epidermis and dermis is weaker C. The older client has less subcutaneous padding on the elbows D. Older adults have a poor diet that increases risk for pressure ulcers
C. The older client has less subcutaneous padding on the elbows
Comparing the changes in vital signs as a person ages, which statement(s) is/are correct? (Select all that apply.) 1) Blood pressure decreases less than heart rate and respiratory rate. 2) Respiratory rate remains fairly stable throughout a person's life. 3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause.
*3) Blood pressure increases; heart rate and respiratory rate decline.* *4) Men have higher blood pressure than women until after menopause.*
The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan? 1) Place the cold pack directly on the skin over the ankle. 2) Apply the cold pack to the ankle for 30 minutes at a time. 3) Check the skin frequently for extreme redness. 4) Keep the cold pack in place for at least 24 hours.
*3) Check the skin frequently for extreme redness.*
The patient is diagnosed with obstructive sleep apnea. Identify the symptoms you would expect the client to exhibit. Choose all that apply. 1) Bruxism 2) Enuresis 3) Daytime fatigue 4) Snoring
*3) Daytime fatigue* *4) Snoring*
What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowler's
*3) Dorsal recumbent* The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal recumbent position). If the patient is unable to assume this position, the nurse should help the patient to a side-lying position. Modified Trendelenburg position is used for central venous catheter insertion. Prone position is sometimes used to improve oxygenation in patients with adult respiratory distress syndrome. Semi-Fowler's position is used to prevent aspiration in those receiving enteral feedings.
Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) Milk and cheese. 2) Bread and pasta. 3) Fruits and vegetables. 4) Lean meats.
*3) Fruits and vegetables.* The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.
From what stage of sleep are people typically most difficult to arouse? 1) NREM, alpha waves 2) NREM, sleep spindles 3) NREM, delta waves 4) REM
*3) NREM, delta waves*
The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take? 1) Do nothing; this is normal postoperative urine output. 2) Increase the infusion rate of the patient's IV fluids. 3) Notify the provider about the patient's oliguria. 4) Administer the patient's routine diuretic dose early.
*3) Notify the provider about the patient's oliguria.* 50 mL in two hours is not normal output. The kidneys typically produce 60 ml of urine per hour. Therefore, the nurse should notify the provider when the patient shows diminished urine output (oliguria). Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. The nurse cannot provide increased IV fluids without a provider's order. The nurse should not administer any medications before the scheduled time without a prescription. The provider may hold the patient's scheduled dose of diuretic if he determines that the patient is experiencing deficient fluid volume.
A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal range for this client, and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1) Add 1°F to 100.8°F to obtain an oral equivalent. 2) Add 2°F to 100.8°F to obtain a rectal equivalent. 3) Obtain a rectal temperature reading. 4) Obtain a tympanic membrane reading.
*3) Obtain a rectal temperature reading.*
Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia? 1) The patient will verbalize a reduction in pain after receiving pain medication and repositioning. 2) The patient will rest quietly when undisturbed. 3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation. 4) The patient will receive pain medication every 2 hours as prescribed.
*3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.*
A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse are advisable? 1) Reassure the patient by entering the room alone. 2) Ask the patient if he is carrying any weapons. 3) Stay between the patient and the door; keep the door open. 4) Make eye contact while stating firmly "I will not tolerate cursing and threats."
*3) Stay between the patient and the door; keep the door open.* Make sure you do not get trapped. You should never enter the room alone if someone is threatening, the nurse must be calm and reassuring. Asking about weapons and setting limits may escalate the situation.
Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process? 1. "I work with my ancillary staff to be able to determine what is abnormal." 2. "The skin is easy to observe for abnormalities when you are giving the bath." 3. "I use the time to really look at my clients and determine what's normal and what's not." 4. "Bath time is an excellent time to get to know your clients and form that nurse-client relationship."
*3. "I use the time to really look at my clients and determine what's normal and what's not."* Take this time to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues. It also provides an opportunity to assess other systems (e.g., circulatory, respiratory) and client behaviors as well. While the nurse is responsible for determining abnormalities, the ancillary staff should be instructed to report any suspicious factors they note. Answer 3 is the most thorough statement regarding the question.
The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1) Closing the patient's door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterile field 4) Remaining 6 inches away from the sterile field during the procedure
*4) Remaining 6 inches away from the sterile field during the procedure*
The nurse should describe pain that is causing the client a "burning sensation in the epigastric region" as: 1. Referred 2. Radiating 3. Deep or visceral 4. Superficial or cutaneous
*3. Deep or visceral* Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may be described as a burning sensation. Referred pain is felt in a part of the body separate from the source of pain, such as with a myocardial infarction, in which pain may be referred to the jaw, left arm, and left shoulder. Radiating pain feels as though it travels down or along a body part, such as low back pain that is accompanied by pain radiating down the leg from sciatic nerve irritation. Superficial or cutaneous pain is of short duration and is localized as in a small cut.
Which of the following symptoms would the nurse expect with a client who is experiencing acute pain? 1. Bradycardia 2. Bradypnea 3. Diaphoresis 4. Decreased muscle tension
*3. Diaphoresis* An expected assessment finding of a client experiencing acute pain would be diaphoresis resulting from sympathetic nerve stimulation. Additional assessment findings of a client experiencing acute pain would be an increased heart rate, respiratory rate, and muscle tension.
Following an assessment of the client, the nurse identifies the nursing diagnosis activity intolerance related to increased weight gain and inactivity. An outcome identified by the nurse should be: 1. Resting heart rate will be 90 to 100 beats/minute 2. Blood pressure will be maintained between 140/80 and 160/90 mm Hg 3. Exercise will be performed 3 to 4 times over the next 2 weeks 4. Achievement of a rating of 3 for activity endurance
*3. Exercise will be performed 3 to 4 times over the next 2 weeks* An appropriate outcome for activity intolerance related to increased weight gain and inactivity is that the client will perform exercise 3 to 4 times over the next 2 weeks. This outcome is realistic, measurable, and addresses the problem. A resting heart rate of 90-100 beats/minute is too high, and it does not address the need to increase activity. This outcome does not state whether this blood pressure is at rest or after exercising. It also does not address the need to increase activity. A more appropriate outcome is that the client will increase his or her activity (over the next 2 weeks).
While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first: 1. Support the client and walk quickly back to the room 2. Lean the client against the wall until the episode passes 3. Lower the client gently to the floor 4. Go for help
*3. Lower the client gently to the floor* If the client has a syncopal episode or begins to fall, the nurse should assume a wide base of support with one foot in front of the other, supporting the client's weight, and then extend the leg, allowing the client to slide against the leg while gently lowering the client to the floor and protecting the client's head. The nurse should not attempt to walk the client quickly back to the room. The nurse should not lean the client against a wall as the client may fall. The nurse should not leave the client alone and go for help.
A priority nursing intervention when caring for a client who is receiving an epidural infusion for pain relief is to: 1. Use aseptic technique 2. Label the port as an epidural catheter 3. Monitor vital signs every 15 minutes 4. Avoid supplemental doses of sedatives
*3. Monitor vital signs every 15 minutes* When clients are receiving epidural analgesia, monitoring occurs as often as every 15 minutes, including assessment of respiratory rate, respiratory effort, and skin color. Complications of epidural opioid use include nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus. A common complication of epidural anesthesia is hypotension. Assessing vital signs is the priority nursing intervention. Because of the catheter location, strict surgical asepsis is needed to prevent a serious and potentially fatal infection. To reduce the risk for accidental epidural injection of drugs intended for IV use, the catheter should be clearly labeled "epidural catheter." Supplemental doses of opioids or sedative/hypnotics are avoided because of possible additive central nervous system adverse effects.
Which of the following is most appropriate when the nurse assesses the intensity of the client's pain? 1. Ask about what precipitates the pain. 2. Question the client about the location of the pain. 3. Offer the client a pain scale to objectify the information. 4. Use open-ended questions to find out about the sensation.
*3. Offer the client a pain scale to objectify the information.* Descriptive scales are a more objective means of measuring pain intensity. Asking the client what precipitates the pain does not assess intensity, but rather it is an assessment of the pain pattern. Asking the client about the location of pain does not assess the intensity of the client's pain. To determine the quality of the client's pain, the nurse may ask open-ended questions to find out about the sensation experienced.
Discussing the client's follow-up dietary needs immediately after the surgery when the client is experiencing discomfort is an error in: 1. Pacing 2. Intonation 3. Timing and relevance 4. Denotative meaning
*3. Timing and relevance* Discussing follow-up dietary needs immediately after surgery when the client is experiencing discomfort is an error in timing and relevance. The client is less likely to be able to pay attention and comprehend instruction when in pain, and immediately after surgery, discussing follow-up dietary needs would seem irrelevant. Pacing has to do with the speed of conversation. This is not an example of an error in pacing. Intonation is the tone of voice used. This is not an example of an error in intonation. Denotative meaning is when a single word can have several meanings. This is not an example of an error in denotative meaning.
The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best? 1) Continue to monitor the pump to see if the crack worsens. 2) Place the pump back on the utility room shelf. 3) A small crack poses no danger so continue using the pump. 4) Clearly label the pump and send it for repair.
*4) Clearly label the pump and send it for repair.* Label it and take it out of service - all organizations have labels which indicate the equipment is not working. Evaluate the policy to determine if Clinical engineering or biomed needs to be contacted.
Which patient teaching would be most therapeutic for someone with sleep disturbance? 1) Give yourself at least 60 minutes to fall asleep. 2) Avoid eating carbohydrates before going to sleep. 3) Catch up on sleep by napping or sleeping in when possible. 4) Do not go to bed feeling upset about a conflict.
*4) Do not go to bed feeling upset about a conflict.*
List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems.
Passive ROM exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return.
A patient with a colostomy complains to the nurse, "I am having really bad odors coming from my pouch." To help control odor, which foods should the nurse advise him to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4) Yogurt and parsley
*4) Yogurt and parsley* Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy.
The nurse is completing an assessment of the client's sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is: 1. "How easily do you fall asleep?" 2. "Do you have vivid, lifelike dreams?" 3. "Do you ever experience loss of muscle control or falling?" 4. "Do you snore loudly or experience headaches?"
*4. "Do you snore loudly or experience headaches?"* To assess for sleep apnea (unlike assessing for narcolepsy or insomnia), the nurse may ask, "Do you snore loudly?" and "Do you experience headaches after awakening?" A positive response may indicate the client experiences sleep apnea.
An adult client reports to the nurse that she has been experiencing constipation recently and is interested in any suggestions regarding dietary changes she might make. Which of the following suggestions provided by the nurse is most likely to minimize the client's complaint? 1. "Have you tried foods like prunes and bran?" 2. "You might find the new flavored bulk laxatives helpful." 3. "What have you tried in the past that hasn't been helpful?" 4. "Increase your fluid intake; have some juice with breakfast."
*4. "Increase your fluid intake; have some juice with breakfast."*
The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client: 1. Uses a banister or wall for support when descending 2. Uses one crutch for support while going up and down 3. Advances the crutches first to ascend the stairs 4. Advances the affected leg after moving the crutches to descend the stairs
*4. Advances the affected leg after moving the crutches to descend the stairs* To descend stairs, the crutches are placed on the stairs and the client moves the affected leg, then the unaffected leg to the stairs with the crutches. The client should continue to use the crutches for support, not the banister or wall. The client should continue to use both crutches for support when going up or down stairs. When ascending stairs, the client moves the unaffected leg up the stair, then the crutches and affected leg.
Which of the following information provided by the client's bed partner is most associated with sleep apnea? 1. Restlessness 2. Talking during sleep 3. Somnambulism 4. Excessive snoring
*4. Excessive snoring* Partners of clients with sleep apnea often complain that the client's snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleep talking is associated with sleep-wake transition disorders; somnambulism is associated with parasomnias (specifically, arousal disorders and sleep-wake transition disorders).
An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is: 1. Confusion 2. Impaired judgment 3. Sensory deficits 4. History of falls
*4. History of falls* According to the falls assessment tool, the greatest indicator of risk is a history of falls. According to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls.
When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should: 1. Disconnect the catheter from the drainage tubing 2. Withdraw urine from a urinometer 3. Open the drainage bag and removing urine 4. Use a needle to withdraw urine from the catheter port
*4. Use a needle to withdraw urine from the catheter port*
The female client states to the nurse, "I'm so distressed. It seems like every time I laugh hard, I wet myself." The nurse knows that this condition is known as a. stress incontinence b. urge incontinence c. functional incontinence d. unconscious incontinence
*a. stress incontinence* Stress incontinence results from increased pressure within the abdominal cavity.
Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse? a. "If you take more morphine, it will not change your pain relief." b. "I'll call the physician and ask for an increased dose." c. "The amount you are taking now is all I can give you." d. "I'm worried if we increase your dose that you will stop breathing."
*b. "I'll call the physician and ask for an increased dose."* There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a tolerance to the effects, which often necessitates an increase in the dose.
When gathering admission assessment data the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" The nurse should a. Explain to the client how weight gain occurs b. Check the calibration and re-weigh the client c. Document the weight as 200 pounds d. Instruct the UAP to re-weigh the client in 2 hours
*b. Check the calibration and re-weigh the client* It is important to FIRST validate data when there is a mismatch between what the client states as history and the data obtained. Validating data often includes ensuring that equipment is functioning properly first.
The nurse is teaching the client about his upcoming procedure and the client is very stressed. It would be most important for the nurse to a. Use humor first to decrease the client's stress level b. Determine if the teaching should take place at a different time c. Introduce himself as the RN to give credibility to his message d. Speak to the client when family members are there so they can teach the client
*b. Determine if the teaching should take place at a different time* Clients who are stressed may be unable to listen fully and will not receive/understand the intended message.
When administering a drug via a parenteral routes, the drug would be absorbed fastest if given per the IM route. a. True b. False
*b. False* Absorption refers to the "movement" of the drug from the site of administration into the blood stream. Therefore, the intravenous, parenteral route leads to "instant" absorption.
The client calls the nurse to the room and states, "Look, my incision is popping open where they did my hip surgery!" The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse's best action is to a. Notify the surgeon STAT. b. Place a clean, sterile 4 x 4 over the incision and monitor the drainage. c. Wrap an ace bandage firmly around the area and have the client maintain bedrest. d. Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon.
*b. Place a clean, sterile 4 x 4 over the incision and monitor the drainage.* A 1 cm separation of wound edges only in the center of a surgical incision on the hip is too small to truly be termed dehiscence. Even if there were a large separation, there are no "internal viscera" to protrude.
Which of the following actions violates a principle that is key to proper hand washing at the bedside? a. Washing your hands for 1 minute b. Shaking your hands dry over the sink c. Using warm, not very hot water d. Using the soap provided by the agency
*b. Shaking your hands dry over the sink* Shaking your hands will not completely remove the excess moisture, allowing for the reacquisition of bacteria on the area.
To maintain proper posture, it is important to a. sleep on the softest mattress possible b. avoid arching shoulders forward when sitting c. keep your knees locked when standing upright d. keep your stomach muscles relaxed to prevent back spasms
*b. avoid arching shoulders forward when sitting* Arching shoulders forward when sitting alters the curvature of the spine and contributes to poor body alignment.
The term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx. a. true b. false
*b. false* The term for this sound of respiratory distress is "stridor."
The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should a. be aware that confused clients don't feel as much pain due to their confusion b. observe the client carefully for changes in behavior or vital signs c. ask the client's family how much pain the client normally has d. use only pain scales that feature numbers or "faces" the client can point to
*b. observe the client carefully for changes in behavior or vital signs* The nurse should observe the confused client for nonverbal cues to pain.
Four nurses are inserting catheters in their clients. Which nurse's statement, related to this intervention, is incorrect? I am inserting this catheter to a. empty your bladder prior to your procedure b. treat your problem of leaking urine c. obtain a sterile urine specimen d. measure the amount of urine left after you emptied your bladder
*b. treat your problem of leaking urine* Insertion of a urinary catheter is not a "treatment" for incontinence. "Never event" by CMS - CAUTI
The nurse is assisting the client in caring for her ostomy. The client states, "Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's best response is a. "I'm sure you will get used to taking care of it eventually." b. "Yes, it is pretty messy, so I'll take care of it for you today." c. "It sounds like you are really upset." d. "You sound very angry. Should I call the chaplain for you?"
*c. "It sounds like you are really upset."* This statement reflects the principles of therapeutic communication.
Which diagnostic test/exam would best measure a client's level of hypoxemia? a. chest x-ray b. pulse oximeter reading c. ABG d. peak expiratory flow rate
*c. ABG* The term "hypoxemia" means low blood oxygen level. Arterial blood gas sampling is the most direct way in which the level of oxygen in the blood can be measured.
The client has been on a low-protein diet. This will most likely affect which pharmacokinetic process? a. Absorption b. Excretion c. Distribution d. Metabolism
*c. Distribution* A low-protein diet may lead to an inadequate level of plasma proteins, which will affect availability of "free" drug.
Of the following factors, which would put a client at greatest risk for impaired skin integrity? a. the medication digoxin b. moisture c. decreased sensation d. dehydration
*c. decreased sensation* Decreased sensation would greatly increase the risk for injury with a tear or break in the skin. This could lead to a delay in seeking treatment due to lack of awareness.
The primary provider has written a medication prescription. The nurse is having difficulty deciphering what has been written. The best strategy to clarify the information is a. Ask the patient what medication the provider prescribed. b. Call the pharmacist and ask her to read the prescription. c. Ask the nurse who knows the provider's handwriting to read the prescription. d. Call the provider and ask him to clarify the prescription.
*d. Call the provider and ask him to clarify the prescription.* All other answers increase the risk of a medication error.
Identify the true statement about devices used when assisting clients to ambulate. a. The client should stand a foot back from the back legs of a walker. b. A cane should be used by the client to support the weakest side of the body. c. A transfer belt should be placed around the client's chest for maximum " lift." d. Each crutch-walking "gait" begins with the client in the tripod position.
*d. Each crutch-walking "gait" begins with the client in the The tripod position is the basic crutch standing position from which the client then moves forward.
Use of the statements "Tell me more about..." or "I see" encourage clients to continue talking and expressing themselves. This is called: a. Summarizing b. Open-ended questions c. Focusing d. Encouraging elaboration
*d. Encouraging elaboration*
The nurse knows that the results of a fecal occult blood test can be inaccurate if a. the client has had an excessive intake of red meat b. the female client is menstruating c. the client takes high doses of vitamin C d. all of the above
*d. all of the above*
ANA results
+ test = 1:20 or 1:40; + in most with SLE; can produce false + in small % of normal population; + result does not confirm disease
Secondary progressive disease
-In some MS patients, the clinical course changes from relapsing-remitting to a steady deterioration, unrelated to acute relapses
The physician prescribes didanosine (ddI [Videx]), 200 mg by mouth every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine, AZT [Retrovir]). Which condition in the client's history warrants cautious use of this drug?
Peripheral neuropathy
Dx of MS
-Involvement of different parts of the CNS at different times -MRI demonstrating multiple lesions -Must be multifocal (2 foci) -must relapse and remit (2 episodes) -Dx probable in patients with one lesion and two episodes or two lesions and one episode -in pts with single clinical episode who don't meet radiographic criteria, a dx of "clinically isolated syndrome" is made -these pts are at risk of developing MS and are given beta-interferon -Repeat MRI 6-12 months later looking for new lesions
Primary progressive disease
-Less commonly patients will have steadily progressive symptoms from the outset -Disability develops at a relatively early stage
Infection (after hip surgery)
-Prophylactic antibiotics -remove foley and drains as soon as possible
What will you see on MRI for MS?
-T1-weighted lesions show hypointense "black holes" in the brain and cervical spinal cord - Likely areas of axonal damage -hyperintense lesions on non-contrast T1 scans have recently been correlated to disease severity and progression -Gadolinium-enhanced T1-weighted images highlight areas of inflammation with breakdown of BBB (newer lesions) -T2-weighted images provide information about disease burden and total number of lesions - typically high signal intensity
More cast care points after the cast is dry
-Watch for breakthrough bleeding (mark the area, circle it, date, and sign site, notice if it is bigger) -cover cast close to groin with plastic once it is dry -neuro-vascular checks with the 5 P's
Client Education for Rehab after hip surgery
-best exercising is walking -Avoid flexion (low chairs, traveling long distances, sitting more than 30 minutes, lifting heavy objects, excessive bending or twisting, stair climbing)
types of tx for MS?
-corticosteroids can help with recovery from acute relapses -Prednisone 60-80mg daily x3-4wks -Long-term tx with corticosteroids = no benefit
Avascular Necrosis (after hip surgery)
-death of tissue due to poor circulation
S/S of fat emboli
-depends on where emboli goes petechia or rash over chest conjunctival hemorrhages snow storm on CXR young males first 36 hours of the fracture (after that it is the DVT)
MS is characterized by..
-episodic neurologic symptoms -under age 55 at onset -single pathologic lesion cannot explain the clinical findings -Multiple inflammatory foci best visualized on MRI
Relapsing-remitting disease
-months to years between initial episode and new symptoms or recurrence --Eventually there are relapses and incomplete remissions leading to progressive disability -Weakness, spasticity, ataxia of limbs -Late findings include •Optic atrophy, nystagmus, dysarthria •Pyramidal, sensory or cerebellar deficits in some or all of the limbs
Initial presentation of MS
-numbness, weakness, tingling or unsteadiness in a limb -Spastic paraparesis -Retrobulbar optic neuritis -Diplopia -Dysequilibrium -Sphincter diturbance (urinary urgency or hesitancy) *Symptoms may disappear after a few days or weeks, but on exam there may be residual deficit
What type of fractures do you see with fat embolisms?
-pelvic, long bones, crushing injuries
How do you toughen the stump?
-press into a soft pillow -then a firm pillow -then on the bed -then on a chair or wall
What is skin traction?
-used short term to relieve muscle spasms and immobilize until surgery -This is when tape or some type of material is stuck to the skin and the weights pull against it. The skin is NOT penetrated
Discuss at risk population for PDD, Autism and Down syndrome.
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Discuss community resources for home health care, meals, equipment, respite care, social services, professional or lay support, and shelters.
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Discuss factors that may contribute to brain tumor formation.
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Discuss health promotion techniques and teaching to be done for a patient and family with a seizure disorder.
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Discuss health promotion techniques for a patient taking anticonvulsants.
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Discuss local and national resources available to patients with Alzheimer's disease.
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Discuss nursing care of the child with MR.
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Discuss nursing implications regarding lab values for the patient prescribed anticonvulsants.
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Discuss techniques used to evaluate the credibility and usefulness of health related information.
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Discuss the differences among home care agencies.
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Discuss the importance of early intervention for the child with PDD, Autism and Down syndrome.
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Discuss the local and national community resources available for patients with seizure disorders.
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Discuss the nursing care of an individual with a seizure disorder.
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A nurse is caring for a cient with type 1 diabetes mellitus. which client complaint would alert the nurse to the presence of a possible hypoglycemic reaction? "1. Tremors 2. Anorexia 3. Hot, dry skin 4. Muscle cramps
1) tremorsdecreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. option 3 is more likely for hyperglycemia, and options 2 and 4 are unrelated to the signs of hypoglycemia.
Which therapeutic communication technique is being used in this nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." A. Restatement B. Offering general leads C. Focusing D. Accepting
ANS: A The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the client's statement has been heard and understood.
"A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which findings is the nurse most likely to observe in this client? Select all that apply: "1. Excessive thirst 2. Weight gain 3. Constipation 4. Excessive hunger 5. Urine retention 6. Frequent, high-volume urination
1, 4, 6 Rationale: Classic signs of diabetes mellitus include polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (excessive urination). Because the body is starving from the lack of glucose the cells are using for energy, the client has weight loss, not weight gain. Clients with diabetes mellitus usually don't present with constipation. Urine retention is only a problem is the patient has another renal-related condition.
648. A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin (Biaxin), esomeprazole (Nexium), and amoxicillin (Amoxil). Which statement by the client indicates the best understanding of the medication regimen?
1. "My ulcer will heal because these medications will kill the bacteria." 2. "These medications are only taken when I have pain from my ulcer." *** 3. "The medications will kill the bacteria and stop the acid production." 4. "These medications will coat the ulcer and decrease the acid production in my stomach."
The nurse identifies which of the follwing nursing diagnoses as highest priority for the pt admitted with PUD and possible perforation?
1. Acute Pain 2. Ineffective Health maintainence 3. Nausea ***4. Impaired Tissue Integrity: GI
A pt w/ a hx of PUD suddenly begins to complain of severe abd pain. The nurse should do which of the following? Select all that apply.
1. Administer the prescribed PPI. 2. Obtain an order for narcotic analgesic ***3. Withhold oral food and fluids. ***4. Place the pt in Fowler's position ***5. Notify the physician
When planning care for pt w/ stomatitis, the n urse identifies which of the following as a priority intervention?
1. Assist to cleanse mouth w/ mouthwash following meals. 2. allow pt to select appealing foods from a menu ***3. provide viscous lidocaine to relieve mouth pain before meals 4. refer to pt to smoking cessation program
626. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?
1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting ***4. A rigid, board-like abdomen
620. The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which item should the nurse include on this list?
1. Coffee 2. Chocolate 3. Fatty foods ***4. Nonfat milk
Complications post-op from hip replacement (4)
1. Dislocation 2. Infection 3. Avascular necrosis 4. Immobility problems
631. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
1. Dorsiflex the client's foot. 2. Measure the abdominal girth. ***3. Ask the client to extend the arms. 4. Instruct the client to lean forward.
"What will the nurse teach the client with diabetes regarding exercise in his or her treatment program? 1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin. 2. With an increase in activity, the body will use more carbohydrates; therefore more insulin will be required. 3. The increase in activity results in an increase in the use of insulin; therefore the client should decrease his or her carbohydrate intake. 4. Exercise will improve pancreatic circulation and stimulate the islets of Langerhans to increase the production of intrinsic insulin.
1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insuli"Rationale: As carbohydrates are used for energy, insulin needs decrease. Therefore during exercise, carbohydrate intake should be increased to cover the increased energy requirements. The beneficial effects of regular exercise may result in a decreased need for diabetic medications in order to reach target blood glucose levels. Furthermore, it may help to reduce triglycerides, LDL cholesterol levels, increase HDLs, reduce blood pressure, and improve circulation."
A client had a left- sided cerebral vascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The client is receiving enternal feedings through a small-bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? 1. Hematuria 2. Unilateral neglect 3. Limited ROM in the right hip 4. Coughing up moderate amount clear, thin sputum
1. Hematuria
A pt hospitalized w/ cirrhosis, ascites, and mild hepatic encephalopathy suddenly vomits 200 mL of bright red blood. which of the following should the nurse do first?
1. Insert a NG tube ***2. Place in Fowler's position 3. contact the physician 4. check stool for occult blood
At a local health fair, a man remarks to the nurse that his urine occasionally appears pink. He ownders if this is anything to be concerned about. How should the nurse respond?
1. Instruct the man to notify his physician if he develops pain or difficulty voiding. ***2. advise the man to make an appointment to see his physician. 3. instruct the man to track the relationship between urine color and his activities. 4. Tell the man to increase his fluid intake to 2 1/2 to 3 quarts per day.
Match the breath sound with the appropriate description. 1) High-pitched sound heard on inspiration in infants 2) High-pitched, continuous musical sound 3) High-pitched popping or low-pitched bubbling sounds 4) Low-pitched continuous sounds that clear with coughing 5) Labored, snoring sound a. Crackles b. Rhonchi c. Stridor d. Wheezes e. Stertor
1. c. High-pitched sound heard on inspiration in infants: Stridor 2. d. High-pitched, continuous musical sound: Wheezes 3. a. High-pitched popping or low-pitched bubbling sounds: Crackles 4. b. Low-pitched continuous sounds that clear with coughing: Rhonchi 5. e. Labored, snoring sound: Stertor
Before beginning the physical assessment of the renal system, then urse should ask the pt to do which of the following?
1. empty the bladder 2. takd several deep breaths ***3. provide a urine specimen 4. drink several glassess of water
Respiratory s/s of anaphylaxis
hoarseness, coughing, sensation of narrowed airway, wheezing, stridor, dyspnea, tachypnea, respiratory arrest
Describe nursing care to assist the patient with mobility, gait, strength, and motor skills.
1.Reposition the client on a regular schedule as dictated by individual situation. ® Allow proper blood circulation, prevents venous stasis and formation of decubitus ulcers 2.Place patient on moderate high back rest position with head at the midline ® allows greater lung expansion and prevent compression on the diaphragm from prolong bed rest. 3.Support body part especially the affected side using pillows or rolls ®Prevention from developing pressure ulcers particularly on bony prominences 4.Keep body aligned and place extremities in proper position ® Proper positioning and turning maintains joint function and prevents contractures. 5.Perform active range of motion on unaffected extremities and passive range of motion exercises on affected extremities every 4 hours. ®Active range of motion exercise improves muscle strength while passive range of motion exercise improves joint mobility 6.Encourage patient to perform certain movements according to ones capability such as moving left upper and lower extremities, moving tongue, and moving head. ®To maintain strength and integrity of the functioning body parts. 7. Raise the siderails and provide a responsible watcher. ®weakness and loss of body coordination are at risk for fall or accidents. 8.Provide enteral feeding via NGT ®Provision of nutrition for metabolic and energy demand. 9. Perform regular skin care. (e.i sponge bath,apply lotion) ®Maintains skin integrity and decreases risk for skin breakdown. 10.Schedule activities with adequate rest periods ®To reduce fatigue and decrease energy demand 11. Provide a positive atmosphere while acknowledging ones difficulty. ®Helps minimize frustration and rechannel energy.
"An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
10 to 15 g of a simple carbohydrate.
"The nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
15 to 20 g of a fast-acting carbohydrate such as orange juice.
"The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with Type 1 diabetes at 1600. Which action should the nurse implement? "1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.
1: ensure the client eats the bedtime snack"1. Humulin N peaks in 6-8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia. (Correct) 2. The food intake at lunch will not affect the client's blood glucose level at midnight. 3. The client's glucometer reading should be done around 2100 to assess the effectiveness of insulin at 1600. 4. Humulin N is an intermediate-acting insulin that has an onset in 2-4 hours but does not peak until 6-8 hours."
A nurse is preparing a plan of care for a client with diabetes mellitus who has hyerglycemia. The priority nursing diagnosis would be: 1. Deficient knowledge 2. Deficient fluid volume 3. Compromised family coping 4. Imbalanced nutrition less than body requirements
2) deficient fluid volumeAn increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe.
You are caring for a 78 year-old female cardiac patient. In preconference, your clinical instructor asks you what is an age-related change in the cardiac system of the older adult? Your best response would be Student Response Value Correct Answer Feedback 1. Decreased blood pressure 2. Decreased cardiac output 3. Increase ability to respond to stress 4. Increased heart recovery rate
2. Decreased cardiac output
The nurse teaching a pt. w/ GERD includes which of the following instructions? Select all that apply
2. Elevate the head of the bed on 6-8 inch blocks 5. avoid lying down for several hours after eating
A nurse is preparing a teaching plan for a client with diabetes Mellitus regarding proper foot care. Which instruction is included in the plan? 1. Soak feet in hot water 2. apply a moisturizing lotion to dry feet but not between the toes 3. Always have a podiatrist cut your toenails, never cut them yourself 4. avoid using mild soap on the feet
2. The client is instructed to use a moisturizing lotion on the feet and to avoid applying the lotion between the toes.
"The nurse is discharging a client diagnosed with diabetes insipidus. Which statementmade by the client warrants further intervention? "1."I will keep a list of my medications in my wallet and wear a Medi bracelet." 2."I should take my medication in the morning and leave it refrigerated at home." 3."I should weigh myself every morning and record any weight gain." 4."If I develop a tightness in my chest, I will call my health-care provider."
2."I should take my medication in the morning and leave it refrigerated at home.""1.The client should keep a list of medication being taken and wear a Medic Alert bracelet. 2. Medication taken for DI is usually every 8-12 hours, depending on the client. Theclient should keep the medication close at hand. 3.The client is at risk for fluid shifts. Weighing every morning allows the client to follow thefluid shifts. Weight gain could indicate too much medication. 4.Tightness in the chest could be an indicator that the medication is not being tolerated; if this occurs the client should call the health-care provider"
"A client with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client's cardiac history, the nurse would expect that the client's initial dose for the thyroid replacement would be:
25 mcg/day.
after change of shift report which pt needs to be assessed first
28 yr old w fx complaining cast is tight
A client is struggling to explore and solve a problem. Which nursing statement would verbalize the implication of the client's actions? A. "You seem to be motivated to change your behavior." B. "How will these changes affect your family relationships?" C. "Why don't you make a list of the behaviors you need to change." D. "The team recommends that you make only one behavioral change at a time."
ANS: A This is an example of the therapeutic communication technique of verbalizing the implied. Verbalizing the implied puts into words what the client has only implied or said indirectly.
The nurse is caring for a client with long-term Type 2 diabetes and is assessing the feet. Which assessment data would warrant immediate intervention by the nurse? "1)The client has crumbling toenails 2)The client has athlete's feet 3)The client has a necrotic big toe 4)The client has thickened toenails."
3) Nectrotic big toe"1)Crumbling toenails indicate tinea unguium, which is a fungus infection of the toenail. 2)Athlete's foot is a fungal infection that is not life threatening. 3)A necrotic big toe indicates "dead" tissue. The client does not feel pain in the lower extremity and does not realize there has been an injury and therefore does not seek treatment. Increased blood glucose levels decrease oxygen supply that is needed to heal the wound and increase the risk for developing an infection. 4)Big, thick toenails are fungal infections and would not require immediate intervention by the nurse; 50% of the adult population has this."
A client has been on bed rest for several days. The client stands, and the nurse notes that the client's systolic pressure drops 20 mm Hg. Which of the following should the nurse document in the medical record? 1. Rebound hypotension 2. Positional hypotension 3. Orthostatic hypotension 4. Central venous hypotension
3. Orthostatic hypotension
Which medication prevents the breakdown of a brain chemical important for memory and thinking and may slow the progress of Alzheimer's disease. 1. memantine (Namenda) 2. ozazepam (Serax) 3. donepezil (Aricept) 4. citalopram (Celexa)
3. donepezil (Aricept)
A client with type I diabetes is placed on an insulin pump. The most appropriate short-term goal when teaching this client to control the diabetes is: "1) adhere to the medical regimen 2) remain normoglycemic for 3 weeks 3) demonstrate the correct use of the administration equipment. 4) list 3 self care activities that are necessary to control the diabetes"
3.) is correct "1) this is not a short-term goal 2) this is measurable, but it's a long-term goal 3) this is a short-term goal, client oriented, necessary for the client to control the diabetes, and measurable when the client performs a return demonstration for the nurse 4) although this is measurable and a short-term goal, it is not the one with the greatest priority when a client has an insulin pump that must be mastered before discharge"
"The nurse is teaching a class on atherosclerosis. Which statement describes the scien-tific rationale as to why diabetes is a risk factor for developing atherosclerosis? (1.Glucose combines with carbon monoxide, instead of with oxygen, and this leads tooxygen deprivation of tissues.2.Diabetes stimulates the sympathetic nervous system, resulting in peripheralconstriction that increases the development of atherosclerosis.3.Diabetes speeds the atherosclerotic process by thickening the basement membraneof both large and small vessels.4.The increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels.
3.Diabetes speeds the atherosclerotic process by thickening the basement membraneof both large and small vessels."1.Glucose does not combine with carbonmonoxide.2.Vasoconstriction is not a risk factor for devel-oping atherosclerosis. 3.This is the scientific rationale why diabetesmellitus is a modifiable risk factor for atherosclerosis. 4.When glucose combines with the hemoglobinin a laboratory test called glycosylated hemo-globin, the result can determine the client'saverage glucose level over the past three (3)months"
A client weighing 158 lb is ordered to receive 5 mg/kg of cyclosporine (Sandimmune) daily. How many milligrams should the client receive?
360
A nurse educator is teaching basic principles of proper lifting technique to a group of newly hired nurses. Use the ATI Active Learning template to complete this item. Under the section Underlying Principles, list 4 key elements of proper lifting technique.
4 Principles of Lifting 1. Use the major muscle groups to prevent back strain and tighten the abdominal muscles to increase support to the back muscles. 2. Distribute the weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and to avoid strain on the smaller muscles. 3. When lifting an object from the floor, flex the hip, knees & back. Get the object to thigh level, keeping the knees bent and the back straightened. Stand up while holding the object as close as possible to the body, bringing the load to the center of gravity to increase stability and decrease back strain. 4. Use assistive devices whenever possible, and seek assistance whenever it is needed.
You are caring for a client who has osteoporosis. The nurse is teaching her about ways to prevent fractures. Which of the following client statements reflects a need for further education? 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if i need to have a bone mineral density check this year." 3. "If i don't drink milk at dinner, i will eat broccoli or cabbage to get the calcium that i need in my diet." 4. "The more frequently i walk the more likely i will be to fall and break my leg. I think i will get a wheelchair so i don't have to walk any more."
4. "The more frequently i walk, the more likely i will be to fall and break my leg. I think i will get a wheelchair so i don't have to walk any more."
The nurse is caring for a client who has right-sided weak-ness. The nurse needs to help the client walk. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? 1. Hold the client's left hand while walking 2. Hold the client's right hand while walking 3. Put a gait belt on the client and provide support on the left side 4. Put a gait belt on the client and provide support on the right side
4. Put a gait belt on the client and provide support on the right side
A client with diabetes mellitus demonstratees acute anxiety when first admitted for the treatment of hyperglycemia. The most appropriate intervention to decrease the client's anxiety would be to 1. administer a sedative 2. make sure the client knows all the correct medical terms to understand what is happening 3. ignore the signs and symptoms of anxiety so that they will soon disappear 4. convey empathy, trust, and respect toward the client
4. The most appropriate intervention is to address the client's feelings related to the anxiety
The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to: 1. prevent varicose veins 2. prevent muscular atrophy 3. ensure joint mobility and prevent contractures 4. facilitate the return of venous blood to the heart
4. facilitate the return of venous blood to the heart
A nurse administers etanercept (Enbrel) by subcutaneous injection to a client with ankylosing spondylitis. Which action should the nurse take to prevent a needle-stick injury?
Place the uncapped needle in the designated puncture-resistant container.
a nurse is interviewing a client with type 2 diabetes mellitus. which statement by the client indicated an understanding of the treatment for this disorder? "1. ""i take oral insulin instead of shots"" 2. ""by taking these medications I am able to eat more"" 3. ""when I become ill, I need to increase the number of pills I take"" 4. ""the medications I'm taking help release the insulin I already make""
4.)Clients with type 2 diabetes mellitus have decreased or imparied insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the insulin by digestion. Options 1, 2 and 3 are incorrect
"The nurse is discussing the importance of exercising to a client diagnosed with Type 2diabetes whose diabetes is well controlled with diet and exercise. Which informationshould the nurse include in the teaching about diabetes? "1.Eat a simple carbohydrate snack before exercising. 2.Carry peanut butter crackers when exercising. 3.Encourage the client to walk 20 minutes three (3) times a week. 4.Perform warmup and cooldown exercises
4.Perform warmup and cooldown exercises "The client diagnosed with Type 2 diabetes whois not taking insulin or oral agents does notneed extra food before exercise.2.The client with diabetes who is at risk forhypoglycemia when exercising should carry asimple carbohydrate, but this client is not atrisk for hypoglycemia.3.Clients with diabetes that is controlled by dietand exercise must exercise daily at the sametime and in the same amount to control theglucose level. 4. [correct] All clients who exercise should perform warmup and cooldown exercises to helpprevent muscle strain and injury"
"The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:
55% to 60% carbohydrate, 30% fat, and 10% to 15% protein.
A nurse is planning to provide instructions to the client how to stand on crutches. In the written instructions, the nurse plans to tell the client to place the crutches:
6-10 inches in front and to the side of the client depending on the body size. This provides a base of support to the client and improves balance
The P/T at greatest risk for developing multiple adverse effects of immobility is a:
80-Y/O woman who has suffered a hemorrhagic cerebrovascular accident (CVA).
Diet for a person with Meniere's Disease
: low sodium, restrict caffeine, restrict nicotine, restrict ETOH
A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient's technique of SMBG, the nurse identifies a need for additional teaching when the patient a. chooses a puncture site in the center of the finger pad. b. washes the puncture site using soap and water. c. says the result of 130 mg indicates good blood sugar control. d. hangs the arm down for a minute before puncturing the site.
A Rationale: The patient is taught to choose a puncture site at the side of the finger pad. The other patient actions indicate that teaching has been effective.
A patient with cancer of the liver has severe ascites, and the health care provider plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the procedure, the nurse a. asks the patient to empty the bladder. b. positions the patient on the right side. c. obtains informed consent for the procedure. d. assists the patient to lie flat in bed.
A Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. The health care provider is responsible for obtaining informed consent.
While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, the nurse should a. obtain a glucose reading using a finger stick. b. administer 1 mg glucagon subcutaneously. c. have the patient eat a candy bar. d. have the patient drink 4 ounces of orange juice.
A Rationale: The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment.
When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately?" b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic?" d. "Is your urine unusually dark-colored?"
A Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar- containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
A client has recently been diagnosed with Type I diabetes and asks the nurse for help formulating a nutrition plan. Which of the following recommendations would the nurse make to help the client increase calorie consumption to offset absorption problems? a. Eating small meals with two or three snacks may be more helpful in maintaining blood glucose levels than three large meals. b. Eat small meals with two or three snacks throughout the day to keep blood glucose levels steady c. Increase consumption of simple carbohydrates d. Skip meals to help lose weight
A Eating small meals with two or three snacks may be more helpful in maintaining blood glucose levels than three large meals.
21. A 63-year-old patient is newly diagnosed with type 2 diabetes. When developing an education plan, the nurse's first action should be to a. assess the patient's perception of what it means to have type 2 diabetes. b. demonstrate how to check glucose using capillary blood glucose monitoring. c. ask the patient's family to participate in the diabetes education program. d. discuss the need for the patient to actively participate in diabetes management.
A Rationale: Before planning education, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient. Cognitive Level: Application Text Reference: p.1264 Nursing Process: Planning NCLEX: Health Promotion and Maintenance
A patient in the outpatient clinic has positive serologic testing for anti-HCV. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Teach the patient that the HCV will resolve in 2 to 4 months. c. Administer immune globulin and the HCV vaccine. d. Instruct the patient on self-administration of -interferon.
A Rationale: Genotyping of HCV has an important role in managing treatment and is done before drug therapy with -interferon or other medications is started. HCV has a high percentage of conversion to the chronic state so the nurse should not teach the patient that the HCV will resolve in 2 to 4 months. Immune globulin or vaccine is not available for HCV.
18. A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). During an acute exacerbation of the patient's arthritis, the health care provider prescribes prednisone (Deltasone) to control inflammation. The nurse will anticipate that the patient may a. require administration of insulin while taking prednisone. b. develop acute hypoglycemia during the RA exacerbation. c. have rashes caused by metformin-prednisone interactions. d. need a diet higher in calories while receiving prednisone.
A Rationale: Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a complication of RA exacerbation or prednisone use. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient is likely to have an increased appetite when taking prednisone, but it will be important to avoid weight gain for the patient with RA. Cognitive Level: Application Text Reference: pp. 1258, 1267 Nursing Process: Planning NCLEX: Physiological Integrity
After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely, which action by the patient indicates that the teaching has been successful? a. The patient disposes of the open insulin vials after 4 weeks. b. The patient draws up the regular insulin in the syringe and then draws up the glargine. c. The patient stores extra vials of both types of insulin in the freezer until needed. d. The patient's family prefills the syringes weekly and stores them in the refrigerator.
A Rationale: Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Freezing alters the insulin molecule and should not be done.
36. After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely, which action by the patient indicates that the teaching has been successful? a. The patient disposes of the open insulin vials after 4 weeks. b. The patient draws up the regular insulin in the syringe and then draws up the glargine. c. The patient stores extra vials of both types of insulin in the freezer until needed. d. The patient's family prefills the syringes weekly and stores them in the refrigerator.
A Rationale: Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Freezing alters the insulin molecule and should not be done. Cognitive Level: Application Text Reference: p. 1261 Nursing Process: Evaluation NCLEX: Physiological Integrity
A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. The nurse should teach the patient that a. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin. b. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis. c. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes. d. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy.
A Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly. A previous episode of ketoacidosis is not a contraindication for intensive insulin therapy. Intensive insulin therapy is not confined to type 2 diabetics and would prevent microvascular changes as well as macrovascular changes. Intensive insulin therapy and an insulin pump are comparable in glucose control.
28. Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness? a. Give the patient a snack of cheese and crackers. b. Have the patient drink a glass of orange juice or nonfat milk. c. Administer a continuous infusion of 5% dextrose for 24 hours. d. Assess the patient for symptoms of hyperglycemia.
A Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity
A homeless patient with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with viral hepatitis and has just been admitted to the hospital. In planning care for the patient, the nurse assigns the highest priority to the patient outcome of a. maintaining adequate nutrition. b. establishing a stable home environment. c. increasing activity level. d. identifying the source of exposure to hepatitis.
A Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as having adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.
22. Cardiac monitoring is initiated for a patient in diabetic ketoacidosis (DKA). The nurse recognizes that this measure is important to identify a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia. b. fluid overload resulting from aggressive fluid replacement. c. the presence of hypovolemic shock related to osmotic diuresis. d. cardiovascular collapse resulting from the effects of hyperglycemia.
A Rationale: The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Fluid overload, hypovolemia, and cardiovascular collapse are possible complications of DKA, but cardiac monitoring would not detect theses. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity
20. A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient's technique of SMBG, the nurse identifies a need for additional teaching when the patient a. chooses a puncture site in the center of the finger pad. b. washes the puncture site using soap and water. c. says the result of 130 mg indicates good blood sugar control. d. hangs the arm down for a minute before puncturing the site.
A Rationale: The patient is taught to choose a puncture site at the side of the finger pad. The other patient actions indicate that teaching has been effective. Cognitive Level: Application Text Reference: p. 1270 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
17. When teaching a patient with type 2 diabetes about taking glipizide (Glucotrol), the nurse determines that additional teaching about the medication is needed when the patient says, a. "Since I can take oral drugs rather than insulin, my diabetes is not serious and won't cause many complications." b. "If I overeat at a meal, I will still take just the usual dose of medication." c. "If I become ill, I may have to take insulin to control my blood sugar." d. "I should check with my doctor before taking any other medications because there are many that will affect glucose levels."
A Rationale: The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide. Cognitive Level: Application Text Reference: p. 1275 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
26. While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, the nurse should a. obtain a glucose reading using a finger stick. b. administer 1 mg glucagon subcutaneously. c. have the patient eat a candy bar. d. have the patient drink 4 ounces of orange juice.
A Rationale: The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity
16. Glyburide (Micronase, DiaBeta, Glynase) is prescribed for a patient whose type 2 diabetes has not been controlled with diet and exercise. When teaching the patient about glyburide, the nurse explains that a. glyburide stimulates insulin production and release from the pancreas. b. the patient should not take glyburide for 48 hours after receiving IV contrast media. c. glyburide should be taken even when the blood glucose level is low in the morning. d. glyburide decreases glucagon secretion.
A Rationale: The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, since hypoglycemia can occur with this category of medication. Metformin should be held for 48 hours after administration of IV contract, but this is not necessary for glyburide. Cognitive Level: Application Text Reference: pp. 1265-1266 Nursing Process: Implementation NCLEX: Physiological Integrity
Amitriptyline (Elavil) is prescribed for a diabetic patient with peripheral neuropathy who has burning foot pain occurring mostly at night. Which information should the nurse include when teaching the patient about the new medication? a. Amitriptyline will help prevent the transmission of pain impulses to the brain. b. Amitriptyline will improve sleep and make you less aware of nighttime pain. c. Amitriptyline will decrease the depression caused by the pain. d. Amitriptyline will correct some of the blood vessel changes that cause pain.
A Rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclics.
32. Amitriptyline (Elavil) is prescribed for a diabetic patient with peripheral neuropathy who has burning foot pain occurring mostly at night. Which information should the nurse include when teaching the patient about the new medication? a. Amitriptyline will help prevent the transmission of pain impulses to the brain. b. Amitriptyline will improve sleep and make you less aware of nighttime pain. c. Amitriptyline will decrease the depression caused by the pain. d. Amitriptyline will correct some of the blood vessel changes that cause pain.
A Rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclics. Cognitive Level: Application Text Reference: p. 1285 Nursing Process: Implementation NCLEX: Physiological Integrity
C
A 65 Year old woman was just diagnosed with parkinson's disease the priority nursing intervention is: a. searching the internet for educational videos b. evaluating the home for environmental safety c. promoting physical exercise and a well balanced diet d. Designing an exercise program to strengthen and stretch specific muscles.
A 60 year old patient has an abrupt onset of anorexia, nausea and vomiting, hepatomegaly, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. During assessment of the patient, it is most important for the nurse to question the patient regarding A. any prior exposure to people with jaundice B. the use of all prescription and OTC (over the counter) medications C. treatment of chronic diseases with corticosteriods D. exposure to children recently immunized for hepatitis B
A and D assess for exposure to hepatitis. Hepatitis was ruled out this is inappropriate. C is incorrect because corticosteroids do not commonly cause liver disease B is correct because overdose of medications can cause liver disease.
During a nurse-client interaction, which nursing statement may belittle the client's feelings and concerns? A. "Don't worry. Everything will be alright." B. "You appear uptight." C. "I notice you have bitten your nails to the quick." D. "You are jumping to conclusions."
ANS: A This nursing statement is an example of the nontherapeutic communication block of belittling feelings. Belittling feelings occur when the nurse misjudges the degree of the client's discomfort, thus a lack of empathy and understanding may be conveyed.
Discuss the age related (pediatric) nursing care and interdisciplinary care for a head injury.
A child advocacy team or child protective services should be contacted if child abuse is suspected, the mechanism of injury is unknown or unexplained, or the history is inconsistent. NB shock is rarely due to isolated head injury except in young children and in patients with medullary injuries or large scalp lacerations. Pediatric head injury has unique issues that make patient management and outcome different from that of adult head injury. Age related aspects will determine a greater or lesser degree of craniocervical junction injuries (disproportionate cranial size to trunk in infancy and early childhood). Other factors are potential underlying congenital anomalies, physiological factors (cerebrovascular reactivity and blood flow), differing support systems needed from that of adults for neuro imaging and specialized medical, nursing and allied health care support. Pediatric rehabilitation and educational needs and goals are different to that of adult head injury. intubating a child is harder than intubating and adult The physical exam is frequently normal CT scan = significant radiation exposure children sometimes cannot talk but frequently vomit due to stress (instead of head injury) Brain is less myelinated, results in greater sensitivity to shearing forces Cranial bones thinner, resulting in greater transmission of a single force to brain Non-fused sutures makes skull easily deformable Children (particularly < 24 months old) are at increased risk of cerebral hypo-perfusion after TBI
RF Hesi Hint #1
A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use, and which methods should not be used? Use: Inspection, Palpation, Stregnth testing Do NOT Use:ROM, this activity promotes pain because ROM is limited.
hyperthyriodism
A excessive secretion of thyriod hormones resulting from different factors including autoimmune stimulation (graves disease) excessive TSH by the pituitary gland,neoplasms and excessive TH medication
Addison's disease
A high protein, high carb diet and hydrocortisone treat ________
When caring for a client in a thyroid crisis, the nurse would question an order for?
A hyper thermia blanket
A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safe sex practices for persons with HIV is accurate?
A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.
thyroid storm
A life-threatening complication of thyroidectomy which involves fever, tachycardia, delirium,and irritability
c
A nurse and a primary care provider inform a client that chemotherapy is recommended for a diagnosis of cancer. Which nursing action is most representative of the concept of holism? a. Offer to come to the client's home to provide needed physical care b. Contact the client's spiritual advisor c. Inquire how this will affect other aspects of the client's life d. Provide the client with information about how to join a support group 1. ch 16
"Laboratory studies indicate that a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose utilization?
A test of serum glycosylated hemoglobin (Hb A1c)
During removal of a fecal impaction, which of the following could occur Because of vaginal stimulation? A) Bradycardia B)Atelectasid C) Tachycardia D) Cardiac tamponade
A) Bradycardia Removing a fecal impaction manually may result in stimulation of the vaginal nerve and resulting bradycardia
Which of the following is a true statement about the effects of medication on bowel illumination? A) Diarrhea commonly occurs with amoxicillin clavulanate use B) Anticoagulants cause a white discoloration of the stool C) Narcotic analgesics increased Gastrointestinal mobility D) Iron salts in pair digestion and cause a green store
A) Diarrhea commonly occurs with amoxicillin clavulanate use Anticoagulants may result in the store having a pink to red to black appearance, whereas iron salts also cause a black stool. Narcotic analgesics decrease gastric mobility.
Which of the following would be a common nursing diagnosis for patient with an ileostomy? A) Disturbed body image B) Constipation C) Delayed growth and development D) Excess fluid volume
A) Disturbed body image Constipation does not occur with the Ileostomy because the drainage is liquid. Growth and development are not affected by the formation of an Ileostomy. Excess fluid Byam is unlikely to occur because the drainage is liquid and probably continual
The client diagnosed with Type I diabetes is found lying unconscious on the floor of the bathroom. Which interventions should the nurse implement first? A. Administer 50% dextrose IVP. B. Notify the health-care provider. C. Move the client to ICD. D. Check the serum glucose level.
A) admin 50% dextrose IVPThe nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.
"When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask? a. ""Have you lost any weight lately?"" b. ""Do you crave fluids containing sugar?"" c. ""How long have you felt anorexic?"" d. ""Is your urine unusually dark-colored?""
A) lost any weight?"a. Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. b. The patient is thirsty but does not necessarily crave sugar- containing fluids. c. Increased appetite is a classic symptom of type 1 diabetes. d. With the classic symptom of polyuria, urine will be very dilute."
Which class of laxative acts by causing the stool to absorb water and swell? A)Bulk-forming B)Emollient C)Lubricant D)Stimulant
A)Bulk-forming Emollients Lubricate the stool; Lubricants soften the stool, making it easier to pass: and Stimulants promotes peristalsis by irritating the intestinal mucosa or stimulating nerve ending in the intestinal wall
"The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
Below-normal serum potassium level
3 P's for Hyperglycemia
Polyuria, Polydipsia, Polyphagia
Which of the following are included in the nursing plan of care to prevent adverse effects when caring for patients with a nasogastric tube in place for gastric decompression's? Select all that apply. A) Irrigation with Saline B) Measure the length of exposed tube C) Measure the pH of the aspirated tube contents D) Administer frequent oral hygiene
A,B,C,D After checking placement, NGT should be Irrigated with 30 to 60 mL of normal saline to maintain patency. The frequency is determined by facility policy, medical order, and nursing judgment. The length of the exposed tubes should be measured after insertion and routinely thereafter, as part of the assessment to verify placement and ensure the tube has not dislodged. Measuring the pH of aspirated two contents is one way to validate to placement in the intestinal tract. The other methods is to visually Assess aspirate to confirm gastric contents. Patients with NGTs Often experience discomfort related to irritation to nasal and throat mucosa And drying of the mucous membranes. Frequent oral hygiene should be administered as well as applying lubricant to the lips
A clinical nurse specialist (CNS) is orienting a new licensed practical nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
A-positive blood to an A-negative client.
Which of the following client statements regarding self-medication administration by an older-adult client requires follow-up teaching by the nurse? A. "I take all the pills ordered once a day at bedtime, so I'm less likely to forget them." B. "I have one pill that needs cut in half. I am going to ask the pharmacist to do that for me." C. "The pharmacist said to keep my pills away from the sunlight, so I put them inside the kitchen cabinet." D. "My daughter comes over each morning and puts my pills into a container that sorts them by the time they are due."
A. "I take all the pills ordered once a day at bedtime, so I'm less likely to forget them."
A nurse is caring for an older adult client preparing for discharge to a nursing center after having hip surgery. Which of the following nursing responses is most therapeutic with a client's concern that she, will never go back home? A. "What makes you think that this transfer to the nursing center will be permanent?" B. "The reason for this transfer is only to support you while you continue to recuperate." C. "The decision to stay in the nursing center is yours to make. When you want to leave no one will stop you." D. "The nursing center is a lovely place with a wonderful staff of caring people. Just give it a chance. You may like it."
A. "What makes you think that this transfer to the nursing center will be permanent?"
which are symptoms of hypoglycemia? A. irritability, B. drowsiness c. Abdominal pain D. nausea and vomiting
A. Irritability: signs of hypoglycemia include irritability, shaky feeling, hunger, headache, dizziness. Other symptoms are hyperglycemia.
While bathing an elderly client who has limited abilities for self-care, the nurse notices several patches of dry skin on the clients heels, elbows, and coccyx. The nurse cleans and dries all the areas well and applies a moisturizing lotion. The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this clients skin is to: A. Revise the client's care plan to show the need for the application of moisturizing lotion B. Assume personal responsibility to apply the moisturizing lotion daily to the client's skin C. Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin D. Inform the staff that the client's skin is showing signs of breakdown and moisturizing lotion needs to be applied daily
A. Revise the client's care plan to show the need for the application of moisturizing lotion
A patient with OA asks the nurse whether he could try glucosamine and chondroitin for control of his symptoms. The best response by the nurse includes the information that a. some patients find these supplements helpful for relieving arthritis knee pain and improving mobility b. although these substances may not help, there is no evidence that they can cause any untoward effects c. these supplements are a fad that has not been shown to reduce pain or increase joint mobility in patients with OA d. only dosages of these supplements available by prescription are high enough to provide any benefit in treatment of OA
A. Some patients find these supplements helpful for relieving arthritis knee pain and improving mobilitiy
A patient taking ibuprofen (Motrin) for treatment of OA has good pain relief but is experiencing increased dyspepsia and nausea with the drug's use. The nurse consults the patient's primary care provider about a. adding misoprostol (Cytotec) to the patient's drug regimen b. substituting naproxen (Naprosyn) for the ibuprofen (Motrin) c. administering the ibuprofen with antacids to decrease the GI irritation d. returning to the use of acetaminophen, but at a dose of 5 g/day instead of 4 g/day
A. adding misoprostol (Cytotec) to the patient's drug regimen
Intermediate Acting Insulin
AM NPH -onset: 1-2 hours -peak: 4-12 hours -duration: 18-24 hours Lente -onset: 1-2.5 hours -peak: 3-10 hours -duration: 18-24 hours
After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, "I'm so proud of you for being assertive. You are so good!" Which communication technique has the leader employed? A. The nontherapeutic technique of giving approval B. The nontherapeutic technique of interpreting C. The therapeutic technique of presenting reality D. The therapeutic technique of making observations
ANS: A The group leader has employed the nontherapeutic technique of giving approval. Giving approval implies that the nurse has the right to pass judgment on whether the client's ideas or behaviors are "good" or "bad." This creates a conditional acceptance of the client.
A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations? A. "You appear to be talking to someone I do not see." B. "Please describe what you are seeing." C. "Why do you continually look in the corner of this room?" D. "If you hum a tune, the voices may not be so distracting."
ANS: A The nurse is making an observation when stating, "You appear to be talking to someone I do not see." Making observations involves verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurse's perceptions.
List three problems associated with immobility.
Venous thrombosis, urinary calculi, skin integrity problems.
Which nursing response is an example of the nontherapeutic communication block of requesting an explanation? A. "Can you tell me why you said that?" B. "Keep your chin up. I'll explain the procedure to you." C. "There is always an explanation for both good and bad behaviors." D. "Are you not understanding the explanation I provided?"
ANS: A This nursing statement is an example of the nontherapeutic communication block of requesting an explanation. Requesting an explanation is when the client is asked to provide the reason for thoughts, feelings, behaviors, and events. Asking "why" a client did something or feels a certain way can be very intimidating and implies that the client must defend his or her behavior or feelings.
The nurse is educating a pregnant client who has gestational diabetes. Which of the following statements should the nurse make to the client? Select all that apply. a. Cakes, candies, cookies, and regular soft drinks should be avoided. b. Gestational diabetes increases the risk that the mother will develop diabetes later in life. c. Gestational diabetes usually resolves after the baby is born. d. Insulin injections may be necessary. e. The baby will likely be born with diabetes f. The mother should strive to gain no more weight during the pregnancy.
ANS: A, B, C, D Gestational diabetes can occur between the 16th and 28th week of pregnancy. If not responsive to diet and exercise, insulin injections may be necessary. Concentrated sugars should be avoided. Weight gain should continue, but not in excessive amounts. Usually, gestational diabetes disappears after the infant is born. However, diabetes can develop 5 to 10 years after the pregnancy.
Which of the following individuals are communicating a message? (Select all that apply.) A. A mother spanking her son for playing with matches B. A teenage boy isolating himself and playing loud music C. A biker sporting an eagle tattoo on his biceps D. A teenage girl writing, "No one understands me" E. A father checking for new e-mail on a regular basis
ANS: A, B, C, D The nurse should determine that spanking, isolating, getting tattoos, and writing are all ways in which people communicate messages to others. It is estimated that about 70% to 90% of communication is nonverbal.
A mother rescues two of her four children from a house fire. In the emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response? A. "The smoke was too thick. You couldn't have gone back in." B. "You're feeling guilty because you weren't able to save your children." C. "Focus on the fact that you could have lost all four of your children." D. "It's best if you try not to think about what happened. Try to move on."
ANS: B The best response by the nurse is, "You're experiencing feelings of guilt because you weren't able to save your children." This response utilizes the therapeutic communication technique of reflection which identifies a client's emotional response and reflects these feelings back to the client so that they may be recognized and accepted.
A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening? A. "What occurred prior to the rape, and when did you go to the emergency department?" B. "What would you like to talk about?" C. "I notice you seem uncomfortable discussing this." D. "How can we help you feel safe during your stay here?"
ANS: B The nurse's statement, "What would you like to talk about?" is an example of the therapeutic communication technique of giving broad openings. Using a broad opening allows the client to take the initiative in introducing the topic and emphasizes the importance of the client's role in the interaction.
Which nursing statement is a good example of the therapeutic communication technique of offering self? A. "I think it would be great if you talked about that problem during our next group session." B. "Would you like me to accompany you to your electroconvulsive therapy treatment?" C. "I notice that you are offering help to other peers in the milieu." D. "After discharge, would you like to meet me for lunch to review your outpatient progress?"
ANS: B This is an example of the therapeutic communication technique of offering self. Offering self makes the nurse available on an unconditional basis, increasing client's feelings of self-worth. Professional boundaries must be maintained when using the technique of offering self.
Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations? A. "My sister has the same diagnosis as you and she also hears voices." B. "I understand that the voices seem real to you, but I do not hear any voices." C. "Why not turn up the radio so that the voices are muted." D. "I wouldn't worry about these voices. The medication will make them disappear."
ANS: B This is an example of the therapeutic communication technique of presenting reality. Presenting reality is when the client has a misperception of the environment. The nurse defines reality or indicates his or her perception of the situation for the client.
An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? A. "Why did you use the client's name on your clinical worksheet?" B. "You were very careless to refer to your client by name on your clinical worksheet." C. "Surely you didn't do this deliberately, but you breeched confidentiality by using the client's name." D. "It is disappointing that after being told, you're still using client names on your worksheet."
ANS: C The instructor's statement, "Surely you didn't do this deliberately, but you breeched confidentiality by using the client's name." is an example of effective feedback. Feedback is a method of communication to help others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice or criticize the individual.
Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" A. Reflecting B. Making observations C. Formulating a plan of action D. Giving recognition
ANS: C The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the client's poor coping choice, may serve to prevent anger or anxiety from escalating.
Pheochromocytoma
Benign tumor of adrenal medulla that causes hypersecretion of epinephrine and norepinephrine causing a hypertensive crisis, tachycardia, diaphoresis, apprehension, h/a, flight or fight, hyperglycemia
When interviewing a client, which nonverbal behavior should a nurse employ? A. Maintaining indirect eye contact with the client B. Providing space by leaning back away from the client C. Sitting squarely, facing the client D. Maintaining open posture with arms and legs crossed
ANS: C When interviewing a client, the nurse should employ the nonverbal behavior of sitting squarely, facing the client. Facilitative skills for active listening can be identified by the acronym SOLER. SOLER includes sitting squarely facing the client (S), open posture when interacting with a client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).
A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? A. "Everyone diagnosed with OCD needs to control their ritualistic behaviors." B. "It is important for you to discontinue these ritualistic behaviors." C. "Why are you asking for help if you won't participate in unit therapy?" D. "Let's figure out a way for you to attend unit activities and still wash your hands."
ANS: D The most appropriate statement by the nurse is, "Let's figure out a way for you to attend unit activities and still wash your hands." This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship or increasing the client's anxiety.
A client who frequently exhibits angry outbursts is diagnosed with antisocial personality disorder. Which appropriate feedback should a nurse provide when this client experiences an angry outburst? A. "Why do you continue to alienate your peers by your angry outbursts?" B. "You accomplish nothing when you lose your temper like that." C. "Showing your anger in that manner is very childish and insensitive." D. "During group, you raised your voice, yelled at a peer, left, and slammed the door."
ANS: D The nurse is providing appropriate feedback when stating, "During group, you raised your voice, yelled at a peer, left, and slammed the door." Giving appropriate feedback involves helping the client consider a modification of behavior. Feedback should give information to the client about how he or she is perceived by others. Feedback should not be evaluative in nature or be used to give advice.
Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I get angry, I get 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 this physical violence." A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations
ANS: D The nurse is using the therapeutic communication technique of making observations when noting that the client smiles when talking about physical violence. The technique of making observations encourages the client to compare personal perceptions with those of the nurse.
A nurse states to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? A. The therapeutic technique of "giving advice" B. The therapeutic technique of "defending" C. The nontherapeutic technique of "presenting reality" D. The nontherapeutic technique of "giving false reassurance"
ANS: D The nurse's statement, "Things will look better tomorrow after a good night's sleep." is an example of the nontherapeutic technique of giving false reassurance. Giving false reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.
A client states, "You won't believe what my husband said to me during visiting hours. He has no right treating me that way." Which nursing response would best assess the situation that occurred? A. "Does your husband treat you like this very often?" B. "What do you think is your role in this relationship?" C. "Why do you think he behaved like that?" D. "Describe what happened during your time with your husband."
ANS: D This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.
An external insulin pump is prescribed for a client with DM. The client asks the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: "a. Gives small continuous dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dosage from the pump before each meal. b. Is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals. c. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream. d. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels"
ANSWER A. An insulin pump provides a small continuous dose of regular insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with additional dosage from the pump before each meal as needed. Regular insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.
"A female client who weighs 210 lb (95 kg) and has been diagnosed with hyperglycemia tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that she has large hands and a hoarse voice. Which of the following would the nurse suspect as a possible cause of the client's hyperglycemia?
Acromegaly
Pituitary
Acromegaly Parlodel (bromocripitine) Sondostatin (octreotide)-injection Dostirex (cabergaline) Somavent Reduce amount of prolacting in body, check GH measurments, teach hyperglycemia
Discuss the teaching plan for the patient with an extra-pyramidal disorder.
Actions of medication Continued support and counseling
Angle-closure Glaucoma
Acute Considered medical emergency
This is considered a medical eye emergency
Acute closed angle glaucoma Retinal detachment
Nursing care for TN focuses on
Acute pain, altered nutrition.
Describe nursing and interdisciplinary care for a patient with a spinal cord injury.
Acute phase: Aggressive respiratory therapy. Above C5 injury are intubated/ventilator. Intermittent positive-pressure breathing (IPPB) are used to prevent atelectasis. Foley catheter, surgery/immobilization, tracheotomy if long-term ventilation is needed. Parentreal nutrition and fluids until the GI tract starts functioning. A diet high in protein and fiber. Bowel program during spinal shock: manual disipaction and small-volume enemas. PT and OT therapy: passive ROM and then aggressive rehab long term. Chronic phase: orthostatic hypotension prevention, dietary management (weight gain likely), skin care/turning, respiratory management.
*Adrenalcortical insufficiency (not enough steroids) is the same as ________ disease. What three things are important to remember about this disease?
Addison's disease (think ADD steroids).--1.) not enough steroids 2.) hyperkalemia (no aldosterone) 3.) shock!
"Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
Administer 2 to 3 L of I.V. fluid over 2 to 3 hours.
A client with type 2 diabetes is sc heduled for major abdominal surgery. How will the nurse anticipate controlling blood glucose levels in this client during the immediate postoperative period?
Administer insulin on a sliding scale basis.
Which nursing intervention is appropriate for a client diagnosed with idiopathic thrombocytopenia purpura (ITP)?
Administering stool softeners, as ordered, to prevent straining during defecation
Which action takes priority for a client who is experiencing a hypersensitivity reaction to latex?
Administering supplemental oxygen
What is the treatment for cushing's disease and what should be given throughout the client's lifetime (on one condition)? What does the client need in their diet pre-treatment (4)?
Adrenalectomy (unilateral or bilateral). If both are removed > lifetime replacement of steroids. Client needs more potassium, less sodium, more protein, and more calcium.
Describe predisposing factors linked to Alzheimer's disease.
Alzheimer's effects cranial nerves, especially #19. patho 1. loss of nerve cells 2. reduce brain size 3. presence of neurofibrillary tangles 4. neuritic plaques by amyloid protein. Aging. One out of eight people over age 65 has Alzheimer's. Nearly half of people over age 85 have the disease. Family history and genetics Another risk factor is family history. Research has shown that those who have a parent, brother or sister with Alzheimer's are two to three times more likely to develop the disease. There appears to be a strong link between serious head injury and future risk of Alzheimer's. It's important to protect your head by buckling your seat belt, wearing your helmet when participating in sports and "fall-proofing" your home. Some evidence suggests that strategies for general healthy aging may also help reduce the risk of developing Alzheimer's. These measures include controlling blood pressure, weight and cholesterol levels; exercising both body and mind; eating a balanced diet; and staying socially active. Scientists don't know yet exactly how Alzheimer's and diabetes are connected, but they do know that excess blood sugar or insulin can harm the brain in several ways: Diabetes raises the risk of heart disease and stroke, which hurt the heart and blood vessels. Damaged blood vessels in the brain may contribute to Alzheimer's disease. The brain depends on many different chemicals, which may be unbalanced by too much insulin. Some of these changes may help trigger Alzheimer's disease. High blood sugar causes inflammation. This may damage brain cells and help Alzheimer's to develop.
Explain the surgical treatment for a TIA.
Angioplasty In selected cases, a procedure called carotid angioplasty, or stenting, is an option. This procedure involves using a balloon-like device to open a clogged artery and placing a small wire tube (stent) into the artery to keep it open. If you have a moderately or severely narrowed neck (carotid) artery, your doctor may suggest carotid endarterectomy (end-ahr-tur-EK-tuh-me). This preventive surgery clears carotid arteries of fatty deposits (atherosclerotic plaques) before another TIA or stroke can occur. An incision is made to open the artery, the plaques are removed, and the artery is closed. Carotid endarterectomy is often not done until several months after a TIA, but a large study showed that people benefit most from the surgery if it is done within 2 weeks of a TIA. Delaying surgery longer than 2 weeks increases the risk for stroke, because a person is more likely to have a stroke in the first few days and weeks after a TIA. Each person must carefully weigh the benefits and risks of surgery and compare them with the benefits and risks of using medicine to reduce the risk of TIA or stroke. The success of either treatment will depend on the amount of blockage you have and which medicine you use. Risks of surgery depend on your age, your health status, the skill and experience of the surgeon, and the experience of the medical center where the surgery is done.
"1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what ""type 2"" means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes a. the pt is totally dependent on an outside source of insulin b. there is a decreased insulin secretion and cellular resistance to insulin that is produced c. the immune system destroys the pancreatic insulin-producing cells d. the insulin precurosr that is secreted by the pancreas is not activated by the liver
Answer B - Rationale: In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately. The other information describes the physiology of type 1 diabetes
Meds for HD: antipsychotics
block dopamine receptors in brain. Restore balance of neurotransmitters
"The nurse caring for a 54-year-old patient hospitalized with diabetes mellitus would look for which of the following laboratory test results to obtain information on the patient's past glucose control? a. prealbumin level b. urine ketone level c. fasting glucose level d. glycosylated hemoglobin level
Answer d: A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus the test can give an indication of glycemic control over approximately 2 to 3 months.
When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of A. smoking B. alcohol use C. diabetes mellitus D. high-fat dietary intake
Answer: B pancreatitis is associated with alcoholism
Discuss the use of anti platelet drugs.
Anti platelet drugs prevent thrombus formation in the arterial system (as opposed to anticoagulants, that prevent thrombosis in the venous system). they work by decreasing the platelet's ability to stick together in the blood, thus forming a clot. Often prescribed prophylactically to pts with a-fib for risk of embolic strokes, but have no other warning signs or indicators of future stroke. Compared with antiplatelet therapy, oral anticoagulation significantly reduces stroke at an average follow-up of one to three years, but does not reduce mortality. Applied to all-comers with atrial fibrillation, aspirin reduces stroke by 20 percent, whereas warfarin (Coumadin) reduces it by 65 percent. But SEVERE Intracranial or extracranial hemorrhage is more common with anticoagulation and must be weighed against its therapeutic benefit.
Describe two classifications of drugs used to treat a TIA.
Anti-platelet drugs. These medications make your platelets, one of the circulating blood cell types, less likely to stick together. When blood vessels are injured, sticky platelets begin to form clots, a process completed by clotting proteins in blood plasma. Anticoagulants. They affect clotting-system proteins instead of platelet function.
"The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?
Antidiuretic hormone (ADH)
What 4 classes of medications are used to treat hyperthyroidism/graves disease?
Antithyroids. Iodine Compounds. Beta Blockers. Radioactive Iodine.
A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?
Aplastic anemia
Discuss assessment methods used to identify changes in patient neurological status?
Ask family what the patient's baseline is Assess LOC, and orientation, if pt is unconcious use the Glascow Coma Scale Assess for numbness and tingling in extremeties Determine if pt has difficulty with sensory functions Assess strength of hands grip and movement of extremities Assess pupils using PEERLA Obtain past medical hx
The nurse would include which of the following in a neurological assessment? a) Palpate the dorsalis pedis pulse. b) Capillary refill of the great toe. c) Inspect the foot for edema. d) Ask the client to plantar flex the toes.
Ask the client to plantar flex the toes. Explanation: A neurological assessment evaluates sensation and motion. Assessing plantar flexion of the toes would be included in a neurological assessment. Capillary refill, palpation of pulses, and inspecting for edema would be included in a vascular assessment.
Discuss nursing care of the patient with neuromuscular disorder.
Assess ability to swallow, chew, and taste Assess weight daily Assess bowel sounds Assess/monitor changes in vital signs Assess respiratory rate, character, and use of accessory muscle Administer oxygen as ordered Administer medications as ordered Teach patient about disease process
LMN signs and symptoms
Asymmetric mm weakness, cramping, and atrophy in the hands, Mm fasciculations due to mm weakness, Mm weakness will continue throughout the body distal to proximal
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
Autoimmune disorders include connective tissue (collagen) disorders.
A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Which teaching will the nurse implement about exercise for this patient? a. "You should not take the morning NPH insulin before you run." b. "Plan to eat breakfast about an hour before your run." c. "Afternoon running is less likely to cause hypoglycemia." d. "You may want to run a little farther if your glucose is very high."
B Rationale: Blood sugar increases after meals, so this will be the best time to exercise. NPH insulin will not peak until mid-afternoon and is safe to take before a morning run. Running can be done in either the morning or afternoon. If the glucose is very elevated, the patient should postpone the run.
A patient with type 1 diabetes who uses glargine (Lantus) and lispro (Humalog) insulin develops a sore throat, cough, and fever. When the patient calls the clinic to report the symptoms and a blood glucose level of 210 mg/dl, the nurse advises the patient to a. use only the lispro insulin until the symptoms of infection are resolved. b. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. c. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. d. limit intake to non-calorie-containing liquids until the glucose is within the usual range.
B Rationale: Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to DKA. Decreasing carbohydrate or caloric intake is not appropriate as the patient will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose.
A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, the nurse gives the highest priority to the goal of a. controlling bleeding. b. maintenance of the airway. c. maintenance of fluid volume. d. relieving the patient's anxiety.
B Rationale: Maintaining gas exchange has the highest priority because oxygenation is essential for life. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs. The other goals would also be important for this patient, but they are not as high a priority as airway maintenance.
A patient with cirrhosis has 4+ pitting edema of the feet and legs and massive ascites. The data indicate that it is most important for the nurse to monitor the patient's a. temperature. b. albumin level. c. hemoglobin. d. activity level.
B Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema. The other parameters should also be monitored, but they are not contributing factors to the patient's current symptoms.
A patient is admitted with an abrupt onset of jaundice, nausea and vomiting, hepatomegaly, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Have you been around anyone with jaundice?" b. "Do you use any prescription or over-the-counter (OTC) drugs?" c. "Are you taking corticosteroids for any reason?" d. "Is there any history of IV drug use?"
B Rationale: The patient's symptoms, lack of antibodies for hepatitis, and the ABRUPT onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Exposure to a jaundiced individual and a history of IV drug use are risk factors for VIRAL hepatitis. Corticosteroid use does not cause the symptoms listed.
10. A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The patient tells the nurse, "I hate to exercise! Can't I just follow the diet to keep my glucose under control?" The nurse teaches the patient that the major purpose of exercise for diabetics is to a. increase energy and sense of well-being, which will help with body image. b. facilitate weight loss, which will decrease peripheral insulin resistance. c. improve cardiovascular endurance, which is important for diabetics. d. set a successful pattern, which will help in making other needed changes.
B Rationale: Exercise is essential to decrease insulin resistance and improve blood glucose control. Increased energy, improved cardiovascular endurance, and setting a pattern of success are secondary benefits of exercise, but they are not the major reason. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity
12. A patient with type 1 diabetes has an unusually high morning glucose measurement, and the health care provider wants the patient evaluated for possible Somogyi effect. The nurse will plan to a. administer an increased dose of NPH insulin in the evening. b. obtain the patient's blood glucose at 3:00 in the morning. c. withhold the nighttime snack and check the glucose at 6:00 AM. d. check the patient for symptoms of hypoglycemia at 2:00 to 4:00 AM.
B Rationale: In the Somogyi effect, the patient's blood glucose drops in the early morning hours (in response to excess insulin administration), which causes the release of hormones that result in a rebound hyperglycemia. It is important to check the blood glucose in the early morning hours to detect the initial hypoglycemia. An increased evening NPH dose or holding the nighttime snack will further increase the risk for early morning hypoglycemia. Information about symptoms of hypoglycemia will not be as accurate as checking the patient's blood glucose in determining whether the patient has the Somogyi effect. Cognitive Level: Application Text Reference: pp. 1263-1264 Nursing Process: Planning NCLEX: Physiological Integrity
1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes a. the patient is totally dependent on an outside source of insulin. b. there is decreased insulin secretion and cellular resistance to insulin that is produced. c. the immune system destroys the pancreatic insulin-producing cells. d. the insulin precursor that is secreted by the pancreas is not activated by the liver.
B Rationale: In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately. The other information describes the physiology of type 1 diabetes. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity
what do crabs live on
blood
25. A patient with type 1 diabetes who uses glargine (Lantus) and lispro (Humalog) insulin develops a sore throat, cough, and fever. When the patient calls the clinic to report the symptoms and a blood glucose level of 210 mg/dl, the nurse advises the patient to a. use only the lispro insulin until the symptoms of infection are resolved. b. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. c. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. d. limit intake to non-calorie-containing liquids until the glucose is within the usual range.
B Rationale: Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to DKA. Decreasing carbohydrate or caloric intake is not appropriate as the patient will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose. Cognitive Level: Application Text Reference: p. 1272 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance
3. During a diabetes screening program, a patient tells the nurse, "My mother died of complications of type 2 diabetes. Can I inherit diabetes?" The nurse explains that a. as long as the patient maintains normal weight and exercises, type 2 diabetes can be prevented. b. the patient is at a higher than normal risk for type 2 diabetes and should have periodic blood glucose level testing. c. there is a greater risk for children developing type 2 diabetes when the father has type 2 diabetes. d. although there is a tendency for children of people with type 2 diabetes to develop diabetes, the risk is higher for those with type 1 diabetes.
B Rationale: Offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes. The risk can be decreased, but not prevented, by maintenance of normal weight and exercising. The risk for children of a person with type 1 diabetes to develop diabetes is higher when it is the father who has the disease. Offspring of people with type 2 diabetes are more likely to develop diabetes than offspring of those with type 1 diabetes. Cognitive Level: Application Text Reference: p. 1256 Nursing Process: Implementation NCLEX: Physiological Integrity
34. The health care provider orders oral glucose tolerance testing for a patient seen in the clinic. Which information from the patient's health history is most important for the nurse to communicate to the health care provider? a. The patient had a viral illness 2 months ago. b. The patient uses oral contraceptives. c. The patient runs several days a week. d. The patient has a family history of diabetes.
B Rationale: Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. A viral 2 months previously illness may be associated with the onset of type 1 diabetes but will not falsely impact the OGTT. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. Cognitive Level: Application Text Reference: p. 1267 Nursing Process: Assessment NCLEX: Physiological Integrity
A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin. a. NPH b. lispro c. detemir d. glargine
B Rationale: Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.
15. A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin. a. NPH b. lispro c. detemir d. glargine
B Rationale: Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin. Cognitive Level: Application Text Reference: p. 1260 Nursing Process: Planning NCLEX: Physiological Integrity
A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. When planning patient teaching, the priority information for the nurse to include is the need for a. vitamin B supplements. b. abstinence from alcohol. c. maintenance of a nutritious diet. d. long-term, low-dose corticosteroids.
B Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.
35. Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient? a. Fasting blood glucose of 130 mg/dl b. Noon blood glucose of 52 mg/dl c. Glycosylated hemoglobin of 6.9% d. Hemoglobin A1C of 5.8%
B Rationale: The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient. Cognitive Level: Application Text Reference: pp. 1281-1282 Nursing Process: Assessment NCLEX: Physiological Integrity
30. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. The nurse teaches the patient that a. the feet should be soaked in warm water on a daily basis. b. flat-soled leather shoes are the best choice to protect the feet from injury. c. heating pads should always be set at a very low temperature. d. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure.
B Rationale: The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided; the patient should see a specialist to treat these problems. Cognitive Level: Application Text Reference: p. 1287 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance
A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? a. The patient's most recent hemoglobin A1C was 6%. b. The patient takes metformin (Glucophage) every morning. c. The patient uses captopril (Capoten) for hypertension. d. The patient's admission blood glucose is 128 mg/dl.
B Rationale: To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast media are administered. The other patient data indicate that the patient is managing the diabetes appropriately.
anti-dsDNA antibody test
blood test done specifically to identify/differentiate DNA antibodies found in SLE; monitors disease activity, response to tx, and establishes prognosis for SLE
33. A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? a. The patient's most recent hemoglobin A1C was 6%. b. The patient takes metformin (Glucophage) every morning. c. The patient uses captopril (Capoten) for hypertension. d. The patient's admission blood glucose is 128 mg/dl.
B Rationale: To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast media are administered. The other patient data indicate that the patient is managing the diabetes appropriately. Cognitive Level: Application Text Reference: p. 1266 Nursing Process: Assessment NCLEX: Physiological Integrity
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to: "A) A social worker from the local hospital B) An occupational therapist from the community center C) A physical therapist from the rehabilitation agency D) Another client with diabetes mellitus and takes insulin"
B) An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.
Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this? A) They will cause a fecal impaction B) They will cause chronic constipation C) They change the pH of the Gastrointestinal track D) They inhibit the intestinal enzymes
B) They will cause chronic constipation Habitual use of laxatives is the most common cause of chronic constipation
During treatment of the patient with an acute attack of gout, the nurse would expect to administer a. aspirin b. colchicine c. allopurinol (Zyloprim) d. probenecid (Benemid)
B. Colchicine
After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says, a. it is important for me to perform my prescribed exercises every day b. I should perform most of my daily chores in the morning when my energy level is highest c. an ice pack to a joint for 10 minutes may help relieve pain and inflammation when I have an acute flare d. I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints
B. I should perform most of my daily chores in the morning when my energy level is highest
In performing a physical assessment for an older adult, the nurse anticipates finding which of the following normal physiological changes of aging? A. Increased perspiration B. Increased airway resistance C. Increased salivary secretions D. Increased pitch discrimination
B. Increased airway resistance Rational: Normal physiological changes of aging include increased airway resistance in the older adult. The older adult would be expected to have decreased perspiration and drier skin as they experience glandular atrophy (oil, moisture, sweat glands) in the integumentary system. The older adult would be expected to have a decrease in saliva. A normal physiological change of the older adult related to hearing is a loss of acuity for high-frequency tones (presbycusis).
Which of the following things must the nurse working with diabetic clients keep in mind about Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)? A. This syndrome occurs mainly in people with Type I Diabetes B. It has a higher mortality rate than Diabetic Ketoacidosis C. The client with HHNS is in a state of overhydration D. This condition develops very rapidly
B. It has a higher mortality rate than Diabetic Ketoacidosis HHNS occurs only in people with Type II Diabetes. It is a medical emergency and has a higher mortality rate than Diabetic Ketoacidosis. This condition develops very slowly over hours or days.
A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, the nurse must explain that: A. Diet and exercise can slow the process considerably B. It usually progresses gradually with a deterioration of function C. Many individuals can be cured if the diagnosis is made early D. Few clients live more than 3 years after the diagnosis
B. It usually progresses gradually with a deterioration of function
The nurse is making an occupied bed. Arrange the following steps in the order the nurse should perform them. A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him. B. Lower the side rail on the side of the bed you are working on. C. Raise the side rail on the side of the bed you are working on. D. After placing clean linens and tucking them under the soiled linens, roll the patient over the "hump" and position him facing you on the near side of the bed.
B. Lower the side rail on the side of the bed you are working on. A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him. D. After placing clean linens and tucking them under the soiled linens, roll the patient over the "hump" and position him facing you on the near side of the bed. C. Raise the side rail on the side of the bed you are working on. First lower the side rail on your side of the bed. This allows you to maintain good body mechanics while positioning the patient (in step 1). Position patient laterally near far side rail, and roll soiled linens under him. Then place clean linens on the side nearest you, and tuck them under soiled linens. Next, roll the patient over the "hump," and position him on his other side, facing you. Do this before raising the near side rail so you do not have to reach across the side rail to help the patient roll and turn to his other side.
When the nurse walks into the patient's room, she notices fire coming from the patient's trash can. Rank the following actions in the order they should be performed by the nurse. A. Activate the fire alarm. B. Move the patient out of the room. C. Close all doors and windows. D. Put out the fire using the proper extinguisher.
B. Move the patient out of the room. A. Activate the fire alarm. C. Close all doors and windows. D. Put out the fire using the proper extinguisher. R.A.C.E. - rescue, alarm, contain, and exstinquish or evacuate
A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-Prone D. Trendelenburg
B. Semi-Fowler's -- The client lies supine with the head of the bed elevated approx. 30 degrees. This position is frequently used to prevent regurgitation and aspiration in clients who have difficulty swallowing. This is the safest position for the client receiving a tube feeding.
Of the following, which describes dementia? A. Quick onset, irreversible B. Slow onset, chronic C. Acute onset, reversible D. Progressive, terminal
B. Slow onset, chronic
Which information obtained by the home health nurse when making a visit to an 88-year-old with mild forgetfulness is of the most concern? A. The patient's son uses a marked pillbox to set up the patient's medications weekly. B. The patient has lost 10 pounds (4.5 kg) during the last month. C. The patient is cared for by a daughter during the day and stays with a son at night. D. The patient tells the nurse that a close friend recently died.
B. The patient has lost 10 pounds (4.5 kg) during the last month. Rationale: A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse.
A nurse is instructing a client who is postoperative about the sequential compression device the provider prescribed. Which of the following client statements should indicate to the nurse that the client understands the teaching. A. This device will keep me from getting sores on my skin. B. This thing will keep the blood pumping through my leg. C. With this thing on my leg muscles wont get weak. D. This device is going to keep my joints in good shape.
B. This thing will keep the blood pumping through my leg. (promotes venous return in the deep veins of the legs and thus helps prevent thrombus formation.
"The guidelines for Carbohydrate Counting as medical nutrition therapy for diabetes mellitus includes all of the following EXCEPT: a. Flexibility in types and amounts of foods consumed b. Unlimited intake of total fat, saturated fat and cholesterol c. Including adequate servings of fruits, vegetables and the dairy group d. Applicable to with either Type 1 or Type 2 diabetes mellitusb. Unlimited intake of total fat, saturated fat and cholesterol"
B. You want to be careful of how much you eat in any food group.
A patient recovering from an acute exacerbation of RA tells the nurse she is too tired to bathe. The nurse should a. give the patient a bed bath to conserve her energy b. allow the patient a rest period before showering with the nurses' help c. tell the patient that she can skip bathing if she will walk in the hall later d. inform the patient that it is important for her to maintain self-care activities
B. allow the patient a rest period before showering with the nurses' help
When administering a mental status examination to a patient with delirium, the nurse should A. give the examination when the patient is well-rested. B. choose a place without distracting environmental stimuli. C. reorient the patient as needed during the examination. D. medicate the patient first to reduce anxiety.
B. choose a place without distracting environmental stimuli.
A patient with gout is treated with drug therapy to prevent future attacks. The nurse teaches the patient that is is the most important to a. avoid all foods high in purine, such as organ meats b. have periodic determination of serum uric acid levels c. perform active ROM of all joints that have been affected by gout d. increase the dosage of medication with the onset of an acute attack
B. have periodic determination of serum uric acid levels
A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is a. You can plan to have a near-normal life since SLE rarely causes death b. it is difficult to tell because to disease is so variable in its severity and progression c. life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids d. most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage
B. it is difficult to tell because the disease is so variable in its severity and progression
To preserve function and the ability to perform activities of daily living, the nurse teaches the patient with OA to a. avoid exercise that involves the affected joints b. plan and organize less stressful ways to perform tasks c. maintain normal activities during an acute episode to prevent loss of function d. use mild analgesics to control symptoms when performing tasks that cause pain
B. plan and organize less stressful ways to perform tasks
"A client is taking Humulin NPH insulin daily every morning. The nurse instructs the client that the mostlikely time for a hypoglycemic reaction to occur is: A) 2-4 hours after administration B) 4-12 hours after administration C) 16-18 hours after administration D) 18-24 hours after administration
B: Rationale: Humulin is an intermediate acting insulin. The onset of action is 1.5 hours, it peaks in 4-12 hours, and its duration is 24 hours. Hypoglycemic reactions to insulin are most likely to occur during the peak time.
COMMON TYPES OF FRACTURES
BURST: Characterized by multiple pieces of bone; often occurs at bone ends or in vertebrae. COMMINUTED: More than one fracture line; more than two bone fragments; fragments may be splintered or crushed. COMPLETE: Break across the entire section of bone, dividing it into distinct fragments; often displaced. DISPLACED:Fragments out of normal position at fracture site. INCOMPLETE:Fracture occurs theough only one cortex of the bone; usually nondisplaced. LINEAR: Fracture line is intact; fracture line is intact; fracture is caused by minor to moderate force applied directly to the bone. LONGITUDINAL:Fracture line extends in the direction of the bone's longitudinal axis. NONDISPLACED: Fragments aligned at fracture site. OBLIQUE: Break occurs at an angle across the bone. Occurs at approximately 45 deg angle across the longitudinal axis of the bone. SPIRAL: Break twists around the bone.Fracture line results from twisting force. STELLATE:Fracture lines radiate from one central point. TRANSVERSE: Break occurs across the bone. Fracture line occurs at a 90 deg angle to longitudinal axis of bone. AVULSION:Bone fragments are torn away from the body of the bone at the site of attachment of a ligament or tendon. COMPRESSION:Bone buckles an deventually cracks as the result of unusual loading force applied to its longitudinal axis. GREENSTICK: One side of a bone is broken; the other side is bent. COLLES':Fracture within the last inch of the distal radius; distal fragment is displaced in a position of dorsal and medial deviation. POTT'S: fracture of the distal fibula, seriously disrupting the tibiofibular articulation; a piece of the medial malleolus may be chipped off as a result of rupture of the internal lateral ligament. IMPACTED: Telescoped fracture, with one fragment driven into another.
Muscle relaxants for MS
Baclofen, dantrolene (may affect muscle strength & hepatoxic), diazepam. used to treat muscle spasms.
Describe nursing care for the client who is experiencing phantom pain after amputation.
Be aware that phantom pain is real and will eventually disappear. Administer pain meds; phantom pain responds to meds.
HHNS
body is deficient of K from diuresis
After a thyroidectomy, how should bleeding be checked for? What position should the patient be placed in? What is important, nutrition-wise? How should laryngeal nerve damage be assessed? Why?
Bleeding should be checked behind the neck. Semi-fowler's position to decrease pooling of blood. Make sure patient gets a lot of calories due to hyperthyroidism. Nerve damage is checked by looking for hoarsness in voice (in unilateral nerve damage), breathing difficulties(in bilateral nerve damage), or inability to speak (in bilateral nerve damage). ---Nerve damage could lead to vocal cord paralysis > airway obstruction > requires trach
Define "pill rolling" and "bradykinesia".
Bradykinesia: since the extrapyramidal system regulates posture and skeletal muscle tone, a result is the characteristic of bradykinesia of Parkinson's. It is a slowness of movement. Slowness in the execution of movement, not initiation (like akinesia). "Stone face". Pill Rolling: The Parkinson's tremor tends to more often affect the hands and causes a movement sometimes referred to as "pill rolling". This "pill rolling" 'tremor' involves the uncontrolled movement of the thumb and finger(s) in a back and forth motion. This may also appear as the thumb and fingers are rubbing together, hence the term "pill rolling" movement. These tremors are usually rhythmic and may occur between 4 to 5 cycles per second. It may only affect one side of the body, or one hand, but as the disease progresses, the tremor may become more generalized affecting many parts of the body.
The nurse would not which finding on the physical assessment of a client wiht a diagnosis of Cushing Disease?
Buffalo hump, Thinning hair, hirsutism, gynicomastia
A P/T with LFT-sided weakness asks his RN, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response?
By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall over.
A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to a. administer glargine (Lantus) insulin. b. initiate oxygen by nasal cannula. c. insert a large-bore IV catheter. d. give 50% dextrose as a bolus.
C Rationale: HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient's blood glucose and would be contraindicated.
. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3.2 mEq/L (3.2 mmol/L). Before notifying the health care provider, the nurse should a. administer the furosemide and withhold the spironolactone. b. give both drugs as scheduled. c. administer the spironolactone. d. withhold both drugs until talking with the health care provider.
C Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.
A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor a. prothrombin time. b. bilirubin levels. c. ammonia levels. d. potassium levels.
C Rationale: The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level since the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but these will not be affected by the bleeding episode.
A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. The nurse would expect the diagnosis to be confirmed with laboratory testing that reveals elevated serum a. calcium. b. bilirubin. c. amylase. d. potassium.
C Rationale: Amylase is elevated early in acute pancreatitis. Changes in bilirubin, calcium, and potassium levels are not diagnostic for pancreatitis.
When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the nurse asks the patient to a. stand on one foot. b. ambulate with the eyes closed. c. extend both arms. d. perform the Valsalva maneuver.
C Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.
24. A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to a. administer glargine (Lantus) insulin. b. initiate oxygen by nasal cannula. c. insert a large-bore IV catheter. d. give 50% dextrose as a bolus.
C Rationale: HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient's blood glucose and would be contraindicated. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Planning NCLEX: Physiological Integrity
There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age: A. Men have the greatest incidence of osteoporosis B. Muscle fibers increase in size and become tighter C. Weight-bearing exercise reduces the loss of bone mass D. Muscle strength does not diminish as much as muscle mass
C. Weight-bearing exercise reduces the loss of bone mass
A type 1 diabetic patient who was admitted with severe hypoglycemia and treated tells the nurse, "I did not have any of the usual symptoms of hypoglycemia." Which question by the nurse will help identify a possible reason for the patient's hypoglycemic unawareness? a. "Do you use any calcium-channel blocking drugs for blood pressure?" b. "Have you observed any recent skin changes?" c. "Do you notice any bloating feeling after eating?" d. "Have you noticed any painful new ulcerations or sores on your feet?"
C Rationale: Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause delayed gastric emptying. Calcium-channel blockers are not associated with hypoglycemic unawareness, although -adrenergic blockers can prevent patients from having symptoms of hypoglycemia. Skin changes can occur with diabetes, but these are not associated with autonomic neuropathy. If the patient can feel painful areas on the feet, neuropathy has not occurred.
29. A type 1 diabetic patient who was admitted with severe hypoglycemia and treated tells the nurse, "I did not have any of the usual symptoms of hypoglycemia." Which question by the nurse will help identify a possible reason for the patient's hypoglycemic unawareness? a. "Do you use any calcium-channel blocking drugs for blood pressure?" b. "Have you observed any recent skin changes?" c. "Do you notice any bloating feeling after eating?" d. "Have you noticed any painful new ulcerations or sores on your feet?"
C Rationale: Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause delayed gastric emptying. Calcium-channel blockers are not associated with hypoglycemic unawareness, although -adrenergic blockers can prevent patients from having symptoms of hypoglycemia. Skin changes can occur with diabetes, but these are not associated with autonomic neuropathy. If the patient can feel painful areas on the feet, neuropathy has not occurred. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity
A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. Which patient outcome is most important for this patient? a. The patient will have a diet and exercise plan that results in weight loss. b. The patient will state the reasons for eliminating simple sugars in the diet. c. The patient will have a glycosylated hemoglobin level of less than 7%. d. The patient will choose a diet that distributes calories throughout the day.
C Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes are also appropriate but are not as high in priority.
7. A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. Which patient outcome is most important for this patient? a. The patient will have a diet and exercise plan that results in weight loss. b. The patient will state the reasons for eliminating simple sugars in the diet. c. The patient will have a glycosylated hemoglobin level of less than 7%. d. The patient will choose a diet that distributes calories throughout the day.
C Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes are also appropriate but are not as high in priority. Cognitive Level: Application Text Reference: p. 1273 Nursing Process: Planning NCLEX: Physiological Integrity
6. During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n) a. fasting blood glucose level. b. urine dipstick for glucose. c. glycosylated hemoglobin level. d. oral glucose tolerance test.
C Rationale: The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed. Cognitive Level: Application Text Reference: pp. 1258-1259 Nursing Process: Planning NCLEX: Physiological Integrity
A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. Which order should the nurse implement first? a. Start an infusion of regular insulin at 50 U/hr. b. Give sodium bicarbonate 50 mEq IV push. c. Infuse 1 liter of normal saline per hour. d. Administer regular IV insulin 30 U.
C Rationale: The most urgent patient problem is the hypovolemia associated with DKA, and the priority is to infuse IV fluids. The other actions can be accomplished after the infusion of normal saline is initiated.
23. A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. Which order should the nurse implement first? a. Start an infusion of regular insulin at 50 U/hr. b. Give sodium bicarbonate 50 mEq IV push. c. Infuse 1 liter of normal saline per hour. d. Administer regular IV insulin 30 U.
C Rationale: The most urgent patient problem is the hypovolemia associated with DKA, and the priority is to infuse IV fluids. The other actions can be accomplished after the infusion of normal saline is initiated. Cognitive Level: Application Text Reference: p. 1280 Nursing Process: Implementation NCLEX: Physiological Integrity
"A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. Following assessment of the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of "a. polyuria b. severe dehydration c. rapid, deep respirations ) d. decreased serum potassium"
C is correct, Signs and symptoms of DKA include manifestations of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms may include lethargy and weakness. As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyeballs become soft and sunken. Abdominal pain is another symptom of DKA that may be accompanied by anorexia and vomiting. Kussmaul respirations (i.e., rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is identified on the breath as a sweet, fruity odor. Laboratory findings include a blood glucose level greater than 250 mg/dL, arterial blood pH less than 7.30, serum bicarbonate level less than 15 mEq/L, and moderate to large ketone levels in the urine or blood ketones.
autoimmune disease
body unable to recognize its own cells as a part of itself; can affect collagenous tissue
When explaining the action of a hyper tonic solution enema, the nurse incorporates which of the following as the basis for action? A) bowel mucosa irritations B) Diffusion of water out of colon C) Osmosis of water into colon D) Softening of fecal contents
C) Osmosis of water into colon Hypertonic solutions draw water into the colon a By osmosis that's stimulating the defecation reflex. Orrills solutions soften fecal contents, and soup solutions distend the intestines and irritate the bowel mucosa
In educating a client with diabetes, what response would reveal need for further education? "A. I should avoid tights B. I should take good care of my toe nails C. I should not go more than 3 days without washing my feet D. I should avoid going barefoot and should wear clean socks
C)I should not go more than 3 days w/o washing my feet"The recommended self-care routine is to wash feet on a daily basis without soaking and carefully cleaning."
A patient is admitted with diabetes mellitus, has a glucose level of 380 mg/dl, and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which of the following respiratory patterns would the nurse expect to find?"A-Central apnea B-Hypoventilation C-Kussmaul respirations D- Cheyne-Stokes respirations"
C-Kussmaul respirationsIn diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored.
A long-term care facility sponsors a discussion group on the administration of medications. The participants have a number of questions concerning their medications. The nurse responds most appropriately by saying: A. "Don't worry about the medication's name if you can identify it by its color and shape." B. "Unless you have severe side affects, don't worry about the minor changes in the way you feel." C. "Feel free to ask your physician why you are receiving the medications that are prescribed for you." D. "Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your medications."
C. "Feel free to ask your physician why you are receiving the medications that are prescribed for you." Rationale: The nurse should encourage the older adult to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs.
An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications? A. "I don't seem to have problems with side effects, but I'll let my doctor know if something happens." B. "I'm lucky since my daughter is really good about keeping up with my medications." C. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something." D. "It shouldn't be too hard to keep it straight since I don't have any really serious health issues."
C. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something."
A nurse caring for older adults in an assistive living facility recognizes that a clients quality of life needs are best determined by: A. Excellent physical, social, and emotional nursing assessments B. A working knowledge of this age-group's developmental needs C. A therapeutic nurse-client relationship that facilitates communication D. The client's need for complete physical, emotional, and cognitive care
C. A therapeutic nurse-client relationship that facilitates communication
"A nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to prepare to: "A. Correct the acidosis B. Administer 5% dextrose intravenously C. Administer regular insulin inraVenously D. Apply a monitor for an electrocardiogram."
C. Administer regular insulin inraVenously Lack (absolute or relative) of insulin is the primary cause of DKA. Treatment consists of insulin administration (regular insulin), intravenous fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not a priority action.
When a fall results in injury and hospitalization, a cycle of disuse may occur over time. When establishing a care plan for the patient and family to prevent this, it is important to remember disuse is most likely a result of: A. Decreasing muscle strength. B. Decreased joint mobility. C. Fear of repeated falls. D. Changes in sensory perception.
C. Fear of repeated falls.
When performing a comprehensive geriatric assessment of an older adult, focus of the nursing assessment is on the patient's: A. Physical signs of aging. B. Immunological function. C. Functional abilities. D. Chronic illness.
C. Functional abilities.
The nurse is working with an overweight client who has a high-stress job and smokes. This client has just received a diagnosis of Type II Diabetes and has just been started on an oral hypoglycemic agent. Which of the following goals for the client which if met, would be most likely to lead to an improvement in insulin efficiency to the point the client would no longer require oral hypoglycemic agents? a. Comply with medication regimen 100% for 6 months b. Quit the use of any tobacco products by the end of three months c. Lose a pound a week until weight is in normal range for height and exercise 30 minutes daily d. Practice relaxation techniques for at least five minutes five times a day for at least five months
C. Lose a pound a week until weight is in normal range for height and exercise 30 minutes daily When type II diabetics lose weight through diet and exercise they sometimes have an improvement in insulin efficiency sufficient to the degree they no longer require oral hypoglycemic agents.
In reviewing changes in the older adult, the nurse recognizes that which of the following statements related to cognitive functioning in the older client is true? A. Delirium is usually easily distinguished from irreversible dementia. B. Therapeutic drug intoxication is a common cause of senile dementia. C. Reversible systemic disorders are often implicated as a cause of delirium. D. Cognitive deterioration is an inevitable outcome of the human aging process.
C. Reversible systemic disorders are often implicated as a cause of delirium. Rationale: Delirium is a potentially reversible cognitive impairment that is often due to a physiological cause such as an electrolyte imbalance, cerebral anoxia, hypoglycemia, medications, tumors, cerebrovascular infection, or hemorrhage.
A nurse is completing discharge teaching to a client who has COPD. The client verbalizes understanding of the orthopneic position when he states, "When I have difficulty breathing at night, I will A. lie on my back with my head and shoulders elevated on a pillow. B. lie flat on my stomach with my head to one side. C. sit on the side of my bed and rest my arms over pillows on top of my raised bedside table. D. lie on my side with my weight on my hips and shoulder with my arms flexed in front of me.
C. sit on the side of my bed and rest my arms over pillows on top of my raised bedside table. The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial to clients who have COPD.
Risk factors for type 2 diabetes include all of the following except: a. Advanced age b. Obesity c. Smoking d. Physical inactivity
C: smoking Additional risk factors for type 2 diabetes are a family history of diabetes, impaired glucose metabolism, history of gestational diabetes, and race/ethnicity. African-Americans, Hispanics/Latinos, Asian Americans, Native Hawaiians, Pacific Islanders, and Native Americans are at greater risk of developing diabetes than whites.
tests use to evaluate HIV progression
CBC, lymphocyte screen, quantitative immunoglobulin, chem panel, anergy panel, Hep B surface antigen, blood cultures, CXR
Diagnostic Tests
CSF examination: look for elevated gamma globulin MRI: look for demyelinating plaques Evoked Potential Testing: the presence of demyelinating lesions on sensory pathways can be confirmed by visual, auditory, or somatosenory evoked potentials. CT Scan: for areas of different densities
42. Hypoparathyroidism can lead to a decreased level in this electrolyte?
Calcium
Steroids decrease serum _____ by making you excrete it through the ____ ______.
Calcium. GI Tract.
"The nursing staff has just been trained how to use and care for a new blood glucose monitor. Which nursing intervention demonstrates proper use of a blood glucose monitor?
Calibrate the machine after installing a new battery.
"While administering morning medications, a nurse enters the room of a client who recently had a thyroidectomy. She observes that the client is sitting up in bed but appears unresponsive. After confirming unresponsiveness, what should the nurse do next?
Call for help.
A client is prescribed levothyroxine daily. An important instruction to give the client regarding administration of this drug is ?
Call the physician immediately at the onset of palpitations or nervousness.
Write four nursing interventions for the care of the blind person and four nursing interventions for the care of the deaf person.
Care of the blind: announce presence clearly, call by name, orient carefully to surroundings, guide by walking in front of client with their hand in your elbow. Care of deaf: reduce distraction before beginning conversation, look and listen to client, give client full attention if they are a lip reader, face client directly.
What discharge instructions should be included concerning a child with a spica cast?
Check clid's circulation. Keep cast dry. Do not place anything under cast. Prevent cast soilage during toileting or diapering. Do not turn child using an abductor bar.
Fertility
Clomid (clomiphene citrate)-to induce ovulation -pt teaching-multiple birth, take basal temp Parladel (bromocriptate mesylate)-amenorrhea, hypogonadism (infertility) -pt teaching-baseline & periodic evals of cardiac, hepatic, renal ftn are recommended, may take up to 8 wks.
A P/T had a LFT sided CVA 3 days ago and is receiving 5000 units of heparin subQ every 12 hrs to prevent thrombophlebitis. The P/T is receiving enteral feedings through a small-bore NG tube because of dysphagia. Which of the following symptoms requires the RN to call the health care provider immediately?
Coffee ground-like aspirate from the feeding tube.
A client has been receiving corticosteroids for the past 5 years for treatment of rheumatoid arthritus. The client is now being admitted for a major surgical procedure. What would be important for the nurse to assess after the clkient returns form surgery?
Continued orders for corticosteroids at or above level the clint was receiving before surgery.
Hyperthyroid Interventions
Cool, quiet environment Promote sleep Cool showers & linen changes High calorie/protein diet Extra fluids, no caffeine or fiber Eye care
A nurse is caring for a client who has been sitting in a chair for 3 hours. Which of the following problems is the client at risk for developing? 1. Stasis of secretions 2. Muscle atrophy 3. Pressure ulcer 4. Fecal impaction
Correct -- 3 - Pressure ulcer Incorrect 1. Stasis of secretions -Sitting in a chair will help prevent stasis of secretions 2. Muscle atrophy - is a complication for a client on prolonged bed rest, not just sitting in a chair. 4. Fecal impaction - complication for a client on prolonged bed rest not just sitting in a chair for brief time.
"A client is admitted with a serum glucose level of 618 mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6° F (38.1° C); a heart rate of 116 beats/minute; and a blood pressure of 108/70 mm Hg. Based on these findings, which nursing diagnosis takes highest priority?
Deficient fluid volume related to osmotic diuresis
A nurse is caring for a client who is post-operative. Which of the following nursing interventions reduce the risk of thrombus development.? (Select ALL that apply) 1. Instruct the client not to use the Valsalva maneuver. 2. Apply elastic stockings. 3. Review laboratory values for total protein level. 4. Place pillows under the client's knee's and lower extremities. 5. Assist the client to change position often.
Correct -->2. Apply elastic stockings.(promotes venous return and prevents thrombus formation) Correct --> 5. Assist the client to change position often. (prevents venous stasis) Wrong 1. Instruct the client not to use the Valsalva maneuver. (increases workload of heart, but it does not affect peripheral circulation) Wrong3. Review laboratory values for total protein level. (important for evaluating his ability to heal and prevent skin breakdown) Wrong4. Place pillows under the client's knee's and lower extremities. (further impairs circulation to lower extremities.)
A nurse is caring for a client with type 1 diabetes mellitus. Which client complaint would alert the nurse to the presence of a possible hypoglycemic reaction ? A. Tremors B. Anorexia C. Hot, Dry skin D. Muscle cramps
Correct Answer A Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classsically as nervousness, irritability, and tremors. Option C is more likely to occur with hyperglycemia. Options B and D are unrealted to the signs of hyperglycemia
The healthcare provider orders 2.5 mg IV of morphine sulfate (Morphine) to be administered to a patient with a ruptured interverterbral disk. The nurse has a 1 milliliter (mL) syringe containing 10 mg of morphine sulfate. How many milliliters of morphine sulfate does the nurse need to withdraw from the syringe?
Correct Answer: 0.25
Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team
Correct Answer: 1 Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.
A patient has the nursing diagnosis of Impaired Swallowing and complains of frequent heartburn. What is the most appropriate action by the nurse? 1. Assist the patient in maintaining a sitting position for 30 minutes after the meal. 2. Teach the patient the "chin tuck" technique when swallowing. 3. Check the patient's mouth for pocketing of food. 4. Assist the patient to a 90-degree sitting position, or as high as tolerated, during meals.
Correct Answer: 1 Rationale: Keeping the patient upright for a time after the meal will help prevent food from being regurgitated back into the esophagus. The position of the patient during the meals as well as teaching the "chin tuck" technique will assist with the swallowing mechanism, but will not help with regurgitation. Pocketing food does not cause regurgitation.
A patient whose status is post-stroke (CVA) has severe right-sided weakness. Physical therapy recommends a quad cane. Which of the following is proper use of the cane by the patient? 1. The patient holds the cane in the left hand. The patient moves the cane forward first, then the right leg, and then the left leg. 2. The cane is held in either hand and moved forward at the same time as the left leg. Then the patient drags the right leg forward. 3. The patient holds the cane in the right hand for support. The patient moves the cane forward first, then the left leg, and then the right leg. 4. The patient holds the cane in the left hand. The patient moves the left leg forward first, then moves the cane and the right leg forward together.
Correct Answer: 1 Rationale: Proper use of the cane is essential to fall prevention. The patient should hold the cane in the left hand. The patient should move the cane forward first, then the right leg, and then the left leg.
A patient is recovering following a carotid endarterectomy. The blood pressure has risen this morning to 168/60. The nurse should do which of the following? 1. Recheck the blood pressure and make sure the correct size cuff was used. Then compare the trend of blood pressure readings and call the physician now. 2. Recheck the blood pressure every hour and report this change to the physician when he or she makes rounds the next time. 3. Record the blood pressure and find out who took this reading. Have that staff member demonstrate his or her blood pressure procedure and offer tips to obtain more accurate readings. 4. Check the standing orders and see if there is a medication ordered p.r.n. for lowering blood pressure. If so, administer it and document the action.
Correct Answer: 1 Rationale: Take a blood pressure reading manually to check technique, compare the results to the last several blood pressures recorded, and call the physician to report this blood pressure. Physicians typically have a range for maintaining the blood pressure following carotid endarterectomy, with standing orders for higher or lower blood pressures. If the blood pressure becomes higher, it is a danger and should be reported to the physician and documented in the patient record along with orders received. Although the skill of the staff is important, it is a priority to notify the physician of the blood pressure reading so that treatment can begin. Antihypertensives may be ordered and administered p.r.n., but physician notification after verification of the reading is the priority, so that further evaluation can occur.
An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed? Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.
Correct Answer: 1,2,5 Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.
The healthcare provider orders 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5 milliliter (mL) ampule containing 60 mg of ketorolac. How many milliliters of ketorolac does the nurse need to withdraw from the syringe?
Correct Answer: 1.25
List two problems that occur with the adrenal medulla. What would happen w/ these things symptoms - BP, Pulse, & flushing/diaphoretic?
Pheochrmocytoma & benign tumors that secrete epinephrine/norepinephrine. BP would increase, pulse would increase, flushing/diaphoretics would increase.
The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. "I will have less pain if I use the halo device." 2. "The halo device will allow me to get out of bed." 3. "I am less likely to get an infection with the halo device." 4. "The halo device does not have to stay in place as long."
Correct Answer: 2 Rationale: A halo device will allow the patient to be mobile since it does not require weights like the Gardner-Wells tongs. The patient's pain level is not dependant on the type of stabilization device used. The patient does not have a great risk of infection with the Garnder-Wells tongs; both devices require pins to be inserted into the skull. The time required for stabilization is not dependant on the type of stabilization device used.
The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia
Correct Answer: 2 Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.
The family of a patient who has had a brain attack (CVA) asks if the patient will ever talk again. The nurse should do which of the following? 1. Explain that the patient's speech will return to normal with time. 2. Explain that it is difficult to know how far the patient will progress. 3. Tell the family that nurses cannot discuss such issues. Tell them to ask the physician. 4. Tell the family what they see today is all they can expect.
Correct Answer: 2 Rationale: Therapeutic communication is needed. It is important to allow hope but be honest by not promising progress, since no one knows how much the patient will improve. Progress may depend on the extent and the areas affected. The nurse does not know that speech will return in time. It is not therapeutic to tell the family to ask the physician, and it does not display a professional, caring attitude.
The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury for two cord segments above and below the affected level." 3. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."
Correct Answer: 2 Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.
The nurse must be alert to complications in the patient who has suffered a ruptured intracranial aneurysm. The nurse should assess the patient for signs of which of the following? Select all that apply. 1. headache 2. hydrocephalus 3. rebleeding 4. vasospasm 5. stiff neck
Correct Answer: 2,3,4 Rationale: Headache is a sign of a probable rebleed. Hydrocephalus, rebleeding, and vasospasm are the three major complications that a nurse must anticipate following a ruptured intracranial aneurysm. Stiff neck is a manifestation of intracranial aneurysm, not a complication.
A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion
Correct Answer: 2,4,5 Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.
A patient hospitalized with a known AV malformation begins to complain of a headache and becomes disorientated. Which is the most appropriate action by the nurse? 1. Recommend to the family members that they start to look for a long-term care facility. 2. Prepare to give aspirin or a "clot buster." 3. Prepare the patient for surgery. 4. Document the changes and monitor closely.
Correct Answer: 3 Rationale: An AV malformation is a cluster of vessels, usually located in the midline cerebral artery, that, if ruptured, becomes a surgical emergency to cut the blood flow to the vessels or the patient will bleed out into the brain. Symptoms of rupture include headache,,change in level of consciousness,, nausea and vomiting, and neurological deficits symptoms that mimic any brain bleed. Giving medication to affect coagulation will only make the bleeding worse. Recommending long-term care and merely documenting the changes are not appropriate interventions for a medical emergency.
While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia
Correct Answer: 3 Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.
"The nursing care for the client in addisonian crisis should perform which intervention?
Place the client in a private room.
A school nurse is called after a student falls down a flight of stairs. The student is breathing, but unconsciousness. After calling the ambulance, which is the most appropriate action by the nurse? 1. Protect the patient's neck and head from any movement. 2. Place the patient on his side to prevent aspiration. 3. Immobilize the neck,,securing the head. 4. Try to rouse the patient by gently shaking his shoulders.
Correct Answer: 3 Rationale: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. If the patient vomits, the nurse should utilize the log-roll technique to turn the patient while keeping the head, neck, and spine in alignment. Rousing the patient by shaking could cause damage to the spinal cord.
A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a stroke (CVA). What is the nurse's priority intervention? 1. Move the patient to the critical care unit. 2. Assess blood pressure. 3. Assess the airway and breathing. 4. Observe urinary output.
Correct Answer: 3 Rationale: In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of highest priority and will continue to be. Blood pressure and output monitoring as well as ensuring appropriate level of care are important interventions, but assessment of the patient's ability to maintain an airway is the most vital.
The nurse realizes that the goal of surgery for a patient with a secondary metastatic spinal cord tumor is 1. complete removal of the tumor and affected spinal cord tissue. 2. eradication of the tumor with excision and drainage. 3. tumor excision to reduce cord compression. 4. exploration to visualize the tumor and obtain a biopsy.
Correct Answer: 3 Rationale: The tumor can exert pressure on the spinal cord, which interferes with function. In the case of secondary metastatic spinal tumor (which means a second site of cancer) and the metastasis (spread of cancer) the patient outcome may be limited to preventing compression on the spinal cord and not totally removing the cancerous lesion. Complete removal along with affected spinal tissue or eradication by excision and drainage would not be likely due to the secondary nature of the tumor and the resulting disability. Biopsy can be accomplished without direct visualization.
A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient asks, "What is the most important thing for me to remember?" Which is an appropriate response by the nurse? 1. "Know your family history." 2. "Keep a list of your medications." 3. "Be alert for sudden weakness or numbness." 4. "Call 911 if you notice a gradual onset of paralysis or confusion."
Correct Answer: 3 Rationale: Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.
Of the following, which groups are the most at risk for bacterial meningitis? Select all that apply. 1. older adults 2. pregnant women 3. military recruits 4. college students 5. low-income
Correct Answer: 3,4 Rationale: Military personnel living on a base and young adults living in close proximity (such as college students living in a dormitory) are at a greater risk of contracting bacterial meningitis. The other populations are at lower risk.
A patient is placed in ventilator support with the diagnosis of botulism and failure to thrive. Which nursing actions would be most appropriate for this patient? Select all that apply. 1. maintaining intravenous fluids at KVO (keep vein open) 2. assessing bowel sounds once a shift 3. referring the patient for a physical therapy consult 4. recording the patient's ongoing calorie count 5. assessing the patient's urinary output every hour
Correct Answer: 3,4,5 Rationale: Maintaining fluids at KVO is inappropriate since this patient will be placed on NPO (nothing by mouth) status while ventilated. It is important that the patient receive adequate fluids for hydration and nutrition since nothing will be consumed by mouth. The patient's bowel sounds need to be assessed more often than once a shift (every one to two hours while in the ICU) since the patient is at risk for a paralytic ileus. Physical therapy will be beneficial for maintaining ROM (range of motion) while the patient is immobile from ventilation and sedation. The nurse must closely monitor the patient's calorie intake to determine nutritional needs while NPO. Any time a patient is on maintenance intravenous fluids urinary output must be monitored closely. Additionally, this particular patient is at risk for urinary retention.
A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which of the following? 1. impending brain death 2. decreasing intracranial pressure 3. stabilization of the patient's condition 4. increased intracranial pressure
Correct Answer: 4 Rationale: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician. This is an emergency situation that requires intervention as the patient's condition is becoming more unstable. Brain death is diagnosed by lack of brain waves and inability to maintain vital function.
A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.
Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.
Discuss the nursing measures in a bowel/bladder training program.
I&O, q2hr offer bedpan or urinal, maintain skin integrity in the perineal area, promote daily intake of 2L, but limit intake at night, high-fiber diet, offer the bedpan/urinal at the same times each day, stool softeners as ordered, increase physical mobility as tolerated (increases peristalsis)
A client with DKA is being treated in the ED. What would the nurse suspect? 1. Comatose state 2. Decreased Urine Output 3. Increased respirations and an increase in pH. 4. Elevated blood glucose level and low plasma bicarbonate level.
Correct Answer: 4 Rationale: In DKA the arteriole pH is lower than 7.35, plasma bicarbonate is lower than 15 mEq/L, the blood glucose is higher than 250, and ketones are present in the blood and urine. The client would be experiencing polyuria and Kussmauls respirations would be present. A comatose state may occur if DKA is not treated.
A client with cirrhosis of the liver develops ascites. Which of the following orders would the nurse expect? A. Restrict fluid to 1000 mL per day. B. Ambulate 100 ft. three times per day. C. High-sodium diet. D. Maalox 30 ml P.O. BID.
Correct answer: A Fluid restriction is a primary treatment for ascites. Restricting fluids decreases the amount of fluid present in the body, thereby decreasing the fluid that accumulates in the peritoneal space. A high sodium diet would increase fluid retention. Physical activities are usually restricted until ascites is relieved. Loop diuretics (such as furosemide) are usually ordered, and Maalox® (a bismuth subsalicylate) may interfere with the action of the diuretics.
The nurse is doing teaching with the family of a client with liver failure. Which of the following foods should the nurse advise them to limit in the client's diet? A. Meats and beans. B. Butter and gravies. C. Potatoes and pasta. D. Cakes and pastries.
Correct answer: A Meats and beans are high-protein foods and are restricted with liver failure. In liver failure, the liver is unable to metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted. This causes problems such as hepatic encephalopathy (neurologic syndrome that develops as a result of rising blood ammonia levels). Although other nutrients, such as fat and carbohydrates, may be regulated, it's most important to limit protein in the diet of the client with liver failure.
A client who recently underwent cranial surgery develops syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following symptoms should the nurse anticipate? A. Edema and weight gain. B. Excessive urinary output. C. Fluid loss and dehydration. D. Low urine specific gravity.
Correct answer: A Syndrome of inappropriate antidiuretic hormone (SIADH) results in an abnormally high release of antidiuretic hormone, which causes water retention as serum sodium levels fall, leading to edema and weight gain. Because of fluid retention, urine output is low. Fluid is restricted to prevent fluid overload rather than replaced. As the urine becomes more concentrated, the specific gravity increases. Other symptoms include nausea, vomiting, seizures, altered mentation, and coma. SIADH is most common with diseases of the hypothalamus but can also occur with heart failure, Guillain-Barré syndrome, meningitis, encephalitis, head trauma, or brain tumors. It may also be triggered by medications.
When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which of the following statements? A. "I should take the Celebrex as prescribed to help control the pain." B. "I should try to stay standing all day to keep my joints from becoming stiff." C. "I can use a cane if I find it helpful in relieving the pressure on my back and hip." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."
Correct answer: B. "I should try to stay standing all day to keep my joints from becoming stiff." Rationale: It is important to maintain a balance between rest and activity to prevent overstressing the joints with OA.
The nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient describes the condition as which of the following? A. Joint destruction caused by an autoimmune process B. Degeneration of articular cartilage in synovial joints C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes
Correct answer: B. Degeneration of articular cartilage in synovial joints Rationale: OA is a degeneration or breakdown of the articular cartilage in synovial joints. The condition has also been referred to as degenerative joint disease.
The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which of the following findings would the nurse expect to be present on examination of the patient's knees? A. Ulnar drift B. Pain with joint movement C. Reddened, swollen affected joints D. Stiffness that increases with movement
Correct answer: B. Pain with joint movement Rationale: OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease.
A 37-year-old forklift operator presents with shakiness, sweating, anxiety, and palpitations and tells the nurse he has type 1 diabetes mellitus. Which of the follow actions should the nurse do first? A. Inject 1 mg of glucagon subcutaneously. B. Administer 50 mL of 50% glucose I.V. C. Give 4 to 6 oz (118 to 177 mL) of orange juice. D. Give the client four to six glucose tablets.
Correct answer: C Because the client is awake and complaining of symptoms, the nurse should first give him 15 grams of carbohydrate to treat hypoglycemia. This could be 4 to 6 oz of fruit juice, five to six hard candies such as Lifesavers, or 1 tablespoon of sugar. When a client has worsening symptoms of hypoglycemia or is unconscious, treatment includes 1 mg of glucagon subcutaneously or intramuscularly, or 50 mL of 50% glucose I.V. The nurse may also give two to three glucose tablets for a hypoglycemic reaction.
A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."
Correct answer: C. "I'm hoping that surgery will be an option for me in the future." Rationale: SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.
"A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented. He has hot, dry skin and the following vital signs: a temperature of 100.6° F (38.1° C), a heart rate of 116 beats/minute, and a blood pressure of 108/70 mm Hg. Based on these findings, which nursing diagnosis takes highest priority?
Deficient fluid volume related to osmotic diuresis
The nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which of the following activity patterns? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C.A regular exercise program of walking D. Frequent rest periods with minimal exercise
Correct answer: C. A regular exercise program of walking Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis.
Teach the patient with ankylosing spondylitis the importance of a. regular exercise and maintaining proper posture b. continuing with physical activity during flare-ups c. avoiding extremes in environmental temperatures d. applying cool compresses for relief of local symptoms
Correct answer: a Rationale: Patients with ankylosing spondylitis (AS) should exercise after pain and stiffness are managed. Postural control is important to minimize spinal deformity. The exercise regimen should include back, neck, and chest stretches. The nurse should educate the patient with AS about regular exercise and attention to posture, local moist-heat applications, and knowledgeable use of drugs. The nurse should discourage excessive physical exertion during periods of active flare-up of the disease. Proper positioning at rest is essential. The mattress should be firm, and the patient should sleep on the back with a flat pillow, avoiding positions that encourage flexion deformity. Postural training emphasizes avoiding spinal flexion (e.g., leaning over a desk), heavy lifting, and prolonged walking, standing, or sitting.
When administering medications to the patient with gout, the nurse would recognize which of the following as a treatment for chronic disease? a. Colchicine b. Febuxostat c. Sulfasalazine d. Cyclosporine
Correct answer: b Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of hyperuricemia in persons with chronic gout. Acute gouty arthritis is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).
In teaching a patient with chronic fatigue syndrome (CFS) about this disorder, the nurse understands that a. palpating tender points is an indicator of CFS severity b. many symptoms are similar to fibromyalgia syndrome c. definitive treatment includes low-dose hydrocortisone d. CFS is characterized by progressive memory impairment
Correct answer: b Rationale: Fibromyalgia syndrome (FS) and chronic fatigue syndrome (CFS) have several commonalities. Both occur in previously healthy, young, and middle-aged women; the cause of both includes an infectious trigger, dysfunction of the hypothalamic-pituitary-adrenal axis or an alteration in central nervous system; and common clinical manifestations are malaise and fatigue, cognitive dysfunction, headaches, sleep disturbances, depression, anxiety, fever, and generalized musculoskeletal pain. Both diseases have symptoms that fluctuate over time, and both disorders have no definitive laboratory tests or joint and muscle examinations. They remain diagnoses of exclusion. Treatment for both disorders is symptomatic and may include antidepressant drugs. Other measures are heat, massage, regular stretching, biofeedback, stress management, and relaxation training.
Assessment data in the patient with osteoarthritis commonly include a. gradual weight loss b. elevated WBC count c. joint pain that worsens with use d. straw-colored synovial fluid
Correct answer: c Rationale: Osteoarthritis pain ranges from mild discomfort to significant disability. Joint pain is the predominant symptom, and the pain generally worsens with joint use.
In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. the production of a variety of autoantibodies directed against components of the cell nucleus
Correct answer: d Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions characteristically are directed against constituents of the cell nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune complexes containing antibody against DNA are deposited in the basement membranes of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and inflammation occurs. The overaggressive antibody response is also related to activation of B and T cells. The specific manifestations of SLE depend on which cell types or organs are involved. SLE is a type III hypersensitivity response.
In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints are damaged by (select all that apply) a. bony ankylosis following inflammation of the joints b. the deterioration of cartilage by proteolytic enzymes c. the development of Heberden's nodes in the joint capsule d.. increased cartilage and bony growth at the joint margins e. invasion of pannus into the joint causing a loss of cartilage
Correct answers: a, e Rationale: Bony ankylosis is the union of the bones of a joint by proliferation of bone cells, resulting in complete immobility. Bony ankylosis occurs with advanced rheumatoid arthritis. Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding cartilage, ligaments, tendons, and joint capsule. Pannus (i.e., highly vascular granulation tissue) forms within the joint. It eventually covers and erodes the entire surface of the articular cartilage. The production of inflammatory cytokines at the pannus-cartilage junction further contributes to cartilage destruction. The pannus scars and shortens supporting structures such as tendons and ligaments, ultimately causing joint laxity, subluxation, and contracture.
8. A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to a. delay eating the noon meal until after the swimming class. b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class. c. time the morning insulin injection so that the peak occurs while swimming. d. check glucose level before, during, and after swimming.
D Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance
When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply) a. avoiding the consumption of high-purine foods b. strategies for good dental hygiene and mouth care c. protecting the extremities from hot and cold temperatures d. maintaining joint function and preserving muscle strength e. performing mouth excursion (yawning) exercises on a daily basis
Correct answers: b, c, d, e Rationale: Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. The nurse should include the following in the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and gingival problems); protection of hands and feet from cold exposure and possible burns or cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures (they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint movement occurs); use of assistive devices as appropriate and organization of activities to preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open mouth) (helps maintain temporomandibular joint function).
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the lower left extremity, which of the following instructions should the nurse provide? (Select ALL that apply) 1 - Hold the cane on the right side. 2. Keep two points of support on the floor. 3. Place the cane 15 inches in front of the feet before advancing. 4. After advancing the cane, move the weaker leg forward. 5. Advance the stronger leg so that it aligns evenly with the cane.
Correct: 1 - Hold the cane on the right side. (hold cane on the uninjured side to provide support for injured leg) 2. Keep two points of support on the floor. (for stability) 4. After advancing the cane, move the weaker leg forward. (cane, weaker leg then stronger leg) Wrong: 3. Place the cane 15 inches in front of the feet before advancing. (s/b 6-10 inches) 5. Advance the stronger leg so that it aligns evenly with the cane. ( should advance the stronger leg past the cane)
A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select ALL that apply) A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 - 3 hours to flex and stretch joints and muscles.
Correct: A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. D. Use smooth movements when lifting and moving clients. Incorrect: C. Keep the knees slightly lower than the hips when sitting for long periods of time. Should be knees HIGHER in order to decrease strain on the lower back. E. Take a break from repetitive movements every 2 - 3 hours to flex and stretch joints and muscles. Nurses should take a break every 15-20 min
cortex, medulla
Corticoids and sex hormones are secreted from the _______ of the adrenal glands, while the catecholamines are secreted from the _________
JRA HH#1
Corticosteroids are used in the short term in low doses during exacerbations. Long term use is avoided because of side effects and their adverse effects on growth.
Discuss the nursing implications for medications ordered for patients with a spinal cord injury.
Corticosteroids: reduces damage and improves functional recovery by protecting the neuromembrane from further destruction. Monitor for increased infection rate, hyperglycemia, GI bleeding. May also use osmotic diuretics, analgesics, antacids, anticoagulants, stool softeners, vasopressors. Histamine H2-receptor antagonists (ranitidine) are used to prevent stress-related gastric ulcers. Antispasmodics: baclofen, diazepam, dantrolene. they are used to control muscle spasm and pain associated with acute or chronic musculoskeletal conditions. they are not always effective in controlling spasticity resulting from cerebral or spinal cord conditions. assess the client's spasticity and involuntary movements. give with food to decrease GI symptoms. monitor for drowsiness and dizziness.
A client presents to the emergency department with an open fracture. What is the first action the nurse should take? a) Assess the client's vital signs and determine allergies. b) Cover the exposed bone with sterile dressing. c) Perform a neurovascular assessment of the affected extremity. d) Assist the physician with reduction of the fracture.
Cover the exposed bone with sterile dressing. Explanation: The exposed bone should be covered with a sterile dressing to protect the deeper tissues from contamination.
The RN is caring for a P/T whose calcium intake must increase because of high risk factors for osteoporosis. The RN would recommend which of the following menus?
Cream of broccoli soup with whole wheat crackers and tapioca for dessert.
Although they don't know why people with hypothyroid get Coronary Artery Disease there is one interesting connection:
Cretinism is Congenital Hypothyroid - from birth - very dangerous and can lead to slowed mental and physical development if undetected.
Myxedema present at birth is known as _______. If a patient states thatt a baby doesn't ever cry, wake up, rarely eats and is the best baby in the world, how would you respond?
Cretinism. Dx w/ myxedema!
"A client is diagnosed with diabetes mellitus. Which data collection finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?
Crying whenever diabetes is mentioned
What syndrome (exogenous)/disease (endogenous) involves the body having too much steroids?
Cushing's syndrome/disease
The nurse defines ageism most accurately as: A. The undervaluing of individuals based on their age. B. Perception of a person's worth based on productivity C. Biases directed towards individuals considered aged D. Discrimination based on an individual's increasing age
D. Discrimination based on an individual's increasing age
Cortisol is another fancy name for ________ or steroids. Thus, hyperocortisolism means too many ____.
Glucocorticoids. Steroids.
A hospitalized diabetic patient receives 12 U of regular insulin mixed with 34 U of NPH insulin at 7:00 AM. The patient is away from the nursing unit for diagnostic testing at noon, when lunch trays are distributed. The most appropriate action by the nurse is to a. save the lunch tray to be provided upon the patient's return to the unit. b. call the diagnostic testing area and ask that a 5% dextrose IV be started. c. ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area. d. request that the patient be returned to the unit to eat lunch if testing will not be completed promptly.
D Rationale: Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.
A patient recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood. b. when an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products. c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic. d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones.
D Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. The other responses are inaccurate.
A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, a. "I may have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories."
D Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.
The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the a. thigh. b. buttock. c. arm. d. abdomen.
D Rationale: Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl (6.7 mmol/L). The nurse will plan to teach the patient about a. use of low doses of regular insulin. b. self-monitoring of blood glucose. c. oral hypoglycemic medications. d. maintenance of a healthy weight.
D Rationale: The patient's impaired fasting glucose indicates pre-diabetes and the patient should be counseled about LIFESTYLE CHANGES to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.
A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. The infection control nurse informs the individual that treatment for the exposure should include a. baseline hepatitis B antibody testing now and in 2 months. b. active immunization with hepatitis B vaccine. c. hepatitis B immune globulin (HBIG) injection. d. both the hepatitis B vaccine and HBIG injection.
D Rationale: The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity. Antibody testing may also be done, but this would not provide protection from the exposure.
19. A hospitalized diabetic patient receives 12 U of regular insulin mixed with 34 U of NPH insulin at 7:00 AM. The patient is away from the nursing unit for diagnostic testing at noon, when lunch trays are distributed. The most appropriate action by the nurse is to a. save the lunch tray to be provided upon the patient's return to the unit. b. call the diagnostic testing area and ask that a 5% dextrose IV be started. c. ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area. d. request that the patient be returned to the unit to eat lunch if testing will not be completed promptly.
D Rationale: Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. Cognitive Level: Analysis Text Reference: p. 1268 Nursing Process: Implementation NCLEX: Physiological Integrity
9. A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, a. "I may have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories."
D Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. Cognitive Level: Application Text Reference: p. 1268 Nursing Process: Evaluation NCLEX: Physiological Integrity
37. The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the a. thigh. b. buttock. c. arm. d. abdomen.
D Rationale: Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Implementation NCLEX: Physiological Integrity
4. A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). When teaching the patient about the reason for these lifestyle changes, the nurse will tell the patient that a. the high insulin levels associated with this syndrome damage the lining of blood vessels, leading to vascular disease. b. although the fasting plasma glucose levels do not currently indicate diabetes, the glycosylated hemoglobin will be elevated. c. the liver is producing excessive glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production. d. the onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise.
D Rationale: The patient with IFG is at risk for developing type 2 diabetes, but this risk can be decreased with lifestyle changes. Glycosylated hemoglobin levels will not be elevated in IFG and the Hb A1C test is not included in prediabetes testing. Elevated insulin levels do not cause the damage to blood vessels that can occur with IFG. The liver does not produce increased levels of glucose in IFG. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity
2. A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl (6.7 mmol/L). The nurse will plan to teach the patient about a. use of low doses of regular insulin. b. self-monitoring of blood glucose. c. oral hypoglycemic medications. d. maintenance of a healthy weight.
D Rationale: The patient's impaired fasting glucose indicates prediabetes and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Planning NCLEX: Physiological Integrity
A bowel training program includes which of the following? A) Using a diet that is low in bulk B) Decreasing fluid intake to 1000 mL C) Administering an enema once a day to stimulate peristalsis D) Allowing ample time for Evacuation
D) Allowing ample time for Evacuation For a bowel training program to be effective, the patient must have ample time for evacuation usually 20 to 30 minutes. Fluid intake is increased to 2500 to 3000 mL, food high in bulk is recommended as part of the program: and a daily enema is not administered in bowel training program. A cathartic Suppository maybe use 30 minutes before the patients usually defecation time to stimulate peristalsis
Which of the following is an appropriate nursing action to promote regular bowel habits? A) Encourage the patient to avoid moving his bowels until a certain time of day B) Encourage the patient to avoid excess fluid intake and too much fiber C) Avoid strenuous exercise to limit stress on the abdominal muscles and impair peristalsis D) Assisting the patient to a normal position as possible to defecate
D) Assisting the patient to a normal position as possible to defecate Sitting upright on a toilet or commode promotes defecation. If the patient must use a bedpan, raise the head of the bed 30 to 45°. Patient should be encouraged to move their bowels at their usual time of the day. However, the patient should not be encouraged to put off defecation if the urge arises before or after their usual time. Patient should be encouraged to consume 2000 to 3000 mL of fluid, preferably water, and increase fiber, to promote regular defecation. Regular exercise improves gastrointestinal activities and aids in defecation
As the nurse prepares to assist Mrs. P with her newly created Ileostomy, She is aware of which of the following? A) An appliance will not be required on the continual basis B) The size of the stoma stabilizes within two weeks C) Irrigation is necessary for regulation D) Fecal drainage will be liquid
D) Fecal drainage will be liquid And appliance is usually required on a continual basis because the fecal drainage is liquid. Stomas size usually stabilizes within 4 to 6 weeks, and Ileostomy Irrigation is not necessary because fecal matter is liquid
The nurse is caring for patients in the student health center. A patient confides to the nurse that the patient's boyfriend informed her that he tested positive for Hepatitis B. Which of the following responses by the nurse is BEST? a. "That must have been a real shock to you" b. "You should be tested for Hepatitis B" c. "You'll receive the Hepatitis B immune globulin HBIG d. "Have you had unprotected sex with your boyfriend"
D. Hepatitis B is transmitted through parenteral drug abuse and sexual contact. Determine exposure before implementing.
Which of the following statements accurately reflects data that the nurse should use in planning care to meet the needs of the older adult? A. 50% of older adults have two chronic health problems. B. Cancer is the most common cause of death among older adults. C. Nutritional needs for both younger and older adults are essentially the same. D. Adults older than 65 years of age are the greatest users of prescription medications.
D. Adults older than 65 years of age are the greatest users of prescription medications. Rationale: Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults
The nurse is aware that the majority of older adults: A. Live alone B. Live in institutional settings C. Are unable to care for themselves D. Are actively involved in their community
D. Are actively involved in their community
The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the majority of older adults: A. Require institutional care B. Have no social or family support C. Are unable to afford any medical treatment D. Are capable of taking charge of their own lives
D. Are capable of taking charge of their own lives
The nurse is setting up an education session with an 85-year-old patient who will be going home on anticoagulant therapy. Which strategy would reflect consideration of aging changes that may exist with this patient? A. Show a colorful video about anticoagulation therapy. B. Present all the information in one session just before discharge. C. Give the patient pamphlets about the medications to read at home. D. Develop large-print handouts that reflect the verbal information presented.
D. Develop large-print handouts that reflect the verbal information presented. Rationale: Option D addresses altered perception in two ways. First, by using visual aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear high-frequency sounds. By developing the handouts in large print, one addresses the possibility of decreased visual acuity. Option A does not allow discussion of the information; furthermore, the text and print may be small and difficult to read and understand.
When administering an enema, list the following steps in the order in which they should be performed. Label the steps from 1 to 6, with 1 being the first step to perform. A. Document the results of the procedure. B. Assess the patient for cramping. C. Insert the tubing about 3 to 4 inches into the rectum. D. Lubricate the tip of the enema tubing generously. E. Raise the container to the correct height and instill the solution at a slow rate. F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.
D. Lubricate the tip of the enema tubing generously. C. Insert the tubing about 3 to 4 inches into the rectum. E. Raise the container to the correct height and instill the solution at a slow rate. B. Assess the patient for cramping. F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema. A. Document the results of the procedure. You must lubricate the tip before inserting the tubing. You would then begin instilling the solution before assessing for cramping that the instillation might produce. Only after the solution is instilled would you ask the patient to hold the solution. The last action is to document the results of the procedure, after the procedure is finished.
What is the best resource (of those listed below) for identifying information regarding an older adult's current functional ability? A. Psychological tests and related exams B. Diagnostic x-rays and lab tests C. Family members who visit occasionally and call weekly D. Neighbor who visits daily and helps the person to the store weekly.
D. Neighbor who visits daily and helps the person to the store weekly.
You are doing some teaching with a client who is starting on a sulfonylurea antidiabetic agent. The client mentions that he usually has a couple of beers each night and takes an aspirin each day to prevent heart attack and/or strokes. Which of the following responses would be best on the part of the nurse? a. As long as you only drink two beers and take one aspirin, this should not be a problem b. The aspirin is alright but you need to give up drinking any alcoholic beverages c. Aspirin and alcohol will cause the stomach to bleed more when on a sulfonylurea drug d. Taking alcohol and/or aspirin with a sulfonylurea drug can cause development of hypoglycemia
D. Taking alcohol and/or aspirin with a sulfonylurea drug can cause development of hypoglycemia Alcohol and/or aspirin taken with a sulfonylurea can cause development of hypoglycemia.
The basic pathophysiologic process of rheumatoid arthritis (RA) is a. destruction of joint cartilage and bones by an autoimmune process b. initiated by a viral infection that destroys the synovial membranes of joints c. the presence of HLA-DR4 antigen that causes inflammatory responses throughout the body d. an immune response that activates complement and produces inflammation of joints and other organ systems
D. an immune response that activates complement and produces inflammation of joints and other organ systems
A 60-year-old woman has pain on motion in her fingers and asks the nurse whether this is just a result of aging. The best response by the nurse includes the information that a. joint pain with functional limitation is a normal change that affects all people to some extent b. joint pain that develops with age is usually related to previous trauma or infection of the joints c. this is a symptom of a systemic arthritis that eventually affects all joints as the disease progresses d. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age
D. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age.
An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: a) is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals b) continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels c) is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream d) gives a small continuously dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dose form the pump before each meal
D.) gives a small continuously dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dose form the pump before each meal An insulin pump provides a small continuous dose of regular insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Regular insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.
Prediabetes is associated with all of the following except: a. Increased risk of developing type 2 diabetes b. Impaired glucose tolerance c. Increased risk of heart disease and stroke d. Increased risk of developing type 1 diabetes
D: Increased risk of developing type 1 diabetes Persons with elevated glucose levels that do not yet meet the criteria for diabetes are considered to have prediabetes and are at increased risk of developing type 2 diabetes. Weight loss and increasing physical activity can help people with prediabetes prevent or postpone the onset of type 2 diabetes.
18. The benefits of using an insulin pump include all of the following except: "a. By continuously providing insulin they eliminate the need for injections of insulin b. They simplify management of blood sugar and often improve A1C c. They enable exercise without compensatory carbohydrate consumption d. They help with weight loss
D: Using an insulin pump has many advantages, including fewer dramatic swings in blood glucose levels, increased flexibility about diet, and improved accuracy of insulin doses and delivery; however, the use of an insulin pump has been associated with weight gain.
EYE TRAUMA
DESCRIPTION: Injury to the eye sustained as the result of sharp or blunt trauma, chemicals or heat. Permanent visual impairment can occur. Every eye injury should be considered an emergency. Protective eye shields in hazardous work environments and during athletic sports may prevent injuries. NURSING PLANS AND INTERVENTIONS:Position the client according to the type of injury; a sitting position decreases IOP. Remove conjunctival foreign bodies unless embedded. **Never attempt to remove a penetrating or embedded object. Do not apply pressure.** Apply cold compresses to eye contusion (black eye). After chemical injuries, irrigate the eye with copious amounts of water. Administer eye meds as prescribed. Explain that an eye patch may be applied to rest the eye. Reading and watching tv may be restricted for 3-5 days. Explain that a sudden increase in eye pain should be reported.
Osteoporosis
DESCRIPTION: Metabolic disease in which bone demineralization results in decreased density and subsequent fractures. Many fractures in older adults occur as result of osteoporosis and often occur prior to the client's falling rather than as the result of a fall **pathologic fracture**. The cause of osteoporosis is unknown. Postmenopausal women are at highest risk **estrogen keeps calcium in bone** NURSING ASSESSMENT: Classic dowager's hump, or kyphosis of the dorsal spine. Loss of height, often 2-3 inches. Back pain, often radiating around the trunk. Pathologic fractures, often occurring in the distal end of the radius and the upper third of the femur. Compression fracture of spine- assess ability to void and defecate. NURSING PLANS AND INTERVENTIONS: Create a hazard-free environment **safety first**. Keep bed in low position. Encourage client to wear shoes or nonskid slippers when out of bed. Encourage environmental safety: adequate lighting, keep floor clear, discourage use of throw rugs, slean spills promptly, keep side rails up at all times. Provide assistance with ambulation: client may need walker or cane. Client may need standby assistance when initially getting out of bed or chair. Teach regular exercise program. ROM exercise several times a day, ambulation several times a day, use of proper body mechanics. Provide diet that is high in protein, calcium, and vitamin D; discourage use of alcohol and caffeine. Preventive measures for females: HRT has been used as a primary prevention straegy for reducing bone loss in the postmenopausal woman. Recent studies demonstrated that HRT may increase a woman's risk of breast cancer, cardiovascular disease, and stroke. If using HRT the benefits should outweigh the risks. Take prescribed meds to prevent further loss of bone mineral density (BMD). **Bisposphonates: inhibits osteoclast-mediated bone resorption, thereby increasing BMD. Common side effects are anorexia, weight loss, and gastritis. Instruct the client to take with full glass of water, take 30 minutes before food or other meds and remain upright for at least 30 minutes after taking**. Fosamax, Bonefos, Actonel. Selective estrogen receptor modulator: to mimmic the effect of estrogen on bone by reducing bone resorption without stimulating the tissues of the breast or uterus. The most common side effects are leg cramps, hot flashes, vaginal dryness. Evista High calium and vitamin D intake beginning in early adulthood. Calcium supplementation after menopause (Tums are an excellent source of calcium). Weight-bearing exercise. Osteopenia is defined as a bone loss that is more than normal and has a T-score less than or equal to a range of -1 to -2.5 but is not yet at the level for a dx of osteoporosis.
Fracture
DESCRIPTION: Any break in the continuity of the bone. Fractures are described by the type and extent of the break. Fractures are caused by a direct blow, crushing force, a sudden twisting motion, or a disease such as cancer or osteoporosis. Comple fracture breaks across the entire cross section of the bone. Incomplete fracture breaks only part of the bone. Closed fracture there is no break in the skin. Open fracture has broken bone that protrudes theough skin or mucous membranes and are much more prone to infection. **update tetanus toxoid, prophylactic antibiotics**. NURSING ASSESSMENT:Signs and symptoms of fracture include: Pain, swelling, tenderness. Deformity, loss of functional ability. Discoloration, bleeding at the site throguh an open wound. Crepitus-crackling sound between two broken bones. Fracture is evident on radiograph. Therapeutic management is based on: reduction of the fracture. Maintenance of realignment by immobilization. **Don't dislodge hematoma**. Restoration of function. Crutches: there should be 2-3 finger widths between the axilla and the top of the crutch. A three-point gait is most common. The client advances both crutches and the impaired leg at the same time. The client then swings the uninvolved leg ahead to the crutches. Cane: It is placed on the unaffected side. The top of the cane should be at the level of the greater trochanter. Walker: Strength of upper extremity and unaffected leg is assessed and improved with exercises, if necessary so that upper body is strong enough to use walker. Client lifts and advances the walker and steps forward.
Juevenile Rheumatoid Arthritis (JRA) or Juevenille Idiopathic Arthritis (JIA)
DESCRIPTION: Chronic inflammatory disorder of the joint synovium. Single or multiple joints may be affected. It may also have a systemic presentation. It occurs between ages 2-5 and 9-12. NURSING ASSESSMENT: Joint swelling and stiffness (usually large joints). Painful joints. Generalized symptoms: fever, malaise and rash. Periods of exacerbations and remissions. Varying severity: mild and self-limited or severe and disabling. Lab data: latex fixation test (usually negative) and elevated ESR. Poorest prognosis: Positive RF and Polyarticular systemic onset. NURSING PLANS AND INTERVENTIONS: Plan home program of prescribed exercise, splinting, and activity. Assist in identifying adaptations in routine (eg. Velcro fasteners, frequent rest periods). Support the maintaining of school schedule and activites appropriate for age. Teach about med regimen: combination drugs are used. Nonsteroidal antiinflammatory drugs: aspirin, Tolmetin sodium, Ibprofen, Naproxen. Antirheumatic drugs-gold salts. corticosteroids-prednisone. Cytotoxic drugs-methotrexate. Teach child and family about side effects and toxic effects of prescribed drugs. Inform child and family that the optimum antiinflammatory effects of drugs may take a month to achieve. Encourage periodic eye exams for early detection of iridocyclitis so to prevent vision loss. encourage family to allow child's independence.
CATARACTS
DESCRIPTION: Condition characterized by opacity of the lens. Aging accounts for 95% of cataracts. The remaining 5% result from trauma, toxic substances, or systemic diseases or are congenital. Safety precatuions may reduce the incidence of traumatic cataracts. Surgical removal is done when vision impairment interferes with ADL's. Intraocular lens implants may be used. Most operations are performed under local anesthesia on an outpatient basis. NURSING ASSESSMENT:Early signs: Blurred vision and decreased color perception. Late signs include: Diplopia (double vision). Reduced visual acuity, progressing to blindness. Clouded pupil, progressing to a milky-white appearance. DX Tests: Ophthalmoscope. Slit-lamp biomicroscope. NURSING PLANS AND INTERVENTIONS: Preoperative: Demonstrate and request a return demonstration of eye medication instillation from client or family member. Develop a postop teaching plan that includes: Warning not to rub or put pressure on eye. Teach that glasses or shaded lens should be worn during waking hours. An eye shield should be worn during sleeping hours. Teach to avoid lifting objects over 15lbs, bending, straining, coughing, or any other activity that can increase IOP. Teach to use a stool softener to prevent straining at stool. Teach to avoid lying on operative side. Teach the need to keep water from getting into eye while showering or washing hair. Teach to observe and report signs of increased IOP and infection (eg. pain, changes in vital signs). *Tylenol should control postop pain.* ***S/S****
Sensorineural Hearing Loss
DESCRIPTION: Form of hearing loss in which sound passes properly through the outer and middle ear but is distorted by a defect in the inner ear. It involves perceptual loss, usually progressive and bilateral. It involves damage to the 8th cranial nerve. (vestibulocochlear). It is detected easily by the use of a tuning fork. Common causes: Infections. Ototoxic drugs-aspirin, lasix, aminoglycasides, vancomycin Trauma Neuromas Noise Aging process- presbycusis NURSING ASSESSMENT: Inability to hear a whisper from 1-2 feet away. Inability to respond if nurse covers mouth when talking, indicating that client is lip reading. Inability to hear a watch tick 5 inches from ear. Shouting in conversation. Straining to hear. Turning head to favor one ear. Answering questions incorrectly or inappropriately. Raising volume of radio or tv. NURING PLANS AND INTERVENTIONS:The nurse should do the following to enhance therapeutic communication with the hearing impaired: Prior to starting conversation, reduce distraction as much as possible. Turn the tv or radio down or off, close the door, or move to a quieter location. Devote full attention to the conversation; do not try to do two things at once. Look and listen during the conversation. Begin with casual topics, and progress to more critical issues slowly. Do not switch topics abruptly. If you do not understand, let the client know. If the client is a lip reader, face them directly. Speak slowly and distinctly; determine whether you are being understood. Allow adequate time for the conversation to take place; try to avoid hurried conversations. Use active listening techniques. Be sure to inform the health care staff of the clients hearing loss. Helpful aids may include a d telephone amplifier, earphone attachments for the radio and tv, and lights or buzzers that indicate the doorbell is ringing, located in the most commonly used rooms of the house.
Conductive Hearing Loss
DESCRIPTION: Hearing loss in which sound does not travel well to the sound organs of the inner ear. The volume of sound is less, but the sound remains clear. If volume is raised, hearing is normal. Hearing loss is the most common disability in the U.S. It usually results from cerumen impaction or middle ear disorders.
Nurse is reviewing the effects of immobility on various body systems. List at least 2 effects on respiratory system.
Decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange Stasis of secretions and decreased and weakened respiratory muscles, resulting in atelectasis and hypo-static pneumonia. Decreased cough response.
Joint Replacement (common for RF clients)
DESCRIPTION: Surgical procedure in which a mechanical device, designed to act as a joint, is used to replace a diseased joint. The most commonly replaced joints: Hip; Knee; Shoulder; Finger Accurate fitting is essential. Client must have healthy bone stock for adequate healing. Infection is the concern postoperatively. NURSING ASSESSMENT: Joint pathology: 1.Osteoarthritis 2. Rheumatoid arthritis 3. Fracture Pain not relieved by medication. Poor ROM in the affected joint. NURSING INTERVENTIONS:Provide postoperative care for wound and joint. Monitor incision site: assess for bleeding and drainage; assess suture line for erythema and edema; assess suction drainage apparatus for proper functioning; assess for signs of infection. Monitor functioning of extremity: check circulation, sensation, and movement of extremity disal to replacement; provide proper alignment of affected extremity. Client will return from the operating room with alignment for the initial postoperative period; Provide abductor appliance (hip replacement) or continuous passive motion (cpm) device if indicated; monitor I&O every shift, including suction drainage. Encourage fluid intake of 3L per day. Enourage client to perform self-care activities at maximal level. Coordinate rehabilitation: work closely with health care team to increase client's mobility gradually. Get client out of bed as soon as possible. Keep client out of bed as much as possible. Keep abductor pillow in place while client is in bed (hip replacement). Use elevated toilet seat and chairs with high seats for those who have had hip or knee replacements (prevents dislocation). Do not flex hip more than 90 degrees (hip replacement) Provide discharge planning that includes rehabilitation on an outpatient basis as prescribed.
Pediatric fractures
DESCRIPTION: Traumatic injury to bone. Fractures that occur in the epiphyseal plate (growth plate) may affect growth of the limb. ASSESSMENT: General condition: visible bone fragments. Pain, swelling, contusions. Child guarding or protecting the extremity. Possibility of being able to use fractured extremity due to intact periosteum. NURSING PLANS AND INTERVENTIONS:Obtain baseline data, and frequently perform neurovascular assessments. Report abnormal assessment promptly! Compartment syndrome may occur; it results in permanent damage to the nerves and vasculature of the injured extremity due to compression. Maintain traction if prescribed. Note bed position, type of traction, weights, pulleys, pins, pin sites, adhesive strips, ace wraps, splints and casts. Skin traction: force is applied to skin. Buck extension traction: lower extremity, legs extended, no hip flexion. Dunlop traction: two lines of pull on the arm. Russell traction: two lines of pull on the lower extremity, one perpendicular, one longitudinal. Bryant traction: both lower extremities flexed 90 degrees at hips (rarely used because extreme elevation of lower extremities causes decreased peripheral circulation). Skeletal traction: pin or wire applies pull directly to the distal bone fragment. 90 degree traction: flexion of hip and knee; lowr extremity is in a boot cast, can also be used on upper extremities. Dunlop traction may be used as skeletal traction. Maintain child in proper body alignment; restrain if necessary. Monitor for problems of immobility. Provide age-appropriate play and toys. Prepare child for cast application; use age-appropriate terms when exlpaining procedures. Provide routine cast care following application; petal cast edges. Teach home cast care to family: neurvascular assessment of casted extremity; not to get cast wet; not to place anything under cast; keep small objects, toys, and food out of cast. Teach family to modify diapering and toileting to prevent cast soilage. Teach that in the presence of a hip spica, family may use a Bradford frame under a small child to help with toileting; they must not use abduction bar to turn child. Teach to seek follow-up care with HCP.
DETACHED RETINA
DESCRIPTION:Hole or tear in, or separation of the sensory retina from, the pigmented epithelium. It can be result of increasing age, severe myopia, eye trauma, retiopathy (diabetic), cataract or glaucoma surgery, family or personal hx. Resealing is done by surgery. Cryotherapy (freezing). Photocoagulation (laser). Diathermy (heat). Scleral buckling (most often used). NURSING PLANS AND INTERVENTIONS: The client may be on bed rest. Place eye patch over affected eye. Administer meds to inhibit accommodation and constriction; cycloplegics (mydriatics and homatropine) are given to dilate pupil before surgery. Administer meds for potop pain: Tylenol, Demerol, oxycodone. If gas bubble is used, position client so bubble can rise against area to be reattached. *****S/S****
NSAIDs AKA Prostoglandin antagonists
DRUGS: Aspirin; Motrin; Indomethacin (RF, Gout); Toradol; Naproxen INDICATIONS: Used as antiinflammatory; antipyretic; analgesic; Can be used with other agents, may alternate with narcotics. ADVERSE REACTIONS: GI irritation, (slow GI bleeds shown by H&H); n/v, constipation. Elevated liver enzymes. Prolonged coagulation time; Tinnitus; thrombocytopenia; fluid retention; Nephrotoxicity; blood dyscrasias. NURSING IMPLICATIONS: 1.Teach to take with food or milk to reduce GI symptoms. 2. Therapeutic serum salicylates level 20-25 mg% 3. Teach to watch for signs of bleeding. 4. Teach to avoid alcohol. 5. Teach to observe for Tinnitus (aspirin toxicity). 6. Administer corticosteroids for severe rheumatoid arthritis. 7.NSAIDs reduce the effect of ACE inhibitors in hypertensive clients. 8. Encourage routine appointments to check liver/renal labs and CBC.
Corticosteroids:
DRUGS: Hydrocortisone; Prednisone; Dexamethasone INDICATIONS: Hormone replacement; Severe Rheumatoid Arthritis; Autoimmune disorders. *decrease the bodies inflammatory response, makes client more prone to infection but mask the signs of inflammation.* ADVERSE REACTIONS: Emotional lability, personality changes. Impaired wound healing, bruise easily. Skin fragility. Abnormal fat deposition. Hyperglycemia, bs increase. Hirsutism, moon face. Osteoporosis *remember steroids leech calcium from the bones*. NURSING IMPLICATIONS: Wean slowly (administer high dose then taper off).; careful monitoring is required during withdrawal (NO cold turkey). Monitor serum potassium (normal: 3.5-5), glucose (normal: 70-100) (can become diabetic), and sodium (normal:136-145). Weigh daily, report weight gain of more than 5lb per week *this could indicate water retention*. Administer with antiulcer drugs or food (zantac, pepsid, tagament) *ulcerogenic*. Use care to prevent injuries. Monitor bp and pulse closely, these can increase bp. *remember to replace calcium, supplement.*
Differentiate decorticate posturing; decerebrate posturing, and flaccid response.
Decorticate posture: an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type of posturing is a sign of severe damage in the brain Decerebrate posture: an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain. Flaccid response: quality of lack of tone of muscular or vascular organ or tissue.
"A 78-year-old client with type 2 diabetes needs a kidney transplant. The client's daughter volunteers to donate a kidney, but the client voices concerns about her daughter's health to the nurse. Which response by the nurse is appropriate?
I'll notify your physician of your concerns and see if he can discuss the procedures with you.
"A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should help formulate a nursing diagnosis of:
Deficient knowledge.
D
Dementia is defines as a a. syndrome that results only in memory loss b. disease associated with abrupt changes in behavior c. disease that is always due to reduced blood flow to the brain d. syndrome characterized by cognitive dysfunction and loss of memory
"A nurse is teaching a group of certified nursing assistants (CNAs) about blood glucose monitoring. Which finding indicates that the CNA understands how to use a blood glucose meter?
Demonstrating correct technique
"A client becomes upset when the physician diagnoses diabetes mellitus as the cause of his signs and symptoms. The client tells the nurse, ""This must be a mistake. No one in my family has ever had diabetes."" Based on this statement, the nurse suspects the client is using which coping mechanism?
Denial
Progestins
Depo-Prohera (shot) Primpro Megace (megestrol)-man made chemical similar to female progestron, used to treat loss of appetitie & wt loss in people with aids TX-advaced breast CA & endometrial CA
"A client with Cushing's syndrome is admitted to the medical-surgical unit. While collecting data, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem?
Depression
A client who suffers an injury in a local high school hockey game presents with left shoulder pain. The client cannot move the left arm, and the left shoulder is lower than the right shoulder. The nurse recognizes the client most likely has a: a) Clavicle fracture b) Dislocated elbow c) Dislocated shoulder d) Cervical injury
Dislocated shoulder Explanation: Clinical manifestations of a dislocated shoulder include pain, lack of motion, feeling of an empty shoulder socket, and uneven posture.
A client with anemia has been admitted to the medical-surgical unit. Which data collection findings are characteristic of iron-deficiency anemia?
Dyspnea, tachycardia, and pallor
"What insulin type can be given by IV? Select all that apply: "A. Glipizide (Glucotrol) B. Lispro (Humalog) C. NPH insulin D. Glargine (Lantus) E. Regular insulin
E) Regular insulinThe only insulin that can be given by IV is regular insulin.
Describe the adaptive equipment available for patient care.
Eating Devices • Nonskid mats to stabilize plates • Plate guards to prevent food from being pushed off plate • Wide-grip utensils to accommodate a weak grasp Bathing and Grooming Devices • Long-handled bath sponge • Grab bars, nonskid mats, handheld shower heads • Electric razors with head at 90 degrees to handle • Shower and tub seats, stationary or on wheels Toileting Aids • Raised toilet seat • Grab bars next to toilet Dressing Aids • Velcro closures • Elastic shoelaces • Long-handled shoe horn Mobility Aids • Canes, walkers, wheelchairs • Transfer devices such as transfer boards and belts
An adult with a diagnosis of hpothyroidism has been prescribed thyroid replacement therapy with levothyroxin. After 2 days, the client calls to complain that she feels no better. The nurse's response should be based on the fact that
Effect of medication are not seen or felt ofr about 3 to 5 days.
Describe postop residual lib care after amputation for the first 48 hours?
Elevate stump for first 24 hours. Do not elevate stump after 48 hours. Keep stump in extended position, and turn client to prone position three times a day to prevent flexion contracture.
Which of the following are general nursing measures for a patient with a fracture reduction? a) Promoting intake of omega-3 fatty acids b) Encourage participation in ADLs c) Examining the abdomen for enlarged liver or spleen d) Assisting with intake of immune-enhancing tube feeding formulas
Encourage participation in ADLs Explanation: General nursing measures for a patient with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the patient for self-care. Omega-3 fatty acids have no implications on the diet of a patient with a fracture reduction. The nurse should not examine the abdomen for enlarged liver or spleen since fracture reduction treatment does not affect these organs. It is unlikely that a patient with a fracture reduction will be prescribed immune-enhancing tube feeding formulas.
Discuss manifestations of autonomic dysreflexia and nursing care to prevent or relieve symptoms.
Exaggerated unopposed autonomic response to noxious stimuli for individuals with SCI at or above T6 (as low as T8). Nursing Interventions: bowel/skin care regimen, flushing catheter daily, monitor for distention, I&O, monitor VS for indicators of AD such as hypertension, pounding HA, bradycardia, blurred vision, nausea, nasal congestion, flushing and sweating above the level of injury. If AD is suspected, raise head 90 degrees to lower BP. Monitor BP q3-5min during hypertensive episode. Assess for the cause, implement measures for removing the noxious stimulus. Could be: Bladder distension, bowel constipation/impaction, skin problems (pressure, infection, injury, heat, pain, cold).
A client with human immunodeficiency virus (HIV) infection is preparing for discharge from the hospital when he complains to a nurse that he continually feels weak. How should the nurse intervene?
Explain to the client that he should schedule periods of rest throughout the day.
Glaucoma Hesi Hint #2
Eye drops are used to cause pupil constrictions **avoid mydriatics** because movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is commonly used. Caution client that vision may be blurred for 1-2 hours after administration of pilocarpine and that adaptation to dark environments is difficult because of pupillary constriction (the desired effect of the drug.)
Secondary Symptoms
Falls, UTI,Incontinence, Anxiety, Contractures, Skin Breakdown, Depression
Hyperthyroidism - (T/F) Beta-blockers can be given to asthmatics or diabetics.
False.
A client with a fracture develops compartment syndrome that requires surgical intervention. The nurse would most likely prepare the client for which of the following? a) Amputation b) Joint replacement c) Bone graft d) Fasciotomy
Fasciotomy Explanation: Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.
The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects which complication? a) Fat embolism syndrome b) Hypovolemic shock c) Reflex sympathetic dystrophy syndrome d) Compartment syndrome
Fat embolism syndrome Explanation: Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion. With compartment syndrome, the patient complains of deep, throbbing, unrelenting pain. With hypovolemic shock, the patient would have a decreased blood pressure and increased pulse rate. Clinical manifestations of reflex sympathetic dystrophy syndrome include severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.
What drugs will they put you on? what will it cause you to do? gain or loose
Fludrocortisone (florinef) which is aldosterone - notice it has "cortisone" in it - this is a steriod - aldosterone is a mineralocorticoide.. a steriod. / Will cause you to gain weight - start retaining water and sodium with aldosterone.
The nurse is caring for a client who has exophthalmos associated with the thyroid disease. What is the cause of exophthalmos?
Fluid and edema in the tissues behind the eye increases pressure.
"During a class on exercise for clients with diabetes mellitus, a client asks the nurse how often he should exercise. Which answer by the nurse is appropriate?
Follow a regular, individualized exercise plan.
The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
Following safe-sex practices
Joint Replacement Hesi Hint #3
Fractures of bone predispose the client to anemia, especially if long bones are involved. Check H&H every 3-4 days to monitor erythropoiesis. Iron can be given PO with meals. (watch for constipation)
Why are fractures of the epiphyseal plate a special concern?
Fractures of the epiphyseal plate (growth plate) may affect the growth of the limb.
Discuss nursing care for the child with ICP.
Frequent assesment of vital signs Careful assement of neurological status Maintaining patent airway Maintaing fluid and electrolyte balance Assesing for s/s of bleeding Parental education and support Elevate HOB 30 degrees, keep head still Use logrolling Nutrition ROM - Mobility Avoid vaso Vagus stimulation Monitor lab values Assess for s/s of infection
What are some causes of conductive hearing loss?
Frequent episodes of ostitis media or otosclerosis
Explain the importance of frequent neuro vital signs in the early phase of neurological injury.
Frequent vitals allows the LPN to report and changes in the vitals immediately to HCP. It also allows nurse to identify the types of interventions the patient may need.
Discuss nursing responsibilities of neurological vital signs.
Full Vital Signs Assess LOC, and orientation, if pt is unconcious use the Glascow Coma Scale Assess strength of hands grip and movement of extremities Assess pupils using PEERLA
Identify terms describing level of consciousness (LOC).
Full: alert, oriented to time place, and person, pt fully understands written and spoken words. Confusion: unable to think rapidly and clearly; easily bewildered (confused) with short attention span and poor memory. Disorientation: disorientened to time, place, and person. Obtundation: appears drowsy and lethargic; responds to verbal and tactile stimuli but quickly drifts back to sleep. Stupor: generally unresponsive; may withdraw purposefully with vigorous or painful stimuli. Coma: unarousable, does not stir or moan in response to stimuli
S&S of cholinergic crisis
GI symptoms, severe muscle weakness, vertigo, resp distress. freq pt need ventilator assistance.
The nurs is administering metformin to a client. What nursing observation would cause the nurse concern regarding side effects of the medication?
Gastrointestianal upset
Discuss components of a nutritional plan for a patient with Alzheimer's disease.
Ginko Biloba seems to improve memory. Antioxidants such as Vit-C, Vit-E, and coenzyme 10 may slow progression. Huperzine A, a traditional Chinese medicine, acts as an acetylcholinesterase inhibitor, encourage fluids and fiber.
"The nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
Glucagon
Name the signs and symptoms of Cushing's Disease according to excess glucocorticoids (hint: think of 4 main functions & picturesss) (8)/sex hormones(3)/mineralcorticoids (3).
Glucocorticoids - growth arrest, depresssion to psychoses, thin extremities/skin, hyperglycemia, moon face, truncal obesity, buffalo hump.---Sex hormones: oil skin/acne, poor sex drive (libido), women with male traits.---Mineralcorticoids: high BP, CHF, weight gain
"The adrenal cortex is responsible for producing which substances?
Glucocorticoids and androgens
"A middle-age female complains of anxiety, insomnia, weight loss, the inability to concentrate, and her eyes feeling ""gritty."" Thyroid function tests reveal the following: a thyroid-stimulating hormone (TSH) level of 0.02 units/ml, a thyroxine level of 20 g/dl, and a triiodothyronine level of 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these findings, the nurse would suspect:
Graves' disease.
Which of the following terms refers to a fracture in which one side of a bone is broken and the other side is bent? a) Avulsion b) Oblique c) Greenstick d) Spiral
Greenstick Explanation: A greenstick fracture is a fracture in which one side of a bone is broken and the other side is bent. A spiral fracture is a fracture twisting around the shaft of the bone. An avulsion is the pulling away of a fragment of bone by a ligament or tendon and its attachment. An oblique is a fracture occurring at an angle across the bone.
Explain the emergency care for a patient experiencing a CVA.
Helping to determine what kind of stroke it is, and acting appropriately. If ischemic, determine if pt is candidate for thrombolytic therapy. If hemorrhagic stroke, measures to reduce bleeding and IICP should be taken. Ischemic: (If non-thrombolytic therapy is needed) Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (eg, mannitol), maintaining the partial pres- sure of carbon dioxide (PaCO2) within the range of 30 to 35 mm Hg, and positioning to avoid hypoxia. Other treatment measures include the following: • Elevation of the head of the bed to promote venous drainage and to lower increased ICP • Possible hemicraniectomy for increased ICP from brain edema in a very large stroke • Intubation with an endotracheal tube to establish a patent airway, if necessary • Continuous hemodynamic monitoring (the goals for blood pressure remain controversial for a patient who has not received thrombolytic therapy; antihyperten- sive treatment may be withheld unless the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg) • Neurologic assessment to determine if the stroke is evolving and if other acute complications are devel- oping; such complications may include seizures, bleeding from anticoagulation, or medication- induced bradycardia, which can result in hypotension and subsequent decreases in cardiac output and cere- bral perfusion pressure During the acute phase, a neurologic flow sheet is main- tained to provide data about the following important mea- sures of the patient's clinical status: • Change in level of consciousness or responsiveness as evidenced by movement, resistance to changes of po- sition, and response to stimulation; orientation to time, place, and person • Presence or absence of voluntary or involuntary movements of the extremities; muscle tone; body pos- ture; and position of the head • Stiffness or flaccidity of the neck • Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position • Color of the face and extremities; temperature and moisture of the skin • Quality and rates of pulse and respiration; arterial blood gas values as indicated, body temperature, and arterial pressure • Ability to speak • Volume of fluids ingested or administered; volume of urine excreted each 24 hours • Presence of bleeding • Maintenance of blood pressure within the desired pa- rameters
with too many mineralocorticoids, what may you see?
High BP, CHF, Weight gain and fluid volume overload
List three of the most common joints that are replaced?
Hip, knee, finger
Insulin
Hormone produced by the pancreas which is central to regulating carbohydrate & fat metabolism in body. -Regular (rapid onset of action, short duration) begins to reduce bs with in 30 mins, peak 1-3 hours, lasts 6-8 hours. -NPH (slower onset, longer duration) onset 2 hours, peak 4-12, duration 18-26 hours. -Lantus
Thyroxine
Hormone which acts as a catalyst; influences metabolic rate, growth, and development
How do the following impact blood pressure? A. Blood pressure cuff too narrow B. Blood pressure cuff too wide C. Assessing immediately after smoking D. Assessing immediately after eating E. Assessing when the client is in mild-to-moderate pain F. Assessing when the client experiences severe pain G. Assessing immediately after exercise
How do the following impact blood pressure? A. Blood pressure cuff too narrow: False Increase B. Blood pressure cuff too wide: False Decrease C. Assessing immediately after smoking: Increase D. Assessing immediately after eating: Increase E. Assessing when the client is in mild-to-moderate pain: Increase F. Assessing when the client experiences severe pain: Increase. Eventually chronic pain modulates to decrease. G. Assessing immediately after exercise: Immediately upon stopping it is increased, but within 5 minutes decreases.
"The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
Hyperkalemia
"On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. The client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
Hypocalcemia
Hypoparathyroidism=____________=_____________
Hypocalcemia=hyperphosphatemia
Diabetes Insipidus
Hyposecretion of ADH causing polyuria, polydipsia, hypernatremia, weight loss, and dehydration
Addison's disease
Hyposecretion of adrenal cortex hormones (insufficiency of cortisol, aldosterone, and androgens)
When evaluating for hypovolemic shock, the nurse should be aware of which of the following clinical manifestations? a) Hypertension b) Bradycardia c) Bounding pulse d) Hypotension
Hypotension Explanation: The nurse should be alert to a weak pulse (thread), decreased blood pressure, decreased urine output, rapid, shallow respirations, and elevated heart rate.
"A client is taking an oral antidiabetic agent, to treat type 2 diabetes. Which statement indicates the need for further client teaching about treatment of this disease?
I often skip lunch because I don't feel hungry.
"A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands her condition and how to control it?
I should avoid becoming dehydrated and pay attention to my need to urinate, drink, or eat more than usual.
"Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
Fracture Hesi Hint #4
In clients with hip fractures, thromboembolism is the most common complication. Prevention includes passive ROM exercises, use of ted hose, elevation of the foot of the bed 25 degrees to increase venous return, and low-dose anticoagulation therapy (lovenox IM or xarelto PO). ****hip fx compare effected to unaffected side- it will be shorter and externally rotated**
RF Hesi Hint #2
In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflammation sets in. The result is deformity marked by: Immobility Pain Muscle spasm The prescribed treatment regimen is corticosteroids for the inflammation; splinting, immobilization, and rest for the joint deformity; and NSAIDS for pain.
What causes Glaucoma?
Increase in IOP r/t ocular disease
Lab results for Hyperthyroid
Increased T3 & T4 Decreased TSH
Lab results for Hypothyroid
Increased TSH Decreased T3 & T4
Patho of Glaucoma
Increased intraocular pressure resulting from inadequate drainage of aqueous humor from the canal of Schlemm or overproduction of aqueous humor
Compartment Syndrome
Increased pressure within a limited space
A 56-year-old client diagnosed with acquired immunodeficiency syndrome (AIDS) is admitted with a closed head injury after being found unconscious on the kitchen floor by her neighbor. The staff suspects domestic abuse, based on information supplied by the neighbor that the client has a restraining order against the husband, who repeatedly tries to visit the client. Which nursing action ensures client safety?
Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client.
A 33-year-old client who tested positive for the human immunodeficiency virus (HIV) is admitted to the medical unit with pancreatitis. A nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director, who says that the client is her neighbor's son. What should the nurse do to protect the client's right to privacy?
Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart.
"A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first?
Initiate fluid replacement therapy.
Safety interventions for hypoparathyroidism
Initiate seizure precautions, place a trach set at the bedside, administer ca gluconate, VS, monitor for tetany
"A client, age 23, is diagnosed with type 1 diabetes. The physician prescribes 15 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles the appropriate equipment, washes her hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?
Inject 35 units of air into the NPH vial; inject 15 units of air into the regular insulin vial and withdraw 15 units of regular insulin; and withdraw 35 units of NPH.
Avonex
Interferon Beta-1A
Betaseron
Interferon Beta-1B
Glipizide (Glucortrol)
Is an oral hypoglycemic agent administered to decrease the serum glucose level & the signs & symptoms of hyperglycemia.
Describe strategies and approaches to prevent a CVA.
Ischemic Stroke Modifiers: • Hypertension (Because HBP damages arteries throughout the body, it is critical to keep your blood pressure within acceptable ranges to protect your brain from this often disabling or fatal event.) • Atrial fibrillation • Hyperlipidemia • Diabetes mellitus (associated with accelerated atherogenesis) • Smoking • Asymptomatic carotid stenosis • Obesity • Excessive alcohol consumption Hemorrhagic Stroke Modifiers: Primary prevention of hemorrhagic stroke is the best ap- proach and includes managing hypertension and ameliorat- ing other significant risk factors. Control of hypertension, especially in people older than 55 years of age, reduces the risk of hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Stroke risk screenings provide an ideal opportunity to lower hemorrhagic stroke risk by identifying high- risk individuals or groups and educating patients and the community about recognition and prevention.
"A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse would be most accurate in stating:
It tells us about your sugar control for the last 3 months.
"While reviewing the food diary of a client with type 2 diabetes, a nurse notices that the client typically skips breakfast. Which instruction by the nurse would be helpful for this client.
It's important to maintain a stable blood sugar throughout the day. Can I help you devise a plan so you can eat breakfast each day?
A 39-year-old softball player has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would you expect the physician to perform? a) Analgesia and immobilization b) Joint manipulation and immobilization c) Heat and immobilization d) Ice and immobilization
Joint manipulation and immobilization Explanation: The physician manipulates the joint or reduces the displaced parts until they return to normal position, then immobilizes the joint with an elastic bandage, cast, or splint for several weeks.
What is the rule when monitoring the usage of mineralcorticoids, such as Fludrocortisone?
Keep weight within + or - 2 lbs of their normal weight
A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? a) Keeping a pillow between the client's legs at all times b) Maintaining the client in semi-Fowler's position c) Turning the client from side to side every 2 hours d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift
Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.
Which of the following is the most common site of joint effusion? a) Elbow b) Knee c) Hip d) Shoulder
Knee Explanation: The most common site for joint effusion is the knee. If inflammation or fluid is suspected in a joint, consultation with a provider is indicated. The elbow, hip, and shoulder are not the most common site of joint effusion.
Describe seven signs and symptoms of increased intracranial pressure.
LOC: EARLY IICP: restleness, irritability, LATE IICP: coma, no response to stimuli Pupils: EARLY IICP: equal round and reactive to light. LATE IICP: sluggish response, progressing to fixed response, pupils may dilate only on one side. Vision: EARLY IICP: decreased visual acuity, blurred vision. LATE IICP: unable to assess Motor Function: EARLY IICP: weakness in on extremity or side. LATE IICP: decorticate or decebrate posturing. Speech: EARLY IICP: difficulty speaking. LATE IICP: cannot assess due to decrease in LOC. Blood Pressure: EARLY IICP: elevated blood pressure. LATE IICP: Cushing's Triad, increased systolic BP, wideining pulse pressure, bradycardia Pulse: EARLY IICP: slighty elevated. LATE IICP: widening pulse. Respiration: EARLY IICP: rate may increase. LATE IICP: decreased respiratory rate or cheyne-stokes breathing. Temperature: EARLY IICP: may be decreased or increased. LATE IICP: significantly elevated. Other sx: EARLY IICP: headaches worse on rising in the morning and with position changes, LATE IICP: Continual headache, projectile vomitiing. Loss of pupil, corneal, gag, and swallowing reflexes.
Which of the following is a factor that inhibits fracture healing? a) Vitamin D b) Maximum bone fragment contact c) Local malignancy d) Exercise
Local malignancy Explanation: Factors that inhibit fracture healing include local malignancy, bone loss, and extensive local trauma. Factors that enhance fracture healing include proper nutrition, vitamin D, exercise, and maximum bone fragment contact.
The human body has 206 bones, which are classified into four categories. Which types of bones are located in the forearm? a) Short bones b) Irregular bones c) Long bones d) Flat bones
Long bones Explanation: Long bones are the type of bone that is located in the forearm, specifically, the ulna.
Which of the following deformity causes a exaggerated curvature of the lumbar spine? a) Lordosis b) Steppage gait c) Kyphosis d) Scoliosis
Lordosis Explanation: Lordosis is an exaggerated curvature of the lumbar spine. Scoliosis is a lateral curving deviation of the spine. Kyphosis is an increased forward curvature of the thoracic spine. Steppage gait is not a type of spinal deformity.
live attenuated vaccine
MMR vaccine is this type of vaccine
"A client with hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which instruction would be most important to include in the client's teaching plan?
Maintain a moderate exercise program.
Which is an outcome for a P/T diagnosed with osteoporosis?
Maintain independence with activities of daily living (ADLs).
Myxedema Coma Priority
Maintain patent airway
"Which intervention is the most critical for a client with myxedema coma?
Maintaining a patent airway
"For a client with Graves' disease, which nursing intervention promotes comfort?
Maintaining room temperature in the low-normal range
How can a nurse best ensure the safety of a client who has a latex allergy?
Make sure that the latex allergy is properly documented.
Explain the differences between Medicare and Medicaid reimbursement.
Medicaid: U.S government sponsored program for low-income individuals and families to pay the cost of health care. Medicaid beneficiaries are low income families and individuals. Covers a wider range than Medicare: hospitalization, x-rays, laboratory services, midwife services, clinic treatment, pediatrics care, family planning, nursing services and in-home nursing facilities for 21+ years, medical and surgical dental care. In some states Medicaid beneficiaries are required to pay the provider a small fee (co-payment) of up to $30 per month for medical services. May require payment of deductibles and co-pay for certain services provided. Program is run by individual states so the type of coverage and policies may vary between states. But generally, patients usually pay no (or very little) part of costs for covered medical expenses. Medicare: U.S government sponsored health care program for people above 65 years of age, people under 65 with certain disabilities and all people with end stage renal disease. Medicare beneficiaries are senior citizens over the age of 65, end stage renal disease, and disabled eligible to receive social security benefits. Divided in to Part A which covers hospital care, Part B which covers medical insurance and Part D covers prescription drugs. May require payment of deductibles and co-pay for certain services provided., Medicare reserves the right to refuse to pay for treatments it deems unnecessary. Small monthly premiums are required for non-hospital coverage. Federally run so the program and coverage is uniform throughout the country. Run by the Health Care Financing Administration.
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
Monitor body temperature.
Differentiate between MS, Myasthenia, and ALS.
Multiple Sclerosis (MS) starts in ages 20-50 usually, in females more than males. It is due to a demylization of the myelin sheaths of neuron cells in the CNS. Symptoms include extreme fatigue, dizziness, muscle twitching/spasms, numbness, tingling, loss of concentration, sensory and/or visual and/or speech impairment., depression. Myasthenia Gravis starts in ages 20-30 usually, and in females more than males. Autoantibodies from the thymus gland directed at acetylcholine receptor sites impair transmission of impulses across the myoneural junction. This reduces the number of receptor sites. The difference (from MS) is that M. Gravis does not affect the CNS, but instad the nerve-muscle communication point of the PNS. Symptoms include at first diplopia (double vision) and ptosis (dooping of eyelids), and often are accompanied by facial muscle weakness, speech and swallowing impairment, and generalized weakness of the muscles. It is purely a motor disorder and has no effect on sensation or coordination Amyotrophic Lateral Sclerosis (ALS) is a fatal disease of known cause. Death usually occurs as a result of infection, respiratory failure, or aspiration with an avg. time from onset of 3 years. There is a loss of motor neurons in the brain and spinal cord, which decreases function of all smooth and skeletal muscles. The muscles eventually atrophy. Symptoms depend on the location of the affected motor neurons, because spefic neurons activate specific muscle fibers Chief complaints are fatigue, progressive muscle weakness, craps, fasciculations (twitching), and incoordination.
"A client receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which life-threatening complication?
Myxedema coma
anticholinesterase/cholinesterase inhibitors
Neostigmine, ambenonium, Pryridostigmine,. enhances effects of acetylcholine at remaining skeletal muscle sites, increases muscle contractions.
Hyperthyroid s/sx:
Nervous, Weight is down, sweaty and hot, exophthamos (irreversable), attention span decreases, appetite increases, irritable, GI is fast, B/P is elevated, thyroid is bigger
"Which of the following signs and symptoms would be seen in a client experiencing hypoglycemia?
Nervousness, diaphoresis, and confusion
When joint manipulation is unsuccessful for a client, he is taken to surgery for surgical repair of his hip injury. He is brought to the ICU where you practice nursing for postoperative recovery. In addition to the regular assessments prescribed by policy, what assessment is completed every 30 minutes for several hours? a) Neurological b) Neurovascular c) Orientation d) Head-to-toe
Neurovascular Explanation: The nurse should perform neurovascular assessments every 30 minutes for several hours, and then at least every 2 to 4 hours for the next 1 or 2 days to detect complications.
is CSF helpful to dx MS?
No, elevated protien and lymphocytes, IgG are not specific to MS.
Global Aphasia
Nonfluent aphasia w/ impaired comprehension. Both Broca's and Wernicke's areas affected.
"A family member is observed looking at the blood glucose flow sheet for a client in the next bed. Which of the following actions would be an appropriate measure for the nurse to take?
Notify the charge nurse about this breach in the client's personal health information.
"A client with type 2 diabetes hasn't received insulin coverage for his afternoon blood glucose levels for 2 days. After further investigation, a nurse discovers that the afternoon blood glucose levels were phoned in from the laboratory but weren't documented in the client's medical record. What should the nurse do with this information?
Notify the physician and complete an incident report.
A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia. Good oral hygiene also is essential to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drugs falls into this category?
Phenytoin (Dilantin)
Describe the role of the nurse in the community setting.
Nurses work in diverse community settings to provide primary nursing and health care across the lifespan. Traditionally community nurses meet a continuum-of-health needs that range from the management of specific disease/s to broader community development and public health promotion needs. Health promotion and intervention consciously centre on the client who is viewed holistically; thus, care also considers the social conditions and relationships that affect an individual or a population's health status. In recent years the community nurse's role has begun to shift, directing more attention to the provision of disease recovery nursing care for transitioning clients as they move out of the hospital environment and into the community context. Additionally, the community nurse's role has become more focused on the provision of early intervention measures to prevent exacerbations or complications for clients living with chronic illness/conditions to prevent unnecessary hospital (re)admission.
"The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
Nursing Plans and Interventions: The Blind Client
On entering room, announce your presence clearly and identify yourself; address client by name. Never touch client unless he or she knows you are there. On admission, orient client thoroughly to surroundings; Demonstrate use of the call bell; Walk client around the room and acquaint them with all objects, chairs, bed, tv, telephone, ect. Guide client when walking; Walk ahead of client, and place their hand in the bend of your elbow; Describe where you are walking, note whether passageway is narrowing or you are approaching stairs, curb, or incline. Always raise side rails for newly sightless persons. Assist with meal enjoyment by describing food and its placement in terms of the face of a clock. When administering meds, inform client of number of pills and give only a half glass of water to avoid spills.
Joint replacement Hesi Hint #1
Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device usually accompanies the client to the postoperative floor. Check drainage often. **200-400 ml in a 24 hr time frame is normal**
Nurse is reviewing the effects of immobility on various body systems. List at least 2 effects on cardiovascular system.
Orthostatic hypotension Less fluid volume in the circulatory system Stasis of blood in the legs Diminished autonomic response Decreased cardiac output leading to poor cardiac effectiveness, which results in increased cardiac workload Increased oxygenation requirement Increased risk of thrombus development
Treatment for spasticity
PT= stretching, gait training, braces Muscle relaxers/ anticholergics for spastic bladder
S/S of hypoparathyroidism----Not enough ____. Serum calc is _____. Serum phos is _____. Other s/s? Tx?
PTH > Down > Up. Other s/s: patient is not sedated. Tx 1.) IV calcium 2.) phosphorus binding drugs (phoslo/calcium acetate).
The nurse is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when collecting data on the client?
Pallor, tachycardia, and a sore tongue
Treatment of Glaucoma
Parasympathomimetics (mimics parasympathetic- rest/relaxation syndrome): Pilocarpine: this drug enhances papillary constriction they are myotic drops. Adverse reactions: Bronchospasm. N/V, diarrhea. Blurred vision, twitching eyelids, eye pain with focusing. Nursing Implications: Use cautiously with pregnancy, asthma, hypertension. Teach proper drop instillation technique. Need for ongoing use of the drug at precribed intervals.*** Blurred vision tends to decrease with regular use of this drug.*** Beta-Adrenergic Receptor Blocking Agents: Timolol/ Carteolol: Inhibits formation of aqueous humor. Adverse Reactions: Side effects are insignificant. Hypotension. Nursing Implications: use cautiously with- hypersensitivity, Asthma, Second or third-degree heart block, HF, Congenital glaucoma, Pregnancy. Teach proper drop instillation technique. Need for ongoing use of the drug at prescribed intervals. Blurred vision tends to decrease with regular use of this drug. Carbonic Anhydrase Inhibitors: Diamox-PO: reduces aqueous humor production. Adverse Reactions: numbness, tingling of hands and feet. Nausea and Malaise. Nursing Implications: Administer orally or IV. Produces diuresis. Assess for metabolic acidosis. Prostaglandin Antagonists: Lumigan: lowers IOP of gluacoma by increasing outflow of aqueous humor. Adverse Reactions: Local irritation. Foreign-body sensation. Increased brown pigmentation of iris. Increased eyelash growth.
Explain the etiology of each extra-pyramidal disorder.
Parkinson's Disease: chronic progressive degenerative neurologic disease that alters motor coordination. Myasthenia Gravis: chronic autoimmune disorder. MS: chronic degenerative disease that damages the myelin sheath aurrounding the axons of the CNS Huntington's disease: progressive neurologic disease. ALS: rapidly progressive, fatal neurologic disease.
The nurse observes the client and notes a shuffling gait. The nurse recognizes this finding is consistent with: a) Lower motor neuron disease b) Scoliosis c) Parkinson's disease d) Paget's disease
Parkinson's disease Explanation: Parkinson's disease is characterized by a shuffling gait.
Differentiate kinds of seizures by types and symptoms.
Partial seizures: simple partial seizures: uncontrolled jerking movements of a finger hand, foot, leg, or the face (jacksonian march). Complete partial seizures: repititive non-purposeful actions (lip-smacking) Generalized seizures: absence seizures: blank stare, blinking of the eyes, eyelid fluttering. Tonic-clonic seizures: sudden onset, most common seizure
"A client with type 2 diabetes was diagnosed with retinopathy. While a nurse reviews the client's medication dosage, the client states, ""I can't read the names on the medicine bottles, so I hope I'm taking the right pills at the right time."" What should the nurse do with this information?
Teach the client how to tell the difference between the medicine bottles.
Examine health promotion techniques and available resources for the patient with a head injury.
Teaching prevention to avoid head injury is key.
A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. The nurse replies that the client will be able to bear weight on the cast when?
The client can bear weight within 20 to 30 minutes of application
"A nurse is prioritizing care for her four-client assignment. Which client should she attend to first?
The client who requires an insulin injection before eating breakfast
D
The clinical diagnosis of dementia is based on a. CT or MRS b. brain biopsy c. electroencephalogram d. patient history and cognitive assessment
Hearing Loss Hesi Hint #1
The ear consists of three parts: the external ear, the middle ear, and the inner ear. Inner ear disorders, or disorders of the sensory fibers going to the CNS, often are neurogenic in nature and may not be helped with a hearing aid. External and middle ear problems, (conductive) may result from infections, trauma or wax buildup. These types of disorders are treated more successfully with hearing aids.
B
The early stage of AD is characterized by a. no noticeable change in behavior b. memory problems and mild confusion c. increased time spent sleeping on or in bed. d. Incontinence, agitation, and wandering behavior
Dysmetria
The inability to control the range of a movement and the force of muscular activity.
Identify common drugs in the treatment of TIA.
The most frequently used anti-platelet medication is aspirin. Aspirin is also the least expensive treatment with the fewest potential side effects. An alternative to aspirin is the anti-platelet drug clopidogrel (Plavix). Also maybe Aggrenox, a combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce blood clotting. The way dipyridamole works is slightly different from aspirin. Ticlid is used when there is an aspirin allergy, are are used with aspirin in order to avoid clots from forming on coronary stents. Persantine is also an antiplatelet used. Anticoagulant drugs include heparin and warfarin (Coumadin). Heparin is used short term and warfarin over a longer term. These drugs require careful monitoring. If atrial fibrillation is present, may prescribe another type of anticoagulant, dabigatran (Pradaxa). Think +10 to differentiate PTT from PT. (C+O+U+M+A+D+I+N + 2. PT.) Vitamin K is the antidote for Coumadin, and Protamine is the antidote for heparin. Heparin should only be used parenterally. Lovenox is used instead of Heparin during pregnancy (does not pass the placenta) and is more long term than Heparin, although not as long-term as Coumadin unless in a LTC. It is a type of Heparin. All are used prophylactically for DVTs, PEs.
A nurse delegates the task of obtaining a blood sample to a nursing assistant trained in venipuncture. When delegating this task, the nurse should understand which delegation principle?
The nurse may delegate the task but she remains accountable for the delegated task.
"A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial data collection findings, the nurse realizes the client's risk for injury is related to:
bone demineralization resulting in pathologic fractures.
Explain the nursing care of the patient with a CVA.
The priority of care during the initial period is preserving functional brain cells and preventing acute complications. Once the client's condition is stable, problems of physical mobility, communication, sensory-perceptual deficits, bowel and urine eliminations, and swallowing present the major nursing challenges. Diags: Ineffective Tissue Perfusion: Cerebral, Risk for Ineffective Airway Clearance, Impaired Physical Mobility, Impaired Verbal Communication, Disturbed Sensory Perception, Impaired Urinary Elimination and Constipation, Impaired Swallowing, Self-Care Deficit
Amputation Hesi Hint #1
The residual limb or stump should be elevated on one pillow. If the residual limb is elevated too high, the elevation can cause a contracture.
Fracture Hesi Hint #3
The risk for the development of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli, is greatest in the first 36 hours after a fracture. It is more common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The initial symptom of a fat embolism is confusion due to hypoxemia. Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is suspected, notify the physician stat, draw blood gases, administer O2, and assist with endotracheal intubation. ****Imobilization and stabilization of the long bones can help prevent fat emboli****
A home care RN is preparing the home for a P/T who is discharges to home following a LFT side stroke. The P/T is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the P/T safety? (Select all that apply.)
The three-legged stool on wheels in the kitchen; The braided throw rugs in the entry hallway and between the bedroom and the bathroom.
"A client with type 2 diabetes tells the nurse in the clinic, ""I keep gaining weight even though I'm not eating all that much. I can't exercise anymore because of these ulcers on my feet. I don't know what to do."" What would be an appropriate response for the nurse to make to this client?
There are other types of exercise that you can do even though you have ulcers on your feet.
Glaucoma Hesi Hint #3
There is an increased incidence of glaucoma in older adult population. Older clients are prone to problems associated with constipation. Therefore, the nurse should assess these clients for constipation and postop complications associated with constipation and should implement a plan of care directed at prevention of and, if necessary, treatment for constipation. **fiber, fluids, exercise**
Sinemet
This drug is given to Parkinson's Disease patients early in the disease course. It is very effective for the management of akinetic symptoms. Tremor and rigidity may also respond to this drug. After a few years of therapy the effectiveness of sinemet wears off and other drugs are prescribed.
Discuss the etiology of seizures.
This is a disorder that involves a sudden episode of abnormal, uncontrolled dis- charge of the electrical activity of the neurons within the brain. The patient may experience a variety of symptoms depending on the type of seizure and the cause.
Myxedema is a disease which causes low ________ levels.
Thyroid (hypothyroidism).
"Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
Thyroid crisis
A client experinces a thyroid storm after removal of the throid gland. The nurse understands the cause of this complication is?
Thyroid hormones moving into the bloodstream during thyroid surgery
A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600 mg by mouth every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?
Tinnitus
This should be available at the bedside of a client who had a thyroidectomy?
Trach kit
"A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess:
Trousseau's sign.
A client with blood type B needs a blood transfusion. Which type of blood can this client receive?
Type B or type O blood
A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300 mg by mouth daily. Before initiating iron therapy, the nurse reviews the client's medical history. Which condition would contraindicate the use of ferrous sulfate?
Ulcerative colitis
Client with hyperthyroidism may experince a problem with bulging eyes. What nursing intervention is important in caring for this problem?
Use saline eye drops frequently and apply ointment to the eyes at night
The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
Use the smallest needle possible for injections.
Immobilized P/T are at risk for impaired skin integrity. Which of the following interventions would reduce the risk? (Select all that apply.")
Using an object, valid scale to assess P/T risk for pressure ulcer development; Using a device to relieve pressure when P/T is seated in chair; Teaching P/T how to shift weight at regular intervals while sitting in a chair; A good rule is: The higher the risk for skin breakdown, the shorter the interval between position changes.
DX adrenal medulla problems. A ________ acid test is a ______ hour _______ specimen test look for increased levels of ____/_____ (catecholamines). What should be done with this test?
Vanylmandelic acid test (VMA) > 24 Hour > Urine > Epi/Norepinephrine. w/ a 24 hour urine you should throw away the first voiding and keep the last voiding.
C
Vascular dementia is associated with a. transient ischemic attacks b. bacterial or viral infection of neuronal tissue c. cognitive changes secondary to cerebral eschemia d. abrupt changes in cognitive function that are irreversibe
"When caring for a client with diabetes insipidus, the nurse expects to administer:
Vasopressin (Pitressin Synthetic).
Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Volkmann's contracture b) Callus c) Subluxation d) Whiplash injury
Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client?
Volume overload
List normal findings in a neurovascular assessment.
Warm extremity, brisk capillary refill, free movement, normal sensation of the affected extremity, and equal pulses.
Identify pain-relief interventions for clients with arthritis.
Warm, moist heat (compresses, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and meds.
Cataract Pt Education
Wear sunglasses outside Smoking cessation Eliminate oral/inhaled corticosteroids
An adult client has diabetes and is beginning glipizide for glucose control. What would be important for the nurse to discuss with the client?
Wearing sunscreen and avoiding direct sunlight
"The nurse is collecting data on a client with hyperthyroidism. What findings should the nurse expect?
Weight loss, nervousness, and tachycardia
"A client who has diabetic retinopathy comes to the emergency department with injuries sustained from tripping on a lamp cord. Which of the following statements would be appropriate for the nurse to make?
When you are ready to go home, would you like a home health care nurse to come, too? She can check for things that can be done to make sure you don't fall again.
D
Which patient is most at risk for developing delirium? a. a 50 year old woman with cholecystitis b. a 19 year old man with a fractured femur c. A 42 year old woman having an elective hysterectomy d. A 78 year old man admitted to the medical unit with complications related to heart failure
Rapid Acting Insulin
With meals Humalong -onset: 15-30 mins -peak: 30-90 mins -duration: 3-5 hours
What is Kennedy's syndrome?
X-linked bulbospinal neuronopathy that has a more benign prognosis
Describe common diagnostic tests for the patient with neurological manifestations.
X-rays CT Scans MRI Cerebral angiography: contrast material is injected and an combined X-ray and fluroscopy is performed. Myelography: X-ray of spinal cord and canal after contrast media is injected. PET: radioactive agent is injected and CT measures metabolic activity of the brain. Ultrasound Carotid duplex study: sound waves identify blood flow velocity to determine the presence of occlusive vascular disease. EEG EMG: needles inserted in muscles to record electrical activity. Evoked potentials: electrodes are placed on scalp and skin to record the visual or auditory stimulus along sensory pathways
"During preoperative teaching for a client who will undergo a subtotal thyroidectomy, the nurse should include which statement?
You must avoid hyperextending your neck after surgery.
"A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?
You'll need less insulin when you exercise or reduce your food intake.
Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? "Going up, the strong leg goes first, then the weaker leg with both crutches." "Going down, the weaker leg goes first with both crutches, then the strong leg." "The weaker leg always goes first with both crutches." "A cane or single crutch may be used instead of both crutches if held on the weaker side."
Your Answer: "The weaker leg always goes first with both crutches." Rationale: Although the crutches (or cane) are always used along with the weaker leg, the weaker leg should go down the stairs first. The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation.
A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? "Using proper body mechanics will prevent you from injuring yourself." "You are physically fit and at lesser risk for injury when transferring the client." "Use the mechanical lift and another person to transfer the client from the bed to the chair." "Use the back belt to avoid hurting your back."
Your Answer: "Use the mechanical lift and another person to transfer the client from the bed to the chair." Rationale: It is prudent for nurses to understand and use proper body mechanics at all times to decrease risk, while keeping in mind the importance of assistive devices and help from other staff. While it is generally accepted that proper body mechanics alone will not prevent injury, many work settings do not yet have "no manual lift" and "no solo lift" policies and resources in place. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
The client is ambulating for the first time after surgery. The client tells the nurse, "I feel faint." Which is the best action by the nurse? Find another nurse for help. Return the client to her room as quickly as possible. Tell the client to take rapid, shallow breaths. Assist the client to a nearby chair.
Your Answer: Assist the client to a nearby chair. Rationale: Placing the client in a safe position is the best maneuver. Leaving the client creates unsafe conditions because the client may faint before being able to return to her room (options 1 and 2). Rapid, shallow breathing (hyperventilation) may increase the dizziness (option 3). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
what does HIV do
breaks down the immune system, you may lose a lot of weight, you will eventually die
To increase stability during client transfer, the nurse increases the base of support by performing which action? Leaning slightly backward. Spacing the feet farther apart. Tensing the abdominal muscles. Bending the knees.
Your Answer: Spacing the feet farther apart. Rationale: A key word in the question is base, and the feet provide this foundation. Leaning backward actually decreases balance (option 1), and tensing abdominal muscles alone (option 3) or bending the knees (option 4) does not affect the base of support. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation.
When assessing a client's gait, which does the nurse look for and encourage? The spine rotates, initiating locomotion. Gaze is slightly downward. Toes strike the ground before the heel. Arm on the same side as the swing-through foot moves forward at the same time.
Your Answer: The spine rotates, initiating locomotion. Rationale: Normal gait involves a level gaze, an initial rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment.
A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? Exercises past the point of resistance. Performs each exercise one time. Performs each series of exercises once a day. Uses the same sequence during each exercise session.
Your Answer: Uses the same sequence during each exercise session. Rationale: When the client performs the movements systematically, using the same sequence during each session, the nurse can evaluate that the teaching was understood and is successful. When performing active ROM the client should exercise to the point of slight resistance, but never past that point of resistance in order to prevent further injury (option 1). The client should perform each exercise at least three times, not just once (option 2). The client should perform each series of exercises twice daily, not just once per day (option 3). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Evaluation.
Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. Increase muscle tone and improve circulation. Increase blood pressure. Increase muscle mass and strength. Decrease heart rate and cardiac output. Maintain joint range of motion.
Your Answers: Increase muscle tone and improve circulation. Increase muscle mass and strength. Maintain joint range of motion. Rationale: Isotonic exercise increases muscle tone, mass, and strength, maintains joint flexibility, and improves circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body (option 4). Little or no change in blood pressure occurs (option 2). Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Planning.
s/sof hyperthyroidism
^ heart rate; ^circulating TH; ^ metabolic rate Caddiac output & peripheral blood flow ^ ; Lipids are depleted & glucose tolerance is decreased
Chvostek's
__________ sign is muscle spasms and twitching around mouth, throat, and cheeks associated with hypocalcemia
Trousseau's
____________ sign is when the pressure from the blood pressure cuff induces muscle spasms in distal extremities with hypocalcemia
Describe techniques to promote independence for the patient with impaired cognition.
a daily routine that they can count on, everything familiar to them has one place inside of their room, encourage as much self-care as possible, demonstrate use of equipment, modify clothing with Velcro and lay out daily clothing, encourage "finger foods" during meals.
Define neuromuscular disorder.
a disorder involving the relationship between nerves and muscles, and especially the weakening or dysfunction of muscles.
A client is admitted to the nursing unit after a l BKA following a crush injury to the foot and lower leg. The client says "I feel my left foot itching". The nurse interprets this how?
a normal response, and indicates the presence of phantom limb sensation.
Dyssynergic bladder
a problem with coordination between the bladder contraction and sphincter relaxation: results in urgency, increase in urinary frequency, hesitancy in initiating urine flow, nocturia, dribbling and incontinence
Systemic lupus erythematosus (SLE)
a progressive systemic inflammatory disease that can cause major organs and systems to fail; CT and fibrin deposits collect in blood vessels on collagen fibers and organs; deposits lead necrosis and inflammation of blood vessels, lymph nodes, GI tract and pleura
Fatigue
a sense of physical tiredness and lack of energy distinct from sadness or weakness Fatigue interferes with physical functioning
CT Scan
a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body.
Lhermitte's sign
a sign of posterior column damage in the spinal cord. Is characterized by flexion of the neck produces a sensation like an electric shock running down the spine and into the LE.
Doppler Ultrasound
a study that uses sound for detection of blood flow within the vessels; used to assess intermittent claudication, deep vein thrombosis, and other blood flow abnormalities
MRI
a technique that uses magnetic fields and radio waves to produce computer-generated images that distinguish among different types of soft tissue; allows us to see structures within the brain
"For a client with hyperthyroidism, treatment is most likely to include:
a thyroid hormone antagonist.
Which of the following factors are risks for the development of diabetes mellitus? (Select all that apply.) a. Age over 45 years b. Overweight with a waist/hip ratio >1 c. Having a consistent HDL level above 40 mg/dl d. Maintaining a sedentary lifestyle
a. Age over 45 years b. Overweight with a waist/hip ratio >1 d. Maintaining a sedentary lifestyle Aging results in reduced ability of beta cells to respond with insulin effectively. Overweight with waist/hip ratio increase is part of the metabolic syndrome of DM II. There is an increase in atherosclerosis with DM due to the metabolic syndrome and sedentary lifestyle.
Which laboratory test should a nurse anticipate a physician would order when an older person is identified as high-risk for diabetes mellitus? (Select all that apply.) a. Fasting Plasma Glucose (FPG) b. Two-hour Oral Glucose Tolerance Test (OGTT) c. Glycosylated hemoglobin (HbA1C) d. Finger stick glucose three times daily
a. Fasting Plasma Glucose (FPG) b. Two-hour Oral Glucose Tolerance Test (OGTT) When an older person is identified as high-risk for diabetes, appropriate testing would include FPG and OGTT. A FPG greater than 140 mg/dL usually indicates diabetes. The OGTT is to determine how the body responds to the ingestion of carbohydrates in a meal. HbA1C evaluates long-term glucose control. A finger stick glucose three times daily spot-checks blood glucose levels.
A patient is admitted to the hospital with a diagnosis of Cushing syndrome. On physical assessment of the patient, the nurse would expect to find a. HTN, peripheral edema, and petechiae b. weight loss, buffalo hump, and moon face with acne c. abdominal and buttock striae, truncal obesity, and hypotension d. anorexia, signs of dehydration, and hyper pigmentation of the skin
a. HTN, peripheral edema, and petechiae (rationale- The effects of glucocorticoid excess include weight gain from accumulation and redistribution of adipose tissue, sodium and water retention, glucose intolerance, protein wasting, loss of bone structure, loss of collagen, and capillary fragility. Clinical manifestations of corticosteroid deficiency include hypotension, dehydration, weight loss, and hyperpigmentation of the skin.)
After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include: a. Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection b. Nothing can be done about the concerns of odor with the appliance. c. Ordering appliances through the client's health care provider d. The appliance will not be needed when traveling.
a. Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. The remaining actions are not appropriate. There are supplies avaliable for clients to help control odor that may be incurred because of the ostomy. Although a prescription for ostomy supplies is needed, you can order the supplies from any medical supplier. Dependent on the location and trainability of the ostomy, appliances are almost always worn throughout the day and when traveling
Which of the following is accurate pertaining to physical exercise and type 1 diabetes mellitus? a. Physical exercise can slow the progression of diabetes mellitus. b. Strenuous exercise is beneficial when the blood glucose is high. c. Patients who take insulin and engage in strenuous physical exercise might experience hyperglycemia. d. Adjusting insulin regimen allows for safe participation in all forms of exercise.
a. Physical exercise can slow the progression of diabetes mellitus. Physical exercise slows the progression of diabetes mellitus, because exercise has beneficial effects on carbohydrate metabolism and insulin sensitivity. Strenuous exercise can cause retinal damage, and can cause hypoglycemia. Insulin and foods both must be adjusted to allow safe participation in exercise.
Which one of the following methods/techniques will the nurse use when giving insulin to a thin person? [Hint] A. Pinch the skin up and use a 90 degree angle B. Use a 45 degree angle with the skin pinched up C. Massage the area of injection after injecting the insulin D. Warm the skin with a warmed towel or washcloth prior to the injection
a. Pinch the skin up and use a 90 degree angle The best angle for a thin person is 90 degrees with the skin pinched up. The area is not massaged and it is not necessary to warm it.
Physician's orders for a client with acute pancreatitis include the following: strict NPO, NG tube to low intermittent suction. The nurse recognizes that these interventions will: a. Reduce the secretion of pancreatic enzymes b. Decrease the client's need for insulin c. Prevent secretion of gastric acid d. Eliminate the need for analgesia
a. Reduce the secretion of pancreatic enzymes
Radiation therapy is used to treat colon cancer before surgery for which of the following reasons? a. Reducing the size of the tumor b. Eliminating the malignant cells c. Curing the cancer d. Helping the bowel heal after surgery
a. Reducing the size of the tumor Radiation therapy is used to treat colon cancer before surgery to reduce the size of the tumor, making it easier to be resected. Radiation therapy isn't curative, can't eliminate the malignant cells (though it helps define tumor margins), can could slow postoperative healing.
Which of the following diets is most commonly associated with colon cancer? a. low fiber, high fat b. low fat high fiber c. low protein, high carb d. low carb, high protein
a. a. low fiber, high fat low fiber, high fat diet reduced motility and increases the chance of constipation. The metabolic end products of this type of diet are carcinogenic. A LOW FAT HIGH FIBER diet is recommended to help avoid colon cancer. Carbohydrates and protein aren't necessarily associated with colon cancer.
A patient newly diagnosed with Type I DM is being seen by the home health nurse. The doctors orders include: 1200 calorie ADA diet, 15 units NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the patient at 5 pm, the nurse observes the man performing blood sugar analysis. The result is 50 mg/dL. The nurse would expect the patient to be a. confused with cold, clammy skin an pulse of 110 b. lethargic with hot dry dkin and rapid deep respirations c. alert and cooperative with BP of 130/80 and respirations of 12 d. short of breath, with distended neck veins and bounding pulse of 96.
a. confused with cold, clammy skin an pulse of 110 hypoglycemia
A patient with acromegaly is treated with a transphenoidal hypophysectomy. Postoperatively, the nurse a. ensures that any clear nasal drainage is tested for glucose b. maintains the patient flat in bed to prevent cerebrospinal fluid leak c. assists the patient with toothbrushing Q4H to keep the surgical area clean d. encourages deep breathing and coughing to prevent respiratory complications
a. ensures that any clear nasal drainage is tested for glucose (Rationale- a transphenoidal hypophysectomy involves entry into the sella turcica through an incision in the upper lip and gingiva into the floor of the nose and the sphenoid sinuses. Postoperative clear nasal drainage with glucose content indicates CSF leakage from an open connection to the brain, putting the patient at risk for meningitis. After surgery, the patient is positioned with the head elevated to avoid pressure on the sella turcica, coughing and straining are avoided to prevent increased ICP and CSF leakage, and although mouth care is required Q4H toothbrushing should not be performed for 7-10post sx.)
Preoperative instructions for the patient scheduled for a subtotal thyroidectomy includes teaching the patient a. how to support the head with the hands when moving b. that coughing should due avoided to prevent pressure on the incision c. that the head and neck will need to remain immobile until the incision heals d. that any tingling around the lips or in the fingers after surgery is expected and temporary
a. how to support the head with the hands when moving (rationale- to prevent strain on the suture line postoperatively, the head must be manually supported while turning and moving in bed, but range-of-motion exercise for the head and neck are also taught preoperatively to be gradually implemented after surgery. There is no contraindication for coughing and deep breathing, and they should be carrier out postoperatively. Tingling around the lips or fingers is a sign of hypocalcemia, which may occur if the parathyroid glands are inadvertently removed during surgery, and should be reported immediately.)
During care of a patient with syndrome of inappropriate ADH (SIADH), the nurse should a. monitor neurologic status Q2H or more often if needed b. keep the head of the bed elevated to prevent ADH release c. teach the patient receiving treatment with diuretics to restrict sodium intake d. notify the physician if the patient's blood pressure decreases more than 20mmHg from baseline
a. monitor neurologic status Q2H or more often if needed Rationale- the patient with SIADH has marked dilution hyponatremia and should be monitored for decreased neurologic function and convulsions every 2 hours. ADH release is reduced by keeping the head of the bed flat to increase left atrial filling pressure, and sodium intake is supplemented because of hyponatremia and sodium loss caused by diuretics. A reduction in blood pressure indicates a reduction in total fluid volume and is an expected outcome of treatment.)
The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when a. the patient appears alert and oriented b. the patient's urinary output has increased c. pulmonary edema is reduced as evidenced by clear lung sounds d. laboratory tests reveal serum elevations of K and glucose and a decrease in sodium
a. the patient appears alert and oriented (rationale- confusion, irritability, disorientation, or depressioni s often present in the patient with Addison's dz, and a positive response to therapy would be indicated by a return to alertness and orientation. Other indication of response to therapy would be a decreased urinary output, decreased serum potassium, and increased serum sodium and glucose. The patient with Addison's would be very dehydrated and volume-depleted and would not have pulmonary edema.)
Products that may contain latex
ace bandages, adhesive/elastic bandages, ambu bag, balloons, BP cuff, catheters, condoms, diaphragms, TEDs, EKG pads, feminine hygiene pads, gloves, IV components, Levin tubes, pads for crutches, prepackaged enema kits, rubber stoppers on med vials, stethoscopes, syringes
what is Guillian-Barre syndrome
acute inflammatory demyelinating disorder of PNS, characterized by acute motor paralysis accompanied w/ paresthesias/numbness (usually ascending)
treatment for SIADH
address low sodim and intercellular swelling resrtict fluid to 1L/day for 3 to 10 days treat with demeclocycline a tetracycline antibiotic
Depression
agitation, irritability, poor memory, loss of appetite and neglect of one's appearance
Discuss the primary characteristics of extra-pyramidal disorders.
akinesia (inability to initiate movement) and akathisia (inability to remain motionless), dystonia. relating to the part of the nervous system that affects body posture and promotes smooth and uninterrupted movement of various muscle groups.
Remission
an abatement in intensity or degree (as in the manifestations of a disease)
A client who is hospitalized with scleroderma signs a document that provides instructions concerning the provision of care if he is unable to make his own treatment decisions. The document is known as:
an advance directive.
Methimazole (Tapazole)
an antithyroid treatment used for hyperthyroidism
scotoma
an isolated area of diminished vision within the visual field
what is herpes simplex 2
anal and vaginal herpes caused by contact
how is clamydia contracted
anal, oral, or vaginal sex
to treat dysphagia w/ MG
anticholinesterase 30 mins prior to meals.
how is herpes treated
antiviral medication
Discuss the common causes of a CVA.
atherosclerosis of large cerebral arteries (thrombotic) a-fib, CHF, endocarditis, rheumatic heart disease, mitral valve disease (embolic) HTN (hemorrhagic) risk factors: male, over 65 years of age, african american, hypertension, DM, obesity, a-fib, atherosclerosis, smoking, high cholesterol diet, excessive use of alcohol, cocaine/heroin, oral contraceptives. Another common cause of intracerebral hemorrhage in the elderly is cerebral amyloid angiopathy, which involves damage caused by the deposit of beta-amyloid protein in the small and medium-sized blood vessels of the brain
Goodpasture's syndrome
autoimmune d/o; autoantibodies made against glomerular basement membrane and alveolar basement membrane; primarily affects lung and kidneys
A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:
autonomy.
Educational pts after cataract surgery
avoid eye strain, avoid rubbing eyes, contact MD about decrease in vision, severe eye pain, increase in eye discharge, take measures to prevent constipation; mild itching is normal
The nurse evaluates her teaching as effective when the pt recovering from acute renal failure states that he will do which of the follwing?
avoid takng durgs that may be nephrotoxic
he goal for pre-prandial blood glucose for those with Type 1 diabetes mellitus is: a. <80 mg/dl b. < 130 mg/dl c. <180 mg/dl d. <6%
b. < 130 mg/dl
Which of the following symptoms is a client with colon cancer most likely to exhibit? a. A change in appetite b. A change in bowel habits c. An increase in body weight d. An increase in body temperature
b. A change in bowel habits The most common complaint of the client with colon cancer is a change in bowel habits. The client may have anorexia, secondary abdominal distention, or weight loss. Fever isn't associated with colon cancer.
"Polydipsia and polyuria related to diabetes mellitus are primarily due to: "a. The release of ketones from cells during fat metabolism b. Fluid shifts resulting from the osmotic effect of hyperglycemia c. Damage to the kidneys from exposure to high levels of glucose d. Changes in RBCs resulting from attachment of excessive glucose to hemoglobin
b. Fluid shifts resulting from the osmotic effect of hyperglycemia Rationale: The osmotic effect of glucose produces the manifestations of polydipsia and polyuria.
"Polydipsia and polyuria related to diabetes mellitus are primarily due to: "a. The release of ketones from cells during fat metabolism b. Fluid shifts resulting from the osmotic effect of hyperglycemia c. Damage to the kidneys from exposure to high levels of glucose d. Changes in RBCs resulting from attachment of excessive glucose to hemoglobin"
b. Fluid shifts resulting from the osmotic effect of hyperglycemia Rationale: The osmotic effect of glucose produces the manifestations of polydipsia and polyuria.
The nurse is planning dietary changes for a client following an episode of pancreatitis. Which diet is suitable for the client? a. Low calorie, low carbohydrate b. High calorie, low fat c. High protein, high fat d. Low protein, high carbohydrate
b. High calorie, low fat
While preparing the client for a colonoscopy, the nurse's responsibilities include: a. Explaining the risks and benefits of the exam b. Instructing the client about the bowel preparation prior to the test c, Instructing the client about medication that will be used to sedate the client d. Explaining the results of the exam
b. Instructing the client about the bowel preparation prior to the test The nurse is responsible for instructing the client about the bowel preparation prior to the test. Answers 1, 3, 4 are the physician's responsibility.
Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient? a. Fasting blood glucose of 130 mg/dl b. Noon blood glucose of 52 mg/dl c. Glycosylated hemoglobin of 6.9% d. Hemoglobin A1C of 5.8%
b. Noon blood glucose of 52 mg/dl The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient.
One of the benefits of Glargine (Lantus) insulin is its ability to: a. Release insulin rapidly throughout the day to help control basal glucose. b. Release insulin evenly throughout the day and control basal glucose levels. c. Simplify the dosing and better control blood glucose levels during the day. d. Cause hypoglycemia with other manifestation of other adverse reactions.
b. Release insulin evenly throughout the day and control basal glucose levels. Glargine (Lantus) insulin is designed to release insulin evenly throughout the day and control basal glucose levels.
A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The patient tells the nurse, "I hate to exercise! Can't I just follow the diet to keep my glucose under control?" The nurse teaches the patient that the major purpose of exercise for diabetics is to a. increase energy and sense of well-being, which will help with body image. b. facilitate weight loss, which will decrease peripheral insulin resistance. c. improve cardiovascular endurance, which is important for diabetics. d. set a successful pattern, which will help in making other needed changes.
b. facilitate weight loss, which will decrease peripheral insulin resistance. Rationale: Exercise is essential to decrease insulin resistance and improve blood glucose control. Increased energy, improved cardiovascular endurance, and setting a pattern of success are secondary benefits of exercise, but they are not the major reason.
S&S of TN
brief, repetitive episodes of sudden severe facial pain. pain is experienced on surface of skin. begins one side of mouth, rises towards ear, eye, or nose on same side of face. can have remissions. less likely to as you age, dull ache present between attacks.
For the diagnosis of ALS or SMA, the EMG should show changes in what 3 areas? (there's 4 total, but you need to see changes in atleast 3 areas to make the dx).
bulbar, cervical, thoracic, lumbosacral
When the patient with parathyroid disease experiences symptoms of hypocalcemia, a measure that can be used to temporarily raise serum calcium levels is to a. administer IV normal saline b. have the patient rebreathe in a paper bag c. administer Lasix as ordered d. administer oral phosphorous supplements
b. have the patient rebreathe in a paper bag (rationale- rebreathing in a paper bag promotes carbon dioxide retention in the blood, which lowers pH and creates an acidosis. An academia enhances the solubility and ionization of calcium, increasing the proportion of total body calcium available in physiologically active form and relieving the symptoms of hypocalcemia. Saline promotes calcium excretion, as does Lasix. Phosphate levels in the blood are reciprocal to calcium and an increase in phosphate promotes calcium excretion.)
An appropriate nursing intervention for the patient with hyperparathyroidism is to a. pad side rails as a seizure precaution b. increase fluid intake to 3000 to 4000ml/day c. maintain bed rest to prevent pathologic fractures d. monitor the patient for Trousseau's phenomenon or Chvostek's sign
b. increase fluid intake to 3000 to 4000ml/day (Rationale-A high fluid intake is indicated in hyperparathyroidism to dilute hypercalcemia and flush the kidneys so that calcium stone formation is reduced.)
A patient with SIADH is treated with water restriction and administration of IV fluids. The nurses evaluates that treatment has been effective when the patient experiences a. increased urine output, decreased serum sodium, and increased urine specific gravity b. increased urine output, increased serum sodium, and decreased urine specific gravity c. decreased urine output, increased serum sodium, and decreased urine specific gravity d. decreased urine output, decreased serum sodium, and increased urine specific gravity
b. increased urine output, increased serum sodium, and decreased urine specific gravity (rationale- the patient with SIADH has water retention with hyponatremia, decreased urine output and concentrated urine with high specific gravity. improvement in the patient's condition reflected by increased urine output, normalization of serum sodium, and more water in the urine, decreasing the specific gravity.)
The most important nursing intervention during the medical and surgical treatment of the patient with a pheochromocytoma is a. administering IV fluids b. monitoring blood pressure c. monitoring I&O and daily weights d. administering B-adrenergic blocking agents
b. monitoring blood pressure38 (rationale- a pheochromocytoma is a catecholamine-producing tumor of the adrenal medulla, which may cause severe, episodic HTN; severe, pounding headache; and profuse sweating. Monitoring for dangerously high BP before surgery is critical, as is monitoring for BP fluctuation during medical and surgical tx.)
A patient who is admitted with acute hepatic encephalopathy and ascites receives instructions about appropriate diet. The nurse determines that the teaching has been effective when the patient's choice of foods from the menu includes a. an omelet with cheese and mushrooms and milk. b. pancakes with butter and honey and orange juice. c. baked beans with ham, cornbread, potatoes, and coffee. d. baked chicken with french-fries, low-fiber bread, and tea.
b. pancakes with butter and honey and orange juice. B Rationale: The patient with acute hepatic encephalopathy is placed on a LOW-protein diet to decrease ammonia levels. The other choices are all higher in protein and would not be as appropriate for this patient. In addition, the patient's ascites indicate that a low-sodium diet is needed and the other choices are all high in sodium.
A patient with hypothyroidism is treated with Synthroid. When teaching the patient about the therapy, the nurse a. explains that caloric intake must be reduced when drug therapy is started b. provides written instruction for all information related to the medication therapy c. assures the patient that a return to normal function will occur with replacement therapy d. informs the patient that medications must be taken until hormone balance is reestablished
b. provides written instruction for all information related to the medication therapy (rationale- because of the mental sluggishness, inattentiveness, and memory loss that occur with hypothyroidism, it is important to provide written instructions and repeat information when teaching the patient. Caloric intake can be increased when drug therapy is started, because of an increased metabolic rate, and replacement therapy must be taken for life. Although most patients return to a normal state with treatment, cardiovascular conditions and psychoses may persist.)
When caring for a patient with nephrogenic DI, the nurse would expect treatment to include a. fluid restriction b. thiazide diuretics c. a high-sodium diet d. chlorpropamide (DIabinese)
b. thiazide diuretics (Rationale- in nephrogenic Di the kidney is unable to respond to ADH, so vasopressin or hormone analogs are not effective. Thiazide diuretics slow the glomerular filtration rate in the kidney and produce a decrease in urine output. Low-sodium diets are also thought to decrease urine output. Fluids are not restricted, because the patient could become easily dehydrated.)
"When caring for a client who's being treated for hyperthyroidism, the nurse should:
balance the client's periods of activity and rest.
"When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of foods such as:
bananas and potatoes.
Diagnosis of ALS
based on S&S and test results for other disorders were negative.
diagnosis of GB
based on S&S, history of recent infection, elevated CSF protein, EMG studies show decreased nerve conduction.
"The nurse is caring for a client who's hypoglycemic. This client will have a blood glucose level:
below 70 mg/dl.
What's the d/o that causes boluses of epi / norepi and what are they: and signs/systoms:
benign tumors - pheochromocytoma / increased B/P and increased HR and pulse
"The nurse is explaining the action of insulin to a client newly diagnosed with diabetes mellitus. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
beta cells of the pancreas.
When evaluating degenerative motor neuron diseases via biopsy, CSF, and CK... what will you see?
biopsy = chanes of denervation atrophy CSF= normal CK= slightly elevated, but not as high as in muscular dystrophies
what are examples of things to cause a yeast infection
birth control, antibiotics, illness, lack of sleep, a weak immune system, tight clothing, stress
"The nurse is working with an overweight client who has a high-stress job and smokes. This client has just received a diagnosis of Type II Diabetes and has just been started on an oral hypoglycemic agent. Which of the following goals for the client which if met, would be most likely to lead to an improvement in insulin efficiency to the point the client would no longer require oral hypoglycemic agents? "a. Comply with medication regimen 100% for 6 months b. Quit the use of any tobacco products by the end of three months c. Lose a pound a week until weight is in normal range for height and exercise 30 minutes daily d. Practice relaxation techniques for at least five minutes five times a day for at least five months"
c. Lose a pound a week until weight is in normal range for height and exercise 30 minutes daily When type II diabetics lose weight through diet and exercise they sometimes have an improvement in insulin efficiency sufficient to the degree they no longer require oral hypoglycemic agents.
During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, which nursing action will be included in the plan of care? a. Encourage the patient to cough and deep breathe. b. Insert the tube and verify its position q4hr. c. Monitor the patient for shortness of breath. d. Deflate the gastric balloon q8-12hr.
c. Monitor the patient for shortness of breath. Rationale: The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. The health care provider inserts the tube and verifies the position. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.
Mr. L. has a seven-year history of hepatic cirrhosis. He was brought to the emergency room because he began vomiting large amounts of dark-red blood. An Esophageal Balloon Tamponade tube was inserted to tamponade the bleeding esophageal varices. While the balloon tamponade is in place, the nurse caring for Mr. L. gives the highest priority to a. assessing his stools for occult blood. b. evaluating capillary refill in extremities. c. auscultating breath sounds. d. performing frequent mouth care.
c. auscultating breath sounds. Rationale: Airway obstruction and aspiration of gastric contents are potential serious complications of balloon tamponade. Frequent assessment of the client's respiratory status is the priority.
When providing discharge instructions to a patient following a subtotal thyroidectomy, the nurse advises the patient to a. never miss a daily dose of thyroid replacement therapy b. avoid regular exercise until thyroid function is normalized c. avoid eating foods such as soybeans, turnips, and rutabagas d. use warm salt water gargles several times a day to relieve throat pain
c. avoid eating foods such as soybeans, turnips, and rutabagas (Rationale- when a patient has had a subtotal thyroidectomy, thyroid replacement therapy is not given, because exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of thyroid tissue regeneration. However, the patient should avoid goitrogens, foods that inhibit thyroid, such as soybeans, turnips, rutabagas, and peanut skins. REgular exercise stimulates the thyroid gland and is encourage. Salt water gargles are used for dryness and irritation of the mouth and throat following radioactive iodine therapy.)
A patient received 6 units of REGULAR INSULIN 3 hours ago. The nurse would be MOST concerned if which of the following was observed? a. kussmaul respirations and diaphoresis b. anorexia and lethargy c. diaphoresis and trembling d. headache and polyuria
c. diaphoresis and trembling indicates hypoglycemia
A patient is admitted to the hospital in thyrotoxic crisis. On physical assessment of the patient, the nurse would expect to find a. hoarseness and laryngeal stridor b. bulging eyeballs and arrhythmias c. elevated temperature and signs of heart failure d. lethargy progressing suddenly to impairment of consciousness
c. elevated temperature and signs of heart failure (rationale- a hyperthyroid crisis results in marked manifestations of hyperthyroidism, with fever tachycardia, heart failure, shock, hyperthermia, agitation, N/V/D, delirium, and coma. Although exophthalmos may be present in the patient with Gravs' dz, it is not a significant factor in hyperthyroid crisis. Hoarsness and laryngeal stridor are characteristic of the tetany of hypoparathyroidism, and lethargy progressing to coma is characteristic of myxedema coma, a complication of hypothyroidism.
During assessment of the patient with acromegaly, the nurse would expect the patient to report a. infertility b. dry, irritated skin c. undesirable changes in appearance d. an increase in height of 2 to 3 inches per year
c. undesirable changes in appearance (Rationale- the increased production of growth hormone in acromegaly causes an increase in thickness and width of bones and enlargement of soft tissues, resulting in marked changes in facial features, oily and coarse skin, and speech difficulties. Height is not increased in adults with growth hormone excess because the epiphyses of the bones are closed, and infertility is not a common finding because growth hormone is usually the only pituitary hormone involved in acromegaly.)
Discuss functional abilities related to area of spinal cord injury.
c1-c3 = no movement or sensation below the neck; ventilator-dependent c4 = movement and sensation of head and neck; some partial function of the diaphragm c5= controls head, neck, and shoulders; flexes elbow c6 = uses shoulder, extends wrist c7-c8 = extends elbow, flexes wrist, some use of fingers T1-T5 = has full hand and finger control, full use of thoracic muscles T6-T10 = controls abdominal muscles, has good balance T11-L5 = flexes and abducts the hips; flexes and extends the knee S1-S5 = full control of legs; progressive bowel, bladder, and sexual function
glucocorticoid deficiency
causes decrease in cardiac output and vascular tone, leading to hypovolemia. pt becomes tachycardic and hypotensive and may develop shock and circulatory response.
decorticate posturing
characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex.
Scleroderma (systemic sclerosis)
chronic CT disease similar to SLE that is characterized by inflammation, fibrosis, and sclerosis; causes fibrotic changes involving the skin, synovial membranes, esophagus, heart, lungs, kidneys, GI tract; Tx directed toward forcing disease into remission
What is Myasthenia Gravis
chronic autoimmune neuromuscular disorder characterized by fatigue, weakness of skeletal muscle.
client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which of the following concepts? a) always keep insulin vials refrigerated b) ketones in the urine signify a need for less insulin c) increase the amount of insulin before unusual exercise d) systematically rotate insulin injections within one anatomic site
d) systematically rotate insulin injections within one anatomic site Insulin doses should not be adjusted nor increased before unusual exercise. If ketones are found in the urine, it possibly may indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, insulin should be administered at room temperature. Injection sites should be rotated systematically within one anatomic site.
A patient with Grave's dz asks the nurse what caused the disorder. The best response by the nurse is a. "The cause of Grave's disease is not known, although it is thought to be genetic." b. "It is usually associated with goiter formation from an iodine deficiency over a long period of time." c. "Antibodies develop against thyroid tissue and destroy it, causing a deficiency of thyroid hormones" d. "In genetically susceptible persons antibodies form that attack thyroid tissue and stimulate overproduction of thyroid hormones."
d. "In genetically susceptible persons antibodies form that attack thyroid tissue and stimulate overproduction of thyroid hormones." (rationale- The antibodies present in Graves' disease that attack thyroid tissue cause hyperplasia of the gland and stimulate TSH receptors on the thyroid and activate the production of thyroid hormones, creating hyperthyroidism. The disease is not directly genetic, but individuals appear to have a genetic susceptibility to become sensitized to develop autoimmune antibodies. Goiter formation from insufficient iodine intake is usually associated with hypothyroidism.)
When working in the community, the nurse will recommend routine screening for diabetes when the person has one or more of seven risk criteria. Which of the following persons that the nurse comes in contact with most needs to be screened for diabetes based on the seven risk criteria? a. A woman who is at 90% of standard body weight after delivering an eight-pound baby b. A middle-aged Caucasian male c. An older client who is hypotensive d. A client with an HDL cholesterol level of 40 mg/dl and a triglyceride level of 300 mg/dl
d. A client with an HDL cholesterol level of 40 mg/dl and a triglyceride level of 300 mg/dl The seven risk criteria include: greater than 120% of standard body weight, Certain races but not including Caucasian, delivery of a baby weighing more than 9 pounds or a diagnosis of gestational diabetes, hypertensive, HDL greater than 35 mg/dl or triglyceride level greater than 250 or a triglyceride level of greater than 250 mg/dl, and, lastly, impaired glucose tolerance or impaired fasting glucose on prior testing.
When taking a health history, the nurse screens for manifestations suggestive of diabetes type I. Which of the following manifestations are considered the primary manifestations of diabetes type I and would be most suggestive of diabetes type I and require follow-up investigation? "a. Excessive intake of calories, rapid weight gain, and difficulty losing weight b. Poor circulation, wound healing, and leg ulcers, c. Lack of energy, weight gain, and depression d. An increase in three areas: thirst, intake of fluids, and hunger
d. An increase in three areas: thirst, intake of fluids, and hunger "The primary manifestations of diabetes type I are polyuria (increased urine output), polydipsia (increased thirst), polyphagia (increased hunger). Excessive calorie intake, weight gain, and difficulty losing weight are common risk factors for type 2 diabetes. Poor circulation, wound healing and leg ulcers are signs of chronic diabetes. Lack of energy, weight gain and depression are not necessarily indicative of any type of diabetes."
A client with a dx of DKA is being treated in an ED. Which finding would a nurse expect to note as confirming this dx?
d. Elevated blood glucose level and low plasma bicarbonate level
The nurse working in the physician's office is reviewing lab results on the clients seen that day. One of the clients who has classic diabetic symptoms had an eight-hour fasting plasma glucose test done. The nurse realizes that diagnostic criteria developed by the American Diabetes Association for diabetes include classic diabetic symptoms plus which of the following fasting plasma glucose levels? a. Greater than 106 mg/dl b. Greater than 126 mg/dl c. Higher than 140 mg/dl d. Higher than 160 mg/dl
d. Higher than 160 mg/dl
A frail elderly patient with a diagnosis of type 2 diabetes mellitus has been ill with pneumonia. The client's intake has been very poor, and she is admitted to the hospital for observation and management as needed. What is the most likely problem with this patient? a. Insulin resistance has developed. b. Diabetic ketoacidosis is occurring. c. Hypoglycemia unawareness is developing. d. Hyperglycemic hyperosmolar non-ketotic coma
d. Hyperglycemic hyperosmolar non-ketotic coma Illness, especially with the frail elderly patient whose appetite is poor, can result in dehydration and HHNC. Insulin resistance usually is indicated by a daily insulin requirement of 200 units or more. Diabetic ketoacidosis, an acute metabolic condition, usually is caused by absent or markedly decreased amounts of insulin.
A patient suspected of having acromegaly has an elevated plasma growth hormone level. In acromegaly, the nurse would also expect the patient's diagnostic results to include a. hyperinsulinemia b. a plasma glucose of less than 70 c. decreased growth hormone levels with an oral glucose challenge test d. a serum sometomedin C (insulin-like growth-factor) of more than 300
d. a serum somatomedin C (Insulin-like-growth-factor) of more than 300 (rationale- a normal response to growth hormone secretion is stimulation of the liver to produce somatomedin C which stimulates growth of bones and soft tissue. The increased levels of somatomedin C normally inhibit growth hormone, but in acromegaly the pituitary gland secretes GH despite elevated somatomedin C levels.)
Causes of primary hypothyroidism in adults include a. malignant or benign thyroid nodules b. surgical removal or failure of the pituitary gland c. surgical removal or radiation of thyroid gland d. autoimmune-induced atrophy of the gland
d. autoimmune-induced atrophy of the gland (rationale- both Graves disease and Hasimotos thyroiditis are autoimmune disorders that eventually destroy the thyroid gland, leading to primary hypothyroidism. Thyroid tumors most often result in hyperthyroidism. Secondary hypothyroidism occurs as a result of pituitary failure, and iatrogenic hypothyroidism results from thyroidectomy or radiation of the thyroid gland.)
A nurse is checking the casted extremity of a client. The nurse would check for which of the following signs and symptoms indicative of infection 1.edema 2. no distal pulses 3.hot spot on the cast
hot spot on the cast which are areas of the cast that are warmer than others
A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to a. delay eating the noon meal until after the swimming class. b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class. c. time the morning insulin injection so that the peak occurs while swimming. d. check glucose level before, during, and after swimming.
d. check glucose level before, during, and after swimming. Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.
Physical changes of hypothyroidism that must be monitored when replacement therapy is started include a. achlorhydria and constipation b. slowed mental processes and lethargy c. anemia and increased capillary fragility d. decreased cardiac contractility and coronary atherosclerosis
d. decreased cardiac contractility and coronary atherosclerosis (rationale- hypothyroidism affects the heart in many ways, causing cardiomyopathy, coronary atherosclerosis, bradycardia, pericardial effusions, and weakened cardiac contractility. when thyroid replacement therapy is started, myocardial oxygen consumption is increased and the resultant oxygen demand may cause angina, cardiac arrhythmias, and heart failures. It is important to monitor patients with compromised cardiac status when starting replacement therapy.)
When lactulose (Cephulac) 30 ml QID is ordered for a patient with advanced cirrhosis, the patient complains that it causes diarrhea. The nurse explains to the patient that it is still important to take the drug because the lactulose will a. promote fluid loss. b. prevent constipation. c. prevent gastrointestinal (GI) bleeding. d. improve nervous system function.
d. improve nervous system function. Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although the medication may promote fluid loss through the stool, prevent constipation, and prevent bearing down during bowel movements (which could lead to esophageal bleeding), the medication is not ordered for these purposes for this patient.
In a patient with central diabetes insipidus, administration of aqueous vasopressin during a water deprivation test will result in a a. decrease in body weight b. increase in urinary output c. decrease in blood pressure d. increase in urine osmolality
d. increase in urine osmolality (rationale- a patient with DI has a deficiency of ADH with excessive loss of water from the kidney, hypovolemia, hypernatreamia, and dilute urine with a low specific gravity. When vasopressin is administered, the symptoms are reversed, with water retention, decreased urinary output that increases urine osmolality, and an increase in blood pressure.)
Colon cancer is most closely associated with which of the following conditions? a. appendicitis b. hemorroids c. hiatal hernia d. ulcerative colitis
d. ulcerative colitis Chronic ulcerative colitis, granulomas, and familial polyps seem to increase a person's chance of developing colon cancer. The other conditions listed have no known effect on the colon cancer risk.
The dawn phenomenon results from a _______ in tissue sensitivity to __________ that occurs between ___-___am (pre-breakfast hyperglycemia); caused by a release of nocturnal growth hormones. TX: give _______-______ insulin at 10pm.
decrease > insulin > 5-8am > intermediate-acting
Immunomodulators SE
decreased ANC, increase liver enzymes, anxiety, confusion, depression, increase suicide. flu-like symptoms,
Cellular response
delayed response; protects agains slow growing bacteria; involved in autoimmune response, allergic run, and rejection of foreign cells
Describe s&s of a spinal cord injury.
depends on the location of the injury and other unique factors. general complications include hypotonia, autonomic dysreflexia, spinal shock, orthostatic hypotension, bradycardia, DVT, pressure ulcers, pain, limited chest expansion, pneumonia, stress ulcers GI, urinary incontinence, neurogenic bladder, UTIs, impotence, decreased vaginal lubrication, join contractures, muscle spasms, muscle atrophy, pathologic fractures, hypercalcemia spinal shock: temporary loss of reflex activity below the level of spinal cord injury, this usually happens 30-60 min after a complete SCI. There is loss of motor function, sensation, spinal reflexes, and autonomic function. other manifestations include bradycardia, hypotension, loss of sweating and temp control, bowel/bladder dysfunction, flaccid paralysis, loss of ability to perspire. could last from days to months before reflex activity returns. within the first year of injury even, the patient is at risk for spinal shock whenever they are moved.
patho of MS
destruction of myelin sheath (plaques) around axons in nervous cells, disrupting/ distorting the conduction of electrical impulses. Only nerves in CNS affected, no peripheral nerves. Early= inflammation/edema around plaques. Later in disease= scarring of glia and degeneration of axon
The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for:
diarrhea
Risk factors associated with osteoporosis
diet low in calcium sedentary lifestyle cigarette smoking long term alcohol assumption chronic illness longe term use of anticonvulsants and furosemide (Lasix)
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
diphenhydramine hydrochloride (Benadryl)
inactivated or killed vaccines
diptheria, pertussis, and tetanus (DTaP) are considered this type of vaccine that produces a weaker response and require regular boosters
polio
disease caused by a virus that affects CNS through mouth causing paralysis respiratory complications and death
Primary-progressive MS
disease progression occurs from the onset either without remissions or with occasional plateaus and temporary improvement
3-11 months
how long can pt. wait to receive immune serum globulin or blood products after varicella vaccine
Discuss the nursing care for a patient experiencing increased intracranial presure.
drugs - osmotic/loop diuretics, elevate HOB 30 degrees, midline position, o2 as ordered, avoid hip flexion and abdominal distention (stool softeners as ordered), monitor temp q2hrs for hyperthermia (no rectal temps), reduce stimulation of environment, turn client gently, limit fluid over 24hr period. barbiturates is used to induce coma, reduces (glucose) metabolism to decrease continued damage to the brain surgical interventions include burr holes (to evacuate hematoma or remove blood clot), craniotomy (relieves pressure of brain tumor), and a brain flap may be removed (to allow room for the brain to expand). post-op care is important, especially relating to IICP and respiratory function. For Head Injuries: tetanus immunization status should be checked and updated, especially when lacerations or contaminated wounds are present. Anticonvulsants may be needed to control or provide prophylaxis for seizure activity. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for minor pain control. Beta-blockers can be prescribed for patients with trauma-induced migraines. hypotension is a indicative of morbidity
Early S&S of ALS
dysfunction of upper motor neurons= spastic weak muscles w/ increased deep tendon reflexes. dysfunction of lower motor neurons= muscle flaccidity, weakness, paralysis, atrophy. slurred speech.
A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which the followin as a high-risk area for pressure and breakdown
elbows if they are used for repositioning instead of trapeze, heel of good leg whih is used as a brace when pushing up in bed. ischial tuberosity, popliteal space, and schilles tendon
A nurse is assigned to care for a client with multiple trauma who is admitted to the hospital. The client has a leg fracture, and a plaster cast had been applied. In positioning the casted leg , the nurse should do what
elevate the leg on pillow continuously for 24-48 hours
Discuss nursing care to promote independence with ADL's.
encourage the client to use the unaffected arm, teach family/client to put clothing on the affected extremity first and then dress the unaffected extremity, consult with occupational therapist to teach the client how to use assistive devices for eating, hygiene, and dressing.
anaphylaxis interventions
estab. patent airway; prep for admin of epinephrine, benadryl, or corticosteroids; control shock; emotional support; teach pt how to use EpiPen for future rxn
How can you detect small lesions?
evoked potentials.
Emotional Lability
excessive emotional reposnisveness characterized by unstable and rapidly changing emotions
In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
extent of immune system damage.
Immune deficiency: data Collection
factors that decrease immune fxn; frequent infections; nutritional status; med hx (corticosteroid long-term use); hx of alcohol or drug abuse
spinal muscular atrophies are... and what chromosome is effected?
familial *chromosome 5.
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
fat.
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:
fluid replacement.
Nursing dx with addson's?
fluid volume deficit
pemphigus data collection
fragile, flaccid bullae lesions; partial thickness wounds that bleed, weep, and form crusts when bullae are disrupted; debilitation, malaise, pain; chewing/swallowing difficulties; leukocytosis, eosinophilia, foul-smelling discharge from skin
MS Problems w/ GU system
freq UTIs, urinary retention, incontinence, impotence. May have spastic bladder= anticholinergics May have flaccid bladder= cholinergics
MS Probs w/ Resp system
freq infections r/t inability to cough, move secretions, breath deeply
HD diagnosis made how?
genetic testing.
The adrenal cortex secretes which hormones:
glucocorticoids, mineralocorticoids and sex hormones
what could you have in the urine of a cushings pt?
glucose and keytones - remember the keytones are made by the breaking down of protein and fat... we have lots of glucocorticoids.
what two weird growth problems might you see symptoms of with too many glucocorticoids with cushings?
growth arrest and thin extremities / skin (lipolysis)
plasmapheresis for GB
helps if given during first 2 weeks of onset. Removes antibiodies and given immunosuppressive meds at same time.
which STD involves a cluster of blisters
herpes
AIDS high risk groups
heterosexual/homosexual contact with high-risk individuals; IV drug abusers; People receiving blood products; health care workers; babies born to infected mothers
With Addison's, there's a problem with what gland: / you think not enough steriods, shock and high potassium? what thoughts do you have about how shock could be an outcome?
with addisons.. it's a problem with the adrenal cortex and there's not enough steroids (the glucocorticoids, sex hormones and mineralocorticoids - these are aldosterone which normal hold water and sodium and get rid of potassium... but we are now getting rid of water and soduim and keeping the potassium. The lack of fluid - dehydration and with dehydration or fluid deficit, always come worst case senario = shock.
hypethyroidism
wt loss, nervousness, tachycardia, exopthalmos, diaphoresis, fever and diarrhea
can you get trich again
yes
diagnosis for pheochromocytoma:
you do a VMA / no vanilla for a week and take it easy. Don't want to release any epi/norepi that you don't have to, so you can see if it comes from a tumor or not.
Why would you need to avoid infection with cushings?
you have too many steriods. glucocorticoids are immunosuppressors... they and antiinflammatory.
client is to begin drug for osteomyelitis: what is included in educating client?
you will need to undergo treatment with iv antibiotics for several weeks
Discuss alternative communication methods with an aphasic patient.
• Face the patient and establish eye contact. • Speak in a normal manner and tone. • Use short phrases, "yes" and "no" questions, and pause between phrases to allow the patient time to understand what is being said. • Limit conversation to practical and concrete matters. • Use gestures, pictures, objects, and writing. • As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. • Be consistent in using the same words and gestures each time you give instructions or ask a question. • Keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. • Ask them to nod the head or blink their eyes, provide pad and pencil, magic slate, flash cards, computerized talking board, and/or pictures boards to help with communication.
Pseudobulbar Palsy
•Bilateral involvement of motor cranial nerves •Similar presentation to Progressive Bulbar Palsy in terms of symptoms •Exam: tongue is spastic and contracted, cannot move quickly from side to side •Upper motor neuron dysfunction •"Pseudobulbar affect" - uncontrollable and inappropriate laughing or crying
What do you know about neuromyelitis optica (Devic disease)?
•Characterized by optic neuritis and acute myelitis with MRI changes that involve at least three segments of the spinal cord (brain MRI usually does not show white matter involvement but if present it does not rule out this dx) •Isolated myelitis or optic neuritis may occur •Specific antibody marker (NMO-IgG) •Treatment is long-term immunosupression
Facts about MS
•Common neurologic disorder •Likely autoimmune; Genetic susceptibility •More common in Western-European descent who live in temperate zones (unheard of in the tropics, but they have more parasites) •Focal, often perivenular lesions of demyelination with reactive gliosis are found in the white matter of the brain, spinal cord and optic nerves •Axonal damage
Subacute combined degeneration of the spinal cord
•Due to vitamin B12 deficiency (pernicious anemia, megaloblastic anemia) •Predominant pyramidal and posterior column deficits plus -Polyneuropathy -Mental changes -Optic neuropathy •Treatment is with vitamin B12 100mg IM daily x 1 week, weekly for 1 month, then monthly forever
Amyotrophic Lateral Sclerosis
•Mixed upper and motor neuron deficit in the limbs •Sometimes there is cognitive decline (fronto-temporal dementia) •Also associated with pseudobulbar affect or parkinsonism •Progressive - fatal within 3-5 years •Patients with bulbar involvement have poor prognosis
Evaluating degenerative motor neuron diseases via NCS you will see:
•Motor conduction is usually normal or slightly reduced •Sensory conduction is normal
Myelopathy of HTLV-1
•Myelopathy develops in some infected pts after an initial latency period of several years •MRI, CSF, EP findings may mimic MS •Differentiated from MS by the presence of HTLV-1 antibodies in blood and CSF •Treatment with oral corticosteroids may be helpful •Prevention of transmission
HIV myelopathy
•Presents as weakness in the legs and incontinence •Spastic paresis and sensory ataxia are seen on physical exam •Late manifestation •Most pts have associated HIV encephalopathy •Diagnosis of exclusion •LP to ruleout CMV polyneuropathy •MRI to exclude epidural lymphoma
types of degenerative motor neuron diseases
•Progressive Bulbar Palsy •Pseudobulbar Palsy •Progressive Spinal muscle atrophy •Primary Lateral Sclerosis •Amyotrophy Lateral Sclerosis
Non-pharmacologic types of Tx for degenerative motor neuron diseases?
•Treatment -Physical therapy - exercise of facial muscles -Braces or walker -Portable suction •Feeding tube gastrostomy •Cricopharyngomyotomy •Tracheostomy •Palliative care