CAT Assessments (Week 6 + 7)

A nurse is teaching a client who was recently diagnosed w/ Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching?

"I should not smoke"

What is 'charting by exception'?

- a system of documentation of abnormal or significant findings only

What is the therapeutic effect of tamoxifen?

- anti-estrogen - suppression of tumor growth - reduced incidence of breast cancer in high-risk patients

Foods that are high in fiber

- black beans - whole grain bed

What are clients at risk for when taking clopidogrel?

- bleeding - postoperative complications (hemorrhage) (Clopidrogel is an antiplatelet agent)

Sildenafil citrate - contraindication?

- current use of isosorbide to treat HF - sildenafil treats erectile dysfunction - taking it concurrently with nitrates can cause life-threatening hypotension

What is nephrotic syndrome? what are common lab findings?

- damage to the kidney - cholesterol levels are often elevated (greater than 200)

what foods are iron rich?

- meat - fish - poultry - dried beans - peas

Treatment measures for a newborn w/ plagiocephaly?

- place the prescribe helmet on your baby's head for 23 hrs a day - the helmet decreases the pressure on the affected side of the skull

Hearing Aid Care

- remove detachable earmolds from the receiver and clean w/ soap and water - whistling sound indicates that the batteries are functioning - turn volume down - never insert a cotton applicator, toothpick, or bobby pins into the ear canal to remove cerumen

3 yr old findings that should be reported to the provider?

- the child cannot walk on tiptoe - child should be able to take a few steps on tiptoe by 30 months

Doxazosin - what does it treat? what are adverse effects?

- treats hypertension and BPH - advere effect: hypotension

Tricyclic antidepressants. What adverse effect should the nurse report to the client's provider?

- urinary retention

Raloxifene - what does it treat? what are adverse effect?

- used for prevention and treatment of osteoporosis in postmenopausal women - jaw pain

Normal Phenytoin Levels for a child:

10-20 Phenytoin is given for epilepsy.

Where is McBurney's point located?

2/3 of the distance from the umbilicous to the right anterior superior iliac spine. Right lower quadrant.

Normal aPTT range

25-30 seconds - measures the time it takes for blood to clot

Prioritize

A client who has HF and is receiving 100% o2 via partial rebreather mask - important to prioritize the REBREATHER mask - important to make sure it inflates properly. - oxygen is a gase that can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.

Prioritize

A client who has epigastric and L arm pain is diaphoretic: - signs of myocardial infarction - should be prioritized!

An unvaccinated health care worker has been exposed to hepatitis B through a needle stick. which of the following should the nurse anticipate administering as post-exposure prophylaxis? a. Hep B immune globulin B. Hep B vaccine and help B immune globulin c. Hep B surface antigen d. Amphotericin B

B. Hep B vaccine and help B immune globulin

What should patients taking digoxin avoid?

Black licorice - may increase the risk of hypokalemia -> arrhythmias

What are methylxanthines used for? What are examples of the medications?

Bronchospasms, Asthma, COPD - Theophylline - Aminophylline

What cranial nerve is the nurse assessing by asking the client to stick out their tongue?

Cranial Nerve XII (12) The hypoglossal nerve controls the movements of the tongue, including protrusion and side-to-side movements.

Apraxia

Difficulty with skilled movements even when a person has the ability and desire to do them.

What is a complication of spinal anesthesia/epidural for pregnant women?

HYPOtension

Which cranial nerves are associated with movement of eyes?

III, IV, VI

Preventing mastitis

Look up

Prescription for opioid withdrawal?

Methadone

Client with PVC - what QRS change should the nurse expect to see on the client's ECG?

Much greater amplitude than the usual QRS complexes

A nurse is caring for a client who has been in the PACU for more than 1 hr, has a RR of 9/min, and is difficult to arouse. Which medication should the nurse expect a prescription for?

Nalaxone - reverses respiratory depression, sedation, and analgesia opiates cause.

Amphotericin B - what is an adverse effect?

Nephrotoxicity - Amphotericin B is an antifungal medication - nephrotoxicity is rapid deterioration in the kidney function due to toxic effect of medications and chemicals - monitor the client's creatinine every 3-4 days and increase fluid intake

Which action should the nurse take to assess for the presence of Turner's sign?

Observe for the presence of ecchymosis on the client's flank. Cullen's sign is around the umbilicus.

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. which action should the nurse include in the client's plan of care?

Offer the client a bedpan every 2 hours.

A client brought to ED - reported heroin overdose. Which following finding should the nurse expect to assess?

Pinpoint pupils - s/s of opioid withdrawal

Expected finding in client with celiac disease?

Steatorrhea - foul, fatty, frothy stools

Asthma medications that are incompatible.

Theophylline and Zileuton - Zileuton impairs the metabolism of certain medications - can cause toxicity due to elevated theophylline

What is a midline catheter and what is it used for?

This catheter is used for longer-term IV fluids and is less irritating to the veins than a regular IV.

What is reaction formation?

a defense mechanism to manage the individual's response to anxiety and stress by demonstrating a behavior opposite to the client's feelings

Stage of Parkinson's Disease: Unilateral involvement. a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

a. Stage 1

Which of the following findings should be assigned an APGAR value of 2? a. a strong cry b. legs and arms slightly flexed c. body pink and extremities blue d. a heart rate of 90 beats per minute

a. a strong cry (2 is the highest score)

Which of the following responses would the nurse expect to see from a client who is in the latent phase of labor? a. contractions every 5-10 minutes b. contractions lasting 1-2 minutes c. cervical dilation 6-7 cm d. cervical effacement of 80%

a. contractions every 5-10 minutes Latent phase: first stage of labor when a woman's body is beginning to change for childbirth.

A nurse is planning a presentation for a group of clients at a health fair about measures to reduce the risk for amputation due to DM. Which of the following interventions should the nurse plan to include? (SATA) a. encourage clients who smoke to consider smoking cessation programs b. encourage clients who have DM to maintain blood glucose levels within expected reference range. c. instruct clients to incorporate regular exercise into their daily routine. d. encourage clients who have DM to examine their feet once per week e. advise clients to shop for appropriate footwear early in the day.

a. encourage clients who smoke to consider smoking cessation programs b. encourage clients who have DM to maintain blood glucose levels within expected reference range. c. instruct clients to incorporate regular exercise into their daily routine. - clients with DM should observe their feet on a daily basis - shoes should be shopper for later in the day because feet tend to be bigger later in the day

A nurse is documenting in the medical record information of a client and suspects opioid use disorder. which of the following manifestations should the nurse expect and document in the client's record? a. euphoria b. rhinnorhea c. yawning d. dilated pupils

a. euphoria This is a behavioral manifestation of opioid analgesics. Rhinorrhea is withdrawal of opioids.

A nurse is caring for a 40 yr old female client who is diagnosed w/ a UTI due to vancomycin-resistant enterococcus. Which of the following is an important nursing consideration when caring for the client? a. institute standard precautions b. avoid antibiotics, as they cannot effectively treat the client c. assign the client to a semi-private room d. place the client on contact isolation precautions

a. institute standard precautions Contact isolation precautions are indicated for VRE.

A client has iron-deficiency anemia - the nurse should encourage the client to increase consumption of which of the following foods? a. lentils b. avocados c. cabbage d. broccoli

a. lentils

A nurse is assessing a client who is taking Varenicline for smoking cessation. Which of the following findings is the nurse's priority? a. mood changes b. nausea c. altered sense of taste d. skin rashes

a. mood changes - this poses the greatest safety risk to the client - developing neuropsychiatric effects can progress to depression and suicide

A nurse is performing suctioning for a client with a tracheostomy. which of the following actions should the nurse take? a. pull suction catheter back 1 cm (0.5) if the client starts coughing b. allow 30 seconds between suctioning passes c. hyperventilate the client w/ 50% O2 for 30 seconds d. perform a maximum of 4 passes with the suction catheter

a. pull suction catheter back 1 cm (0.5) if the client starts coughing - allow 1 minute between suctioning passes to prevent hypoxia - hyperventilate w/ 100% O2 at least 2 minutes before suctioning - perform a maximum of 3 passes w/ suction

An earlier, childlike behavior in response to stress or conflict. a. regression b. altruism c. displacement

a. regression

A nurse is planning an in-service session about involuntary commitment to mental health facilities for a group of newly licensed nurses. which of the following pieces of information should the nurse include: a. the client can challenge hospitalization following emergency treatment b. involuntary commitment requires the hospitalization of the client c. a client who is competent but committed involuntary is unable to make treatment decisions d. court hearings should be held 7 days after emergency commitment

a. the client can challenge hospitalization following emergency treatment

A client has a fingerstick glucose level of 380 and urine dipstick is positive for ketones. what should the initial intervention of administration be?

administer 0.9% saline solution at 10mL/kg

What type of catheter would the nurse use most often when caring for ambulatory day surgery clients?

an 18 gauge catheter - used for preoperative clients so it can accommodate the rapid infusion of blood and blood products in case client experiences hemorrhage and/or hypovolemia.

nosocomial infection

an infection acquired during hospitalization - same as HAI

Patient has decreased hemoglobin, platelets, WBC, and neutrophil count. What is the priority?

assignment to a private room w/ neutropenic precautions

Diagnostic for hepatitis C? a. indirect bilirubin b. HCV RNA testing c. AST d. ALT

b. HCV RNA testing - provides information on the virus and can determine the viral load, or degree of infection.

Stage of Parkinson's Disease: Bilateral and midline involvement. a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

b. Stage 2

An adaptive defense mechanism. It is characterized by channeling strong or unpleasant feelings into good works for others. a. regression b. altruism c. displacement

b. altruism

Infant has an ET tube in place due to increased ICP. Which of the following interventions should the nurse include in the plan of care to reduce ICP? a. suction the ET tube every 2 hr b. maintain a quiet environment c. use two pillows to evaluate the infant's head d. administer a stool softener e. place the infant in trendelenburg position

b. maintain a quiet environment d. administer a stool softener

A nurse is caring for a client who is in labor and has HIV. which of the following procedures should the nurse identify as being safe for this client? (SATA) a. vacuum extraction b. oxytocin infusion c. use of forceps d. cesarean birth e. internal fetal monitoring

b. oxytocin infusion d. cesarean birth

A nurse is planning care for a child who is in skeletal traction. which of the following interventions should the nurse include in the plan? (SATA) a. remove the weights to reposition the client b. provide a high-fiber diet c. assess the pin sites every 4 hr d. limit oral fluid intake e. ensure the rope's knot is in contact w/ the pulley

b. provide a high-fiber diet c. assess the pin sites every 4 hr - the knot in the rope should NOT touch the pulley, because this will alter the weight of the traction

Which of the following findings should indicate to the nurse that the client has developed tardive dyskinesia (TD)? a. feelings of inner restlessness b. writhing motion of the tongue c. fine tremors of the hands d. jerking movements of the shoulders e. involuntary pelvic rocking

b. writhing motion of the tongue d. jerking movements of the shoulders e. involuntary pelvic rocking Haloperidol and other first generation antipsychotic medications can cause TD.

When should infants receive iron?

by 2-3 months after birth - breast milk contains low iron - premature baby Ex: an 11 week old infant who was born at 33 weeks gestation and receives feeding of breast milk by bottle

Which of the following vaccine is mandated the Occupation Safety and Health Administration (OSHA) for healthcare workers? a. Influenza b. TB c. Hepatitis B d. Hepatitis C

c. Hepatitis B - transmitted through infected blood and bodily secretions

Stage of Parkinson's Disease: Unsteadiness when turning. a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

c. Stage 3

Occurs when an individual transfers strong feelings about a person, situation, or object to a less-threatening person, object, or situation. a. regression b. altruism c. displacement

c. displacement

Which of the following should a nurse include when preparing a discharge teaching plan for a client who was just diagnosed w/ polycytemia vera? (SATA) a. bathe in hot water to reduce itching b. decrease fluid intake c. elevate the legs and feet when sitting d. report any swelling in the lower extremities e. take iron supplements daily

c. elevate the legs and feet when sitting d. report any swelling in the lower extremities Polycythemia vera = disorder of the bone marrow that results in increased production of blood cells, including red cells, white cells, and platelets.

A nurse is caring for a client for whom the respiratory therapist has just removed the ET. which of the following actions should the nurse take first? a. instruct the client to cough b. administer oxygen via face mask c. evaluate the client for stridor d. keep the client in a semi-to high- Fowler's position

c. evaluate the client for stridor - important to continuously evaluate respiratory status

A nurse is caring for a 68 yr old client w/ paraplegia. The client has developed pneumonia. which of the following factors should a nurse consider most important to aid in the client's recover and prevention of further episodes of pneumonia? a. well-ventilated room b. advance directives c. improved mobility d. hydration

c. improved mobility Pneumonia is the most common infection associated w/ immobility.

A provider is caring for a patient admitted for treatment of depression. which of the following behaviors exhibited by the patient indicate a readiness for discharge? a. interactions w/ staff and peers b. sleeping for 4 hrs in the afternoon and 4 hrs at night c. verbalization of feeling in control of self and situations d. statements of dissatisfaction over not being able to perform at work

c. verbalization of feeling in control of self and situations depressed clients often feel powerless and inability to influence others/situations

A client with anorexia nervosa sates, "If I gain weight, I'll never get a boyfriend." Which of the following cognitive distortions is the client displaying?

catastrophizing - assuming the worst possible outcomes will occur

What is a finding in a preschooler who has HIV?

chronic diarrhea

Stage of Parkinson's Disease: Prominent symptoms of the disease. Cognitive decline. a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

d. Stage 4

A nurse is assessing an older adult client. which of the following findings should the nurse report to the provider? a. decreased cough reflex b. decreased urinary bladder capacity c. decreased sebum production d. decreased spinal column movement

d. decreased spinal column movement - onset of lower back tenderness and restricted spinal column movement - indicate a compression fracture due to osteoporosis

Which of the following specimens should the nurse delegate a UAP to collect? a. wound drainage for culture b. urine from an indwelling catheter c. blood for an ABG test d. random stool specimen

d. random stool specimen - does not require sterile technique or the skills of a licensed nurse

A nurse is providing discharge instructions to a 17 yr old client who is post-operative appendectomy. which of the following statements by the client implies an understanding of the discharge instructions? a. i will report bruising and soreness around the wound b. i can resume heavy lifting after two days c. i can resume normal activity after 6 weeks d. take colace 'docusate sodium' twice daily

d. take colace 'docusate sodium' twice daily - prevents constipation caused by narcotic medication and abdominal surgery

A nurse is assessing a 4 yr old child's cognitive development during a well-child visit. which of the following should the nurse expect the child to display?

development of the supergo

Anxiety disorder - nonpharmacological ways to promote good sleep habits. which recommendation should the nurse make?

eat a light snack containing carbs before bedtime - a little caffeine daily is okay

What finding indicates that the client is developing an infection?

erythema at the incision site

Lithium toxicity - priority finding to report?

fine hand tremors = lithium toxicity Lithium is a mood stabilizer commonly used in the treatment of bipolar disorder.

What should the nurse do to help expel the placenta?

have the mother feed the newborn a. suckling will induce neural stimulation of the posterior pituitary gland, which in turn will release oxytocin and cause uterine contractions.

A nurse is caring for a client who just had coronary artery bypass surgery. the nurse knows not to rewarm the client too rapidly due to a risk of which of the following complications?

hypotension

Involuntary Admission - when is this justified?

if the client is a danger to others

Adverse effect of prednisone

infection Prednisone is a corticosteroid medication that can suppress the immune system, making individuals more susceptible to infections.

Administering an otic medication to an adult client

pull the pinna oc the client's ear upward and outward

What is the diagnostic procedure for Legg-Calve-Perthes disorder?

radiographs - a child with this exhibits necrosis to the femoral head, can be diagnosed with radiograph or MRI to the hip and pelvis

A client is scheduled to undergo an ECT> which of the following interventions should the nurse include?

reorient the client to the environment after ECT - ECTs cause confusion after - client can awaken 15 minutes after

Triaging- Green

stable (walking wounded)

Triaging- Yellow

stable who can wait 30-60 min for treatment (moderate burn, eye injury)

A client who is recovering from a crisis and asks for help in completing the recovery process - what type of prevention?

tertiary prevention

Client discharge with 2 Jackson-Pratt drains. Which of the following pieces of information should the nurse include in the teaching?

the drainage tubes often are removed at the same time as stitches

What is the best time in the menstrual cycle for a woman to perform breast-self examination?

the week after menstruation (hormones are lowest. high hormones make breast feel different)

What is the purpose of prescribing a client a transdermal fentanyl patch?

they're opioid-tolerant

Adolescent with type 2 DM. Where should the nurse recommend injecting the insulin during basketball competitions?

thigh

A nurse is providing teaching to a client who recently completed detoxification from alcohol and has a new rx for acamprosate. Which of the following statements should the nurse make?

this medication might cause you to have episodes of diarrhea.

Adverse effect of Furosemide?

tinnitus (ringing of the ears)

Type O blood

universal donor - anyone can receive type O blood no matter their blood type

Triaging- Red

unstable (occluded airway, active hemorrhaging)

Triaging- Black

unstable with massive injuries that will probably prove fatal (massive body trauma) support and comfort measures

What is the most appropriate for delivering a predicted O2 concentration in a client with unstable COPD?

venturi mask - delivers FIO2 - titrates the oxygen concentration in clients w/ unstable COPD

Pernicious anemia - what is it? what is a common finding?

vitamin b12 deficiency - common finding: paresthesias (tingling or numbness) - this is due to lack of B12 - neurologically