final adulth health 1
A public health nurse that is assessing a pt that lives with a family members that has bruising on their body comes into the clinic, a family member then explains that the bruises are from falls and nurse thinks its from abuse, what does the nurse do
1st, the nurse should report the finding to the supervisor.
What age is greatest risk for pressure injuries
65 year old.
For cranial nerve V/5 unable to feel facial pain, what is this called
facial neuroglia
A nurse is caring for 4 clients, which does she assess 1st
gas exchanges for abnormalities 1st, a opioid overdose
A nurse is doing a surgically interview, glucosamine, APAP and ginkgo, and nurse tells pts to stop taking which one
gingko is to be stopped 2 weeks before the surgery
What type/class of medication do you use with a pt who is in alkalosis for acid loss
Diuretic
For a confused older adult what scale do you use that will tell us their pain
Faces
Who would a nurse refer to if a pt cannot feed themselves
OT
The student nurse learns that the most important function of inflammation and immunity is which purpose
Providing protection against invading organisms
When planning delegation tasks to AP, a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation
The AP has the knowledge and skill to perform the task, Means the right person
Its an Older adult's 1st time being seen for geriatric care, and nurse asks about supplemental herb use for what
To do medication reconciliation for possible interactions.
Which pt has the highest risk for cardiovascular disease is
a pt with DM
72 year old women what would a sign of cancer
be loss tone in the ligaments
A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer. Which factor in the client's history helped the nurse form this conclusion
exposed to radiation
Pulmonary embolize
is a blood clot in the lungs you would see pt on warfin or heparin PE sometimes causes hypoxia
Cranberry juice is beneficial because
it can prevent bladder infections.
What is a instinctive spirometer
it's a slow inhaler to prevent pneumonia and aids in deep breathing
What are plantar flexion contractions
its foot drop, its foot that needs to be put in a boot at times.
A nurse just gave the wrong medication to the the wrong pt, what does the nurse 1st do
Assess
What are the 4 pillars of ethical principals
Autonomy - respect for the patient's right to self-determination Beneficence - the duty to 'do good' Non-Maleficence - the duty to 'not do bad' Justice - to treat all people equally and equitably.
acidosis side effects are
Diarrhea acidosis
The nurse understand which information under centered care
Definition of pt recognize the client as a source of his or her care.
What is risk factors for metabolic acidosis
Diarrhea, AKI,
Risk factors for cataracts are
age
Pt is admitted for sepsis what do you always do
always do culture 1st the especially in little and older pts
MRSA antibiotic resistance, if a pt has mrsa give them
antibiotics
When a nurse interviews a pt is taking a daily dosage of supplements what do we want to know most
ask what they are taking the supplements for
How is a that has chronic kidney disease would have a reduce erthypoticin (erythropoietin)
because of the decreased RBC in the chronic disease
What are the common side effects for these 3 medications Garlic Ginger and Ginkgo
bleeding
The nurse is assessing for reproductive health problems,what are those
bleeding, pain, masses, discharge.
Signs and symptoms of lactose intolerances
bloating diarrhea gas
If a pts serum K is not within normal ranges, what does the nurse do
call the provider to inform of results, prior to admn medications
Ginkgo adverse effect
can cause bleeding
If your pt is on airborne precautions, what do you follow
can they ambulate in the hall no, do they need to wear a mask yes n95, and be in a negative pressure room and we need to stand six feet away
If you are a nurse in ophthalmology clinic who do we see 1st
cataracts surgery follow up.
What are signs and symptoms of malnutrition
cold intolerance, decreased vital capacity, mental status, dry flaky skin
Pupliary construction is assessed through
cranial nerve 3
What are age related GI changes
decreased GI mobility, large intestine pertussis, decreased observation, decrease gastric bile juices, decreased need to pass stool, pancreatic vessels classification, decreased fat digestion
What does a pulmonary emboli cause
decreased perfusion; hypoxemia; and if large enough right sided heart failure
Post recover care for colonoscopy
do vitals q 15-30 minutes, asses for rectal bleeding, no need for pain meds, encourage to pass gas, no driving
Giving antibiotics what has to occur for it to be given
dosage, length, route, med,
Some ways to teach kidney health
drink water daily, encourage q 2 hours, provide peritoneal care after voiding , asses for UTI, Leave the bathroom light on at night
68 yr postmenopausal pt that is bleeding from vaginal canel indicates
endometrial cancer.
What ppe do you take off 1st
gloves
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination XI
have patient shrug their shoulders against resistance.
A nurse is assisting a pt to the bathroom and the pt is starting to fall what do we do
help pt to the ground to get help.
How to help falls in older pts
railings , avoid rugs, why is it good to put a nightlight in a pts room: to see better
Pulmonary Embolism
life-threatening blood clot in the lungs caused by an embolus from a vein in the lower extremity or from clots that form from a major surgery
A patient has had lung cancer and is suspected to have metastasis. On what system should the nurse focus the assessment to determine this complication
liver most common for lung metastasis
Risk falls is a older client that is disorientated
make sure you are rounding hourly and teaching the client about the call light and do not pull up the side rails.
What are risk factors that affect immunity
medications corticosteroid's, age, malnourished, nutritional status, substance abuse pt
An older adult that was AAO and is now agitate wje should do what
move them closer to the nurse's station.
A nurse is caring for a total hip arthoplasty and pt is on PCA pump for morphine, what does the nurse do
need to assess 1st. auscultate bowel sounds for gastric mobility
I don't have to go to the hospital after using Epinerphine is said by the pt is this correct
no
When a pt has lung cancer and has one metastasis to the liver, is it now liver cancer
no it's the still lung cancer however its just metastasis
Preprocedure for pulmonary function testing includes
none its PRN
If a pt has hearing loss we want to make sure to
not yell, assess if they have you get *hearing aids, assess do they have assistant device
Assessing a client blueish tint what do you check
o2, respirations everything with o2
AIDS pts can have thrush from
oral candidiasis
Older pt who is at a risk for falls, what are some interventions
place bedside table closer to pt, when bed or wheelchair is not in use place in locked, give pt information on how to be safer teach balance and exercise stretching to the pt
What are complications of immobility
pressure injury in bony prominences in the heel in the sacrum , skin infections, skin integrity
Pt who has stage 3 pressure ulcer what can be included in the plan of care
reposition q 2 hours
Autonomy
respect for the patient's right to self-determination
Major Adverse effects of morphine are
respirations, GI mobility 12-20 normal, pt being sleepy is normal finding
5 rights of delegations
right task, right circumstance, right person, right direction/communication, and right supervision/evaluation
Presence of edema can be seem in a pt that
shoes are fitting more tightly
If a patient is malnourished and does not want to eat and is mentally ill, how can we as a nurse help
sit and eat with them
What is the nursing management for a pulmonary emboli
stabilizing the cardiopulmonary system and anticoagulant therapy
What are risk factors for osteoarthritis
stress on the joints, weight obesity, old age, smoking for 30 years
A nurse is preparing for a catchier
tell me more about what your fears are.
What cranial nerve will cause a pt not be able to shrug their shoulders or move their neck
the spinal accessory 11 crainal XI
Nurse is setting goals for pts with AIDS at end of life, what is it that a client will need help with
their pain.
alkalosis for acid loss causes
vomiting
What shows fluid overload
weight gain over 5 lbs
Fluid overload
weight gain, edema, decreased skin turgor, distended neck veins, decreased O2 then 90%
pertussis
whooping cough, pt is put on droplet precaution
4 things that a home health nurse will find on a pt that are NOT normal findings are
worst thing that needs to be address 1st is a dysphagia
If I palpate the pts skin and it stays in indented is that pitting edema
yes
It a pt is on contact precautions can a pt go to CT scan
yes they can we just need to tell the radiology dept and make sure they are informed.
How can you prevent Glaucoma
you can prevent it, you can have intraocular pressure measured 1-2 times a year.
