Final

The nurse is evaluating understanding after a teaching session for mechanical cardiac valve replacement surgery. Which statement by the patient indicates understanding of teaching?

"I will need anticoagulant for life."

Type I hypersensitivity reaction

-Anaphylactic (immediate) -Requires previous exposure to the antigen -Can lead to death -Mediated by IgE (remember epi) > which induces the release of histamine from mast cells & basophils -Examples: allergy to PNC, bee sting, shell fish

Type II hypersensitivity reaction

-Cytotoxic -Antibody attacks the antigen leading to lysis (complement mediated) -IgG & IgM are the principal antibodies involved -Examples: hemolytic anemia, thrombocytopenia

Type IV hypersensitivity reaction

-Delayed hypersensitivity reactions -Ex: transplant rejection, tubercular caseous necrosis, contact dermatitis.

Type III hypersensitivity reaction

-Immune-Complex Reaction -Local or systemic -Immediate or delayed -Ex: Systemic lupus erythematosus, acute glomerulonephritis, and rheumatoid arthritis.

Cranial nerve VI

Abducens (eye motor lateral eye movement)

What technique should nurse use to assess glossopharyngeal nerve?

Ask the patient to open their mouth and say "Ah" and note symmetry of the upper palate.

The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)?

Assess the client's eye opening and response to stimuli

The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury?

Avoid rubbing the eye on the affected side of the face

Structural and motor changes related to aging that may be assessed in geriatric patients during an examination of neurologic function include which of the following?

Decreased or absent deep tendon reflexes.

A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient?

EEG

Cranial nerve VII

Facial (expressions)

Cranial nerve IX

Glossopharyngeal (gagging and swallowing)

Cranial nerve XII

Hypoglossal (tongue movement)

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes.

A nurse is planning care for a client who has heart failure. Which of the following interventions should the nurse include in the plan of care?

Limit fluid intake to 2 L per day

Cranial nerve III

Oculomotor (eye motor pupil size and reactivity)

Cranial nerve I

Olfactory (smell)

Cranial nerve II

Optic (vision)

The nurse is caring for a client with manifestations of dilated cardiomyopathy. When planning care, which consideration would the nurse make?

Place bed in a high or semi-high Fowler's position as needed.

What is a nurses priority assessment for client on ACE inhibitors?

Renal function

Put renin angiotensin aldosterone system in proper order:

Renin-> Angiotensinogen -> Angiotensin I -> ACE -> Angiotensin II

The nurse is teaching a client with an acute exacerbation of ulcerative colitis about an appropriate diet. Which food selected by the client indicates that dietary teaching is effective?

Scrambled eggs

Cranial nerve XI

Spinal accessory (head and shoulder movement)

Passive acquired immunity

Temporary immunity transmitted from a source outside the body that has developed immunity through previous disease or immunization. i. Examples include immunity resulting from the transfer of antibodies from the mother to an infant in utero or through breast-feeding or receiving injections of immune globulin.

Ascending colostomy

The output is often liquid to semiliquid, and gas is common

Sigmoid colostomy

The output is usually pasty to a formed consistency, and gas is common.

Descending colostomy

The output may be pasty to a formed consistency, and gas is common.

Transverse colostomy

The output often is liquid to pasty, and gas is common

Cranial nerve V

Trigeminal (chewing and facial sensation)

Cranial nerve IV

Trochlear (eye motor down and lateral)

Cranial nerve X

Vagus (pharynx and larynx)

Cranial nerve VIII

Vestibulocochlear (hearing and balance)

The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid?

Washing his face

Axon hillock

cone shaped region of an axon where it joins the cell body that generates cell impulses

Cell body

contains nucleus and keeps cell functional

Myelin sheath

covers the axon of some neurons and helps speed neural impulses

Nodes of Ranvier

gaps in the myelin sheath that allow diffusion of ions

Dexa scan testing, recommends for all women except certain categories, what categories:

pregnancy; claustrophobia; inability to tolerate required positioning due to age, debility, or disability; metal implants

Schwann cells

produce myelin in PNS

Cell membrane

protects the cell

Dendrites

receive messages from other cells

Axon terminal

the end of an axon which forms junction with other cells

Axon

the extension of a neuron, ending in branching terminal fibers, through which messages pass to other neurons or to muscles or glands

A nurse is caring for a client who will undergo total knee replacement and will have an autologous transfusion. Which statement will the nurse include when teaching the client about the transfusion?

· "You typically donate blood 4 to 6 weeks before the surgery."

As a nurse, you are assigned to four patients. Which patient do you need to see first?

· A patient admitted yesterday with atrial fibrillation with decreased level of consciousness

Which drug classes are considered first-line treatment for heart failure? Select all that apply.

· ACE · ARBS · Beta-blockers · Loop diuretics

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.)

· Assess the client for bleeding. · Monitor the daily activated partial thromboplastin time (aPTT) results. · Use an IV pump for the infusion.

=A nurse is planning care for a client who has a small bowel obstruction and a NG tube in place. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)

· Document the NG drainage w/ client's output. · Assess bowel sounds. · Provide oral hygiene every 2 hr. Monitor NG tube for placement.

A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing?

· Elevate the head of the bed 60 degrees.

The RN supervising a senior nursing student is discussing methods for preventing acute kidney injury (AKI). Which points would the RN be sure to include in this discussion? Select all that apply.

· Encourage patients to avoid dehydration by drinking adequate fluids. · Instruct patients to drink extra fluids during periods of strenuous exercise. · Record intake and output and weigh patients daily. · Monitor laboratory values that reflect kidney function.

What can be a complication of a ventriculostomy used to monitor ICP?

· Hemorrhage and infection

Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be the most indicative sign of increasing intracranial pressure?

· Increased restlessness

The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan?

· Need for careful monitoring for cardiac symptoms. · Need for carefully regulated exercise. · Need for dietary modifications.

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.)

· Night sweats · Cardiac murmur · Osler's nodes

A client with a closed reduction of a wrist fracture has a plaster cast applied. Which nursing intervention is the highest priority immediately after the procedure?

· Performing a peripheral circulation assessment

Pathophysiology behind CJD:

· Prion is a unique pathogen because it lacks nucleic acid, which enables the organism to withstand conventional means of disinfection and sterilization. The prion crosses the blood-brain barrier and is deposited in brain tissue and causes degeneration of brain tissue

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

· Provide frequent oral and nares care.

How do you manage a patient with hepatic encephalopathy?

· Reduce the production and absorption of ammonia with lactulose or rifaximin. Identify and treat precipitating factors like infections, gastrointestinal bleeding, or medications. Monitor and manage electrolyte imbalances, particularly sodium and potassium. Ensure proper nutrition, avoid excessive protein intake, and consider branched-chain amino acids supplementation if needed.

The nurse is caring for a client with celiac disease. Which clinical manifestations can the nurse expect to find?

· Steatorrhea

Which statements are true regarding Standard Precautions? (Select all that apply.)

· Use personal protective equipment as needed for client care. · Wear gloves when touching client excretions or secretions.

What are medications that can be given to a client who needs immediate control of esophageal variceal bleeding?

· octreotide (Sandostatin) and vasopressin (Vasostrict)