Med Surg Final
Contractures
Shortening or contraction of a muscle. May be due to spasms or paralysis and may be permanent
Body mechanics
The proper use of the body to facilitate lifting and moving and prevent injury
Purulent drainage
Thick green, yellow, or brown drainage
Ringing in the ears
Tinnitus
Pronation
Turning the palm downward
↓es production aqueous humor; used with other drugs to control pressures in clients for whom beta blockers are contraindicated [acetazolamine (Diamox)]
Carbonic anhydrase inhibitors
Earwax
Cerumen
Occurs when there is a problem transferring sound waves anywhere along the pathway through the outer ear, tympanic membrane or middle ear (ossicles)
Conductive hearing loss
List at least 3 causes of sensorineural hearing loss:
Congenital Nose injury Age
The nurse is participating in a family meeting with a client who is identifying preferences for end-of-life care. Which action will the nurse take to follow end-of-life care choices? Tell the family to file the client's living will with an attorney. Encourage the family to petition the court for a durable power of attorney. Contact the primary health care provider for a prescription for life-sustaining treatment. Discontinue medications and treatments for a "do not resuscitate" (DNR) prescription.
Contact the primary health care provider for a prescription for life-sustaining treatment
Prone
Lying face down
Dorsal recumbent (supine)
Lying on the back
A combination of both conductive and sensorineural hearing losses
Mixed hearing loss
Abduction
Movement away from the midline of the body
Supination
Movement that turns the palm up
ROM
Range of motion
The nurse is assessing a client with limited mobility after a stroke. What would the nurse do to assess the client for contractures: Orientation Muscle flexibility Range of motion Muscle strength
Range of motion
A normal fasting glucose is A. <80 mg/dL B. <100 mg/dL C. <110 mg/dL D. <125 mg/dL
<100 mg/dL
Angle-closure glaucoma
>30 mm/Hg
Death affects everyone who knows the dying client including the nurse. List 3 ways that a nurse may therapeutically deal with the loss of a client:
Attend memorial service; attend wake; talk with one another; turn to your faith; prayer; yoga; meditate, etc.
The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority? Checking the respiratory rate Assessing for nausea Evaluating for sacral redness Auscultating bowel sounds
Checking the respiratory rate The patient's respiratory rate is the highest priority of care while using PCA medication because of the possible respiratory depression. The other areas also require assessment but do not reflect immediately life-threatening complications.
Constricts the pupil of the eye and facilitates aqueous humor outflow (pilocarpine)
Cholinergics (miotics)
A state in which opposing forces are balanced
Equilibrium
A small passageway that connects the throat to the middle ear
Eustachian tube
Person becomes overwhelmed by grief and cannot function
Exaggerated
Exudates
Fluid, cells, and other substances (pus) that filter from cells or capillaries ooze into lesions or areas of inflammation
Nursing diagnoses r/t glaucoma:
Focus on problems associated with the temporary/permanent visual impairment, resultant increased risk for injury, and psychosocial problems of anxiety
It is important for the nurse to teach the patient who has type I diabetes to rotate insulin injection site in order to prevent A. Hypoglycemia B. Infection C. Pain D. Lipodystrophy
Lipodystrophy
Disuse syndrome
Loss in the ability to perform ADL functions as a result of a sedentary lifestyle disability Approximately 14.2% of elders living in the community experience difficulty completing one or more ADLs because of health-related problems. Approximately 21.6% of elders report difficulties with instrumental ADLs (IADLs). The need for assistance in ADLs and IADLs increases with age.
Orthotics
Making and fitting of orthopedic appliances, such as arch supports, used to support, align, prevent, or correct deformities
A small bone in the middle ear which transmits vibrations of the eardrum to the incus
Malleus
Gait
Manner of walking
Survivors not aware that behaviors interfere with normal functioning
Masked grief
A surgical procedure that removes diseased mastoid air cells
Mastoidectomy
Any change in the developmental process that is normal expected during a lifetime
Maturational
Adduction
Movement toward the midline of the body
A surgical incision into the eardrum to relieve pressure or drain fluid
Myringotomy
Involuntary eye movement causing the eyes to move side-to-side or up-and-down
Nystagmus
Exercise
Purposeful physical activity that is planned, structured, and repetitive, and that improves or maintains physical fitness
The nurse checks the patient's blood glucose and the result is 54mg/dL. What is the next action the nurse should take? A. Assess level of consciousness B. Administer a 15g fast-acting carbohydrate snack C. Recheck the blood glucose D. Administer 50% dextrose solution IV
Recheck the blood glucose
Why are corticosteroid otic drops used for external otitis media?
Reduce inflammation
List at least 4 manifestations of hearing loss:
Failure to respond to voices Inappropriate responses Loud speech Abnormal awareness of sound
List at least 4 risk factors for hearing loss:
Family history Congenital malformations Low birth weight Ototoxic drugs
Debridement
Removal of foreign material and dead or damaged tissue from a wound
Shear
Remove (fleece or hair) by cutting; remove the hair or fleece from; cut with or as if with shears; N: shears; pair of scissors
A client at potential risk for a pressure ulcer is assessed by the nurse. A laboratory study the nurse should examine is: Serum albumin Serum glucose Prothrombin time Sedimentation rate
Serum albumin
The nurse is caring for a client at the end of life. The client is ordered a regular dosage of narcotics and short-acting narcotics for breakthrough pain. When administering the narcotics, the nurse is correct to realize which of the following? Death is imminent. Side effects must be treated. Dosages are restricted. client may become sedated.
Side effects must be treated
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? Stage III Stage II Stage IV Stage I
Stage III A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
Answer the following questions about advance directives: T or F An advance directive is...allows a person to make known his/her wishes about treatment at end-of-life
T
Answer the following questions about advance directives: T or F An advance directive is...forms can be found on the Internet
T
T or F Cranial nerve 8 is for both hearing and balance.
T
Instrumental activities of daily living (IADL)
The ability to use the telephone, go shopping, prepare meals, complete housekeeping tasks, do laundry, use private or public transportation, take medications, and handle finances
After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? The family member places contaminated dressings in a plastic grocery bag. The family member uses clean tap water to clean the wound. The family member uses a lift sheet to reposition the patient. The family member dries the wound using a hair dryer on a low setting.
The family member dries the wound using a hair dryer on a low setting Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care.
List at least 3 signs/symptoms/manifestations of open-angle glaucoma (vague; client often unaware of them)
The loss of peripheral vision Mild headaches Vision impairments- Halo around lights
An area of tissue in the eye responsible for draining the aqueous humor
Trabecular meshwork
A small pointed eminence of the external ear, in front of the concha, projecting backward over the meatus
Tragus
Allows light to pass through but diffuses the light in a way that makes objects appear blurred
Translucent
Forms the eardrum between the outer and middle ear
Tympanic membrane
Activity tolerance
Type and amount of exercise or work that a person is able to perform
List the 5 stages of the grieving process, in order, according to Elisabeth Kubler-Ross:
denial anger bargaining depression acceptance
Classic clinical manifestations of diabetes include polyuria, polydipsia, and A. polykalemia B. polyphagia C. polyarthria D. polysuria
polyphagia
Cut
skin: subcutaneous—beneath the skin.
Risk for disturbed sensory perception: visual (low vision). List at least 5 nursing interventions:
Address the patient by name Orient the patient (Time, place, name) State the purpose of the visit TV can be useful to maintain orientation Provide visual aids
Which question asked by the nurse will give the most information about the patient's metastatic bone cancer pain? "How much medication do you take for the pain?" "How long have you had this pain?" "How would you describe your pain?" "How often do you take pain medication?"
"How would you describe your pain?" Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain will elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning "How would you describe your pain?" is the best initial question.
A patient with chronic back pain has learned to control the pain with the use of imagery and hypnosis. The patient's spouse asks the nurse how these techniques work. Which response by the nurse is accurate? "The strategies work by affecting the perception of pain." "These techniques block the pain pathways of the nerves." "These strategies prevent transmission of stimuli from the back to the brain." "The therapies slow the release of chemicals in the spinal cord that cause pain."
"The strategies work by affecting the perception of pain." Cognitive therapies affect the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn.
Contusion
(n.) bruise, injury (The contusions on his face suggested he'd been in a fight.)
Any loss that is less tangible and uniquely defined by the grieving client
Perceived
A tangible loss that is usually understood by all who are award of its value to the grieving client
Actual loss
Fistula
Abnormal passageway between two organs or between an internal organ and the body surface
A noncancerous tumor on the main nerve leading from the inner ear to the brain
Acoustic neuroma
AROM
Active range of motion
Dilates the pupil of the eye; reduces production of aqueous humor and increases it absorption
Adrenergic agonists (mydriatics)
Grieving before that client has died or a loss has occurred
Anticipatory
Absence of the lens of the eye usually removed during surgery
Aphakia
Requires individual adaptation through the grieving process
Personal loss
↓production of aqueous humor without causing pupillary constriction [timolol maleate (Timoptic)]
Beta-adrenergic blockers
Thrombus
Blood clot
Sanguinous drainage
Bloody drainage
A patient who has had good control for chronic pain using a fentanyl (Duragesic) patch reports rapid onset pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." How will the nurse document the type of pain reported by this patient? Somatic pain Breakthrough pain Neuropathic pain Referred pain
Breakthrough pain Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system. Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.
Ecchymosis
Bruise
Dehiscence
Bursting open of a wound, especially a surgical abdominal wound
Increased intraocular pressure and gradual loss of vision
Glaucoma
Bedridden clients are assessed every shift for evidence of impaired skin integrity due to shear and friction. When making this assessment, the nurse assesses the: Hands B. Soles of feet C. Heels D. Knees
Heels
Dermis
Inner layer of skin
Morning hyperglycemia that is characterized by a relatively normal blood glucose level until approximately 3:00 am when blood glucose levels begin to rise is called A. Dawn phenomenon B. Symogi effect C. Peak effect D. Insulin waning
Dawn phenomenon
Eschar
Dead matter that is sloughed off from the surface of the skin, especially after a burn
Desiccation
Dehydration; the process of being rendered free from moisture
Active grieving held back and resurfaces at a later date in response to something trivial
Delayed grief
Third intention
Delayed or secondary closure; wounds are sutured after granulation tissue has begun to form
A procedure that employs temperatures as low as -1120 to destroy portions of the ciliary body to reduce aqueous humor production
Diathermy
Homan's sign
Discomfort behind the knee upon forced dorsiflexion of the foot.
List at least 3 causes of conductive hearing loss:
Ear wax Foreign body Infection
List at least 3 signs/symptoms/manifestations of angle-closure glaucoma
Eye pain and discomfort Mild or severe headache Red conjunctiva (irritation)
Answer the following questions about advance directives: T or F An advance directive is...irrevocable
F
Answer the following questions about advance directives: T or F An advance directive is...should only be completed if a person knows that he/she is terminal
F
T or F The most common form of glaucoma in adults is angle-closure glaucoma
F
What category of insulin is rapid acting? A. Humalog B. Humalog R C. Humulin N D. Glargine (Lantus)
Humalog
Initial skin redness in a client susceptible to pressure ulcers should be documented by the nurse as tissue Anoxia Eschar Hyperemia Ischemia
Hyperemia
A small, anvil-shaped bone in the middle ear
Incus
Initial intervention for a person with type I diabetes includes A. Diet and exercise B. Insulin C. Oral hypoglycemics D. Weight loss
Insulin
A surgical procedure to remove part of the iris
Iridectomy
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? Obtain cultures of the wound. Continue to monitor the wound for drainage. Redress the wound with wet-to-dry dressings. Begin antibiotic administration.
Obtain cultures of the wound The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.
May be administered systemically; to rapidly reduce intraocular pressure [mannitol (Osmitrol)]
Osmotic agents
Reconstruction of bones of the middle ear with the use of prosthesis
Ossiculoplasty
Pain in the inner or outer ear
Otalgia
Ear discharge
Otorrhea
Epidermis
Outer layer of skin
Compare/contrast palliative sedation v euthanasia or physician-assisted suicide:
Palliative sedation: Is NOT euthanasia or physician assisted suicide The intent is to relieve symptoms NOT hasten death Generally considered appropriate in only the most difficult situations e.g. intractable pain, dyspnea, seizures
The nurse is caring for a client with Huntington chorea who has decided to refuse all food and beverages. For which type of suffering will the nurse assess the client before supporting the client's decision? Select all that apply. Social Physical Spiritual Grieving Psychological
Social Physical Grieving Psychological
Maceration
Softening of tissue by soaking
Evisceration
The displacement of organs outside of the body.
Hemiparesis
Weakness on one side of the body
Compare Weber and Rinne test:
Weber test: Tuning for in middle of scalp, should be heard bilaterally Rinne test: Tuning fork near ear, heard through air conduction
Open-angle glaucoma
22-32 mm/Hg
Incision
A cut made in order to get inside something
Place the following steps in eye drop administration in order from the first to the last: Wash hands Have client place finger on lacrimal duct Identify client and explain procedure Place one drop of medication in conjunctival sac Have client close eyes gently and roll around Document medication administration
3,1,4,5,2,6
Center of gravity
A 3D point where the total weight of the body may be considered to be concentrated.
Wound
A break in the skin or mucous membrane
Sinus tract
A cavity or channel underneath the wound that has the potential for infection
Embolus
A clot that breaks lose and travels through the bloodstream.
Friction
A force that opposes motion between two surfaces that are in contact
Scar
A mark on the skin that is left after a cut or other wound has healed.
Bandage
A piece of soft material that covers and protects an injured part of the body
Hematoma
A solid swelling of clotted blood within the tissues.
Biofilm
A surface-coating colony of one or more species of prokaryotes that engage in metabolic cooperation.
First intention
A type of wound healing (closure) for wounds with little tissue loss, such as a surgical incision.
Second intention
A type of wound healing for wounds with tissue loss, as in pressure ulcers; the wound remains open and fills with scar tissue.
The nurse manager of an oncology unit is concerned that the staff are experiencing symptoms of chronic loss caused by the death of many long-term clients. Which action will the manager take to support the staff's resilience? Select all that apply. Allow flexibility in scheduling. Assign support groups between staff. Encourage picking up shifts. Promote collaborative relationships. Ensure fairness with assignments.
Allow flexibility in scheduling Promote collaborative relationships. Ensure fairness with assignments
What is the purpose of an ear wick used in the treatment of external otitis media?
Allows drops to travel through the ear canal
Avulsion
An injury in which soft tissue is torn completely loose or is hanging as a flap.
Pressure ulcer
Any lesion caused by unrelieved pressure that results in damage to underlying tissue
Risk for injury: List at least 3 nursing interventions:
Assess ability to perform ADL Keep high traffic areas clear of clutter Don't rearrange patient's environment
Anxiety r/t actual/potential loss of sight: List at least 3 nursing interventions:
Assess cues of anxiety; verbal and nonverbal Encourage verbalization Assess effect of loss of sight on lifestyle
Why are topical antibiotics rather than systemic antibiotics used to treat external otitis media?
Less systemic effects; antibiotics go directly to infection source
Occurs when societal norms do not define the loss as a loss within traditional definitions
Disenfranchised
Nonorganic hearing loss characterized by hearing loss without a detectable corresponding pathology in the auditory system
Functional hearing loss
A nurse is working with a family of a deceased client and assisting them in working through their grief and mourning. Which of the following would be the priority to promote healthy accommodation of the loss by the family? Helping the family recognize the loss has occurred Assisting the family in expressing their feelings of loss Encouraging the family to remember the relationship they had with the client Urging them to give up their old attachments to the client
Helping the family recognize the loss has occurred
List 2 interventions that may be used for a terminally ill client with dyspnea:
If a cause is known, treat the cause Morphine sulfate Low flow oxygen Sedatives (if morphine does not fully control the dyspnea) Nonpharmacological interventions: fan, positioning the client with pillows, encouraging imagery, deep breathing, conserve client energy, etc.
Surgery for glaucoma:
Indicated for client with acute angle-closure glaucoma and for clients with chronic open-angle glaucoma that is not effectively controlled by medication; GOAL: to improve the drainage of aqueous humor from the anterior chamber of the eye
Hypostatic pneumonia
Inflammation of the lung from stasis or pooling of secretions
Ischemia
Lack of blood supply
Hemiplegia
Paralysis of one side of the body
PROM
Passive range of motion
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? The patient has several incisions that formed keloids. The patient takes oral hypoglycemic agents daily. The patient states that the ulcers are very painful. The patient has had the heel ulcers for 6 months
The patient has had the heel ulcers for 6 months The use of oral hypoglycemics indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the past 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's pain will be implemented, but pain does not directly affect wound healing.
A sudden spinning sensation often triggered by moving the head too quickly
Vertigo
An eye examination that can detect dysfunction in central and peripheral vision
Visual field testing
The transparent gelatinous tissue filling the eyeball behind the lens
Vitreous humor
AN ELDERLY CLIENT HAS PRESENTED TO THE CLINIC WITH A NEW DIAGNOSIS OF OSTEOARTHRITIS. THE CLIENT'S DAUGHTER IS ACCOMPANYING HIM AND THE NURSE HAS EXPLAINED WHY THE INCIDENCE OF CHRONIC DISEASES TENDS TO INCREASE WITH AGE. WHAT RATIONALE FOR THIS PHENOMENON? WITH AGE, BIOLOGIC CHANGES REDUCE THE EFFICIENCY OF BODY SYSTEMS. OLDER ADULTS OFTEN HAVE LESS SUPPORT AND CARE FROM THEIR FAMILY, RESULTING IN ILLNESS. THERE IS AN INCREASED MORBIDITY OF PEERS IN THIS AGE GROUP, AND THIS LEADS TO THE OLDER ADULT'S DESIRE TO ALSO ASSUME THE SICK ROLE. CHRONIC ILLNESSES ARE DIAGNOSED MORE OFTEN IN OLDER ADULTS BECAUSE THEY HAVE MORE CONTACT WITH THE HEALTH CARE SYSTEM
WITH AGE, BIOLOGIC CHANGES REDUCE THE EFFICIENCY OF BODY SYSTEMS
A patient who uses a fentanyl (Duragesic) patch for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone tablets, but the patient is asleep when the nurse returns with the medication. Which action is best for the nurse to take? Wait until the patient wakes up and reassess the pain. Consult with the health care provider about changing the fentanyl (Duragesic) dose. Wake the patient and administer the hydrocodone. Suggest the use of nondrug therapies for pain relief instead of additional opioids.
Wake the patient and administer the hydrocodone Because patients with chronic pain frequently use withdrawal and decreased activity as coping mechanisms for pain, sleep is not an indicator that the patient is pain free. The nurse should wake the patient and administer the hydrocodone.
Patterned
Wound caused by object which leaves imprint representing outline of object
Normal intraocular pressure
10-21 mm/Hg
The kidneys will start to excrete glucose when the blood sugar rises above A. 150mg/dL B. 200mg/dL C. 250mg/dL D. 300mg/dL
200mg/dL
The American Dietetic Association recommends that for all levels of caloric intake, the percentage of calories from carbohydrates should not exceed A. 30% B. 50% C. 60% D. 75%
60%
An opacity of the crystalline lens of the eye
Cataract
A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? Change the patient's bedding frequently. Change the patient's position every 1 to 2 hours. Record the size and appearance of the ulcer weekly. Apply a hydrocolloid dressing over the ulcer.
Change the patient's position every 1 to 2 hours. The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching.
Atelectasis
Collapsed lung; incomplete expansion of alveoli
Argon laser used to destroy portions of the ciliary body to reduce aqueous humor production
Cyclocryotherapy
A nurse who provides care on an acute medical unit has observed that health care providers are frequently reluctant to refer clients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply. Financial pressures on health care providers Client reluctance to accept this type of care Strong association of hospice care with prolonging death Advances in "curative" treatment in late-stage illness Ease of making a terminal diagnosis
Financial pressures on health care providers Client reluctance to accept this type of care Advances in "curative" treatment in late-stage illness
Compare hospice v palliative care...
Hospice care is a special kind of care that focuses on the quality of life for people and their caregivers who are experiencing an advanced, life-limiting illness. Hospice care provides compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible. Individual usually has a prognosis of 6 months or less. Can be carried out in the home, long-term care or hospice facilities. Palliative care is specialized medical care for people living with a serious illness, such as cancer or heart failure. Patients in palliative care may receive medical care for their symptoms, or palliative care, along with treatment intended to cure their serious illness. Having palliative care doesn't necessarily mean that you're likely to die soon - some people receive palliative care for years. You can also have palliative care alongside treatments, therapies and medicines aimed at controlling your illness, such as chemotherapy or radiotherapy. Both palliative care and hospice care provide comfort. But palliative care can begin at diagnosis, and at the same time as treatment. Hospice care begins after treatment of the disease is stopped and when it is clear that the person is not going to survive the illness.
Small segment of iris removed to facilitate outflow of aqueous humor
Iridectomy
The nurse is visiting the home of a client who has refused all medical treatment for a terminal illness. Which assessment findings indicate to the nurse that the client will die within a few hours? Select all that apply. Irregular pulse Mottled extremities Apnea lasting 45 seconds Verbalizing incoherent phrases Systolic blood pressure of 80 mm Hg with no diastolic reading
Irregular pulse Mottled extremities Apnea lasting 45 seconds
List an intervention that may be used for a terminally ill client with anorexia/dysphagia:
Keep easily digestible foods at the bedside
Noninvasive; uses a laser to create multiple small perforation in the iris of the eye
Laser iridotomy
Argon laser used to create multiple burns around the trabecular meshwork to increase outflow of aqueous humor
Laser trabeculoplasty
Newer class of ophthalmics to ↑ aqueous humor output [latanoprost (Xalatan)]
Prostaglandin analogs
Dressing
Protective covering placed over a wound
Gait belt
Name given to a transfer belt when it is used to assist a resident when walking.
Granulation tissue
New tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
Consists of usual feelings, behaviors and reactions to a loss
Normal grief
Serosanguinous drainage
Pink to pale red and contains a mix of serous fluid and red, bloody fluid
The external part of the ear; the auricle
Pinna
The nurse visits the home of a client with terminal illness. Which assessment findings indicate to the nurse that the client might die within a few months? Select all that apply. Refuses to eat Sleeps most of the day Reports feeling fatigued Onset of generalized weakness Does not want to visit with family members
Refuses to eat Reports feeling fatigued Onset of generalized weakness Does not want to visit with family members
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? Skin flushing Decreasing blood pressure Rising body temperature Muscle cramps
Rising body temperature The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature.
Abrasion
Scrape of the skin due to something abrasive
Three fluid-filled bony channels in the inner ear
Semicircular canals
Caused by damage to the inner ear (cochlea) or the nerve from the ear to the brain vestibulocochlear nerve
Sensorineural hearing loss
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? Separation of the proximal wound edges Patient complaint of increased incisional pain Blood glucose of 136 mg/dL Oral temperature of 101° F (38.3° C)
Separation of the proximal wound edges Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly.
Epithelialization
Stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink
Answer the following questions about advance directives: T or F An advance directive is... allows a person to be his/her own power of attorney (POA)
T
Answer the following questions about advance directives: T or F An advance directive is... is a medical directive
T
A patient who has fibromyalgia reports pain at level 7 (0 to 10 scale). The patient tells the nurse, "I feel depressed because I ache too much to play golf." Which patient goal has the highest priority when the nurse is developing the treatment plan? The patient will exhibit fewer signs of depression. The patient will say that the aching has decreased. The patient will report pain at a level 2 of 10. The patient will be able to play a round of golf.
The patient will be able to play a round of golf The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.
Necrosis
Tissue death
Subcutaneous tissue
Tissue, largely fat, that lies directly under the dermis and serves as an insulator of the body.
Laceration
To cut
Stab
To injure someone with a sharp pointed object such as a knife
A test to determine the intraocular pressure on the eye
Tonometry
A client nearing the end of life is unconscious and is experiencing gurgling from the respiratory tract. Which route will the nurse use to provide the client atropine? Oral Rectal Topical Intravenous
Topical
Filtration surgery; permanent fistula created to drain aqueous humor
Trabeculectomy
A surgical procedure performed for the reconstruction of the eardrum and/or the ossicles
Tympanoplasty
Name at least 4 interventions that can be used with an individual with impaired hearing:
Use low tone of voice Speak slowly Reduce background Face the person
Evidence-based medical and nursing research has identified cardiovascular disease as the most prevalent chronic disease in the United States. Under this classification, one condition is the most common. Using this information, a nurse practitioner, treating a 50-year-old man, would do which of the following? Make certain that the patient was aware of the signs of coronary artery disease. Write a prescription for a serum cholesterol level. Teach the patient how to assess his blood pressure weekly. Suggest activity modifications and treatments to help minimize the physical limitations of dyspnea.
Write a prescription for a serum cholesterol level
Grief reactions do not subside and continue over long periods
Chronic grief
The three main clinical features of diabetic ketoacidosis are (select all that apply) A. hyperglycemia B. hypotension C. dehydration with electrolyte loss D. acidosis E. seizures
hyperglycemia dehydration with electrolyte loss acidosis
