NRN 163 Cognition and tissue integrity
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? Applying talcum powder to the irradiated areas daily after bathing Avoiding using deodorant soap on the irradiated areas Wearing a lead apron during direct contact with the client Removing thoracic skin markings after each radiation treatment
Avoiding using deodorant soap on the irradiated areas Explanation: Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water and a mild soap only and leave the area open to air. No deodorants or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.
The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply. Request an alternating-pressure mattress. Reposition the client every 2 hours. Elevate the head of the bed to 50 degrees. Obtain daily cultures. Cover with protective dressing
Cover with protective dressing. Reposition the client every 2 hours. Request an alternating-pressure mattress. Explanation: The client has a stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria, and obtaining frequent cultures (unless prescribed otherwise) is not necessary
An 84-year-old patient has returned from the PACU. The patient is orientated to name only. The patients' family is very upset because before having surgery the patient knew the family. The patient is diagnosed with delirium. What should the nurse explain to the patient's family? Delirium usually lasts only a short time. There is nothing to worry about. Delirium involves a progressive decline in memory loss. Delirium is generally more prevalent in women
Delirium usually lasts only a short time. Explanation: Delirium occurs secondary to a number of causes, including physical illness, medication or alcohol toxicity, dehydration, fecal impaction, malnutrition, infection, head trauma, lack of environmental cues, and sensory deprivation or overload. Delirium differs from other types of dementia in that delirium begins with confusion and progresses to disorientation. It affects men and women equally, has symptoms that are reversible with treatment, and with treatment is short-term I nature. Progressive memory loss is seen in Alzheimer's disease. Although delirium usually is short term and resolves with treatment, it can be a life-threatening complication for hospitalized elderly clients and requires significant attention
A nurse is assessing a client diagnosed with schizophrenia. When documenting the findings, which would the nurse identify as a positive symptom? Select all that apply. Hallucinations Anhedonia Alogia Delusions Avolition
Delusions Hallucinations Explanation: Positive symptoms reflect an excess or distortion of normal functions, including delusions and hallucinations. Negative symptoms reflect a lessening (or complete loss) of normal functions, such as restriction or flattening in the range and intensity of emotion (diminished emotional expression); reduced fluency and productivity of thought and speech (alogia); withdrawal and inability to initiate and persist in goal-directed activity (avolition); and inability to experience pleasure (anhedonia)
A 76-year-old client has a significant history of congestive heart failure. During his semiannual cardiology examination, for what should you, as his nurse, specifically assess? Select all that apply. Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion. Examine the client's eyes for excess tears. Examine the client's joints for crepitus.
Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion. Explanation: During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion. Excess tears are not part of the checklist
From the standpoint of cognitive therapy, the term cognition refers to what? Dysfunctional ways of responding to situations Faulty thought patterns that result in abnormal behavior An idea How clients think about themselves and their world
How clients think about themselves and their world Explanation: Cognitive therapy focuses on how clients think about themselves and their world. Addressing cognitions, cognitive therapy posits that how a person perceives an event, rather than the event itself, determines its relevance and the emotional response to it. Cognitive therapy helps clients recognize the process and results of their thinking.
A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? Administering tetanus prophylaxis Applying antimicrobial ointment Covering the area with a sterile dressing Rinsing the area with copious amounts of water
Rinsing the area with copious amounts of water Explanation: The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.
A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. Which of the following demonstrates that the nurse understands the correct procedure for preparing this medication? The intermediate-acting insulin is withdrawn before the short-acting insulin. The short-acting insulin is withdrawn before the intermediate-acting insulin. If administered immediately, there is no requirement for withdrawing one type of insulin before another. Different types of insulin are not to be mixed in the same syringe
The short-acting insulin is withdrawn before the intermediate-acting insulin. Explanation: When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next, a practice referred to as "clear to cloudy."
when assessing a sacral wound which would be a stage I? Blanchable Non-blanchable Open wound to subcutaneous Open wound to bone
non blanchable Explanation: A stage I pressure ulcer is characterized by erythema that does not blanch with pressure and progresses to dusky blue-gray, with elevated temperature of the surrounding skin, swollen and congested tissue, and complaints of discomfort. A stage II ulcer is a partial-thickness wound charaterized by breaks in the skin, edema, drainage, and possible infection. A stage III ulcer is a full-thickness wound that extends into the subcutaneous tissue, has drainage and necrosis, and most likely is infected. A stage IV pressure ulcer is a full-thickness wound that extends to underlying muscle and bone, with necrosis, drainage, and deep pockets of infection
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? nasal cannula flow rate pedal pulses IV fluid infusion rate capillary refill
pedal pulses Explanation: With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.
