nursing 3 exam 2 notes

a client with rheumatoid arthritis has experienced increasing pain and progressing inflammation of the hands and feet. what would be the expected goal of the likely prescribe treatment regimen

minimizing damage

The nurse should advise a client with gout to avoid which food

organ meats and scallops

which of the following would a nurse encourage a client with gout to limit

purine rich foods

a client with systemic lupus erythematosus has a classic rash of lesions on the cheeks in the bridge of the nose. What term should the nurse use to describe this characteristic pattern.

butterfly rash

a client with a history of osteoarthritis. which signs and symptoms should the nurse expect to find on physical assessment

joint pain crepitus heberdens nodes

which of the following may be the first and only physical sign of symptomatic osteoarthritis

limited passive movement

a client is diagnosed with SLE what is The most appropriate action for the nurse to take in order to evaluate the client stage of disease?

review the client's medical record

all nurses to be teaching plan for a client diagnosed with osteoarthritis. what instruction should the nurse give to the client to minimize injury?

install safety devices in the home

a client with early-stage rheumatoid arthritis asks the nurse what to do to help ease the symptoms of disease. What would be the best response by the nurse

the healthcare provider could prescribe anti-inflammatory drugs

the nurse is teaching a client about Rheumatic disease. what statement best helps to explain autoimmunity

your symptoms are as a result of your body attacking itself

A client complaining of palpitations and a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching? "I should eat foods rich in protein." "I should increase my fluid intake." "I'll enroll in an aerobic exercise program." "I can still drink coffee and tea."

"I can still drink coffee and tea." The client requires more teaching if he states that he may drink coffee and tea. Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren't restricted but high-calorie foods are.

A client with atrial fibrillation asks why it is important to recognize the signs of a stroke. What should the nurse respond to this client? "To encourage you to take your medications as prescribed." "Most people with atrial fibrillation develop stokes as a side effect." "So you can respond quickly and prevent adverse effects." "So you can recognize the signs of stroke in a family member."

"Most people with atrial fibrillation develop stokes as a side effect." Explanation/Rationale: It is most important that the client (and family) is able to detect early signs of complications such as stroke to assure prompt treatment and reduce adverse effects.

The nurse is preparing to administer clopidogrel bisulfate to a client with coronary artery disease (CAD). The client asks the nurse, "Why am I getting this medication?" Which statement by the nurse would be most appropriate? "This medication will help decrease your blood pressure if you take it daily." "This medication will help prevent your blood from clotting in the arteries." "It will help decreases your LDL cholesterol." "It will help decrease your chance of developing deep vein thrombosis."

"This medication will help prevent your blood from clotting in the arteries." Explanation/Rationale: Clopidogrel is an antiplatelet agent that prevents clots from forming in the arteries.

The nurse is providing care for a 45-year-old patient who has just learned she is in the second trimester of pregnancy. The patient thought she was experiencing manifestations of menopause until she recognized fetal movement. Which diagnostic test does the nurse expect to be prescribed for this patient? 1. Amniocentesis 2. Ultrasonography 3. Daily fetal movement count 4.Chorionic villi sampling

1. Amniocentesis

The nurse who is analyzing a rhythm strip that has a regular rhythm counts 25 small boxes between R waves. The heart rate would be: 50/min 75/min 60/min 80/min

60/min Using the small box method on a rhythm that is regular , the nurse would divide 1500 by 25 . This will equate to a heart rate of 60/min. Using the large box method, since there are 5 small boxes in one big box, divide 300 (# big boxes in 1 minute) by 5 (#big boxes between R waves) this would equal 60/min.

A client was admitted to the hospital with a diagnosis of aortic regurgitation. On assessment, the nurse notes which positive indicator for this disease process? A lower systolic pressure reading in the lower extremity than in the upper extremity A narrowed pulse pressure Presence of a pulse deficit A pulse that has a rapid upstroke and then collapses

A pulse that has a rapid upstroke and then collapses Aortic regrurgitation causes a classic pulse pattern (Corigan's pulse or Water Hammer pulse) which is characterized by a rapid upstroke and a sudden collapse.

The nurse is analyzing the electrocardiogram (ECG) strip of a stable client admitted to the telemetry unit. The ECG strip demonstrates PR intervals that measure 0.24 seconds. Which of the following is the nurse's most appropriate action? Document the findings and continue to monitor the client. Stimulate gag reflex to terminate the dysrhythmia. Activate the rapid response team. Apply oxygen via nasal cannula and obtain a 12-lead ECG.

Apply oxygen via nasal cannula and obtain a 12-lead ECG. Explanation/Rationale: A PR interval of 0.24 seconds indicates a first degree AV block. This conduction abnormality is usually benign and does not require treatment. This finding should be documented and continue to monitor the patient.

The nurse is caring for a 24-year-old woman who is G1P0 at 40 weeks, 1 day gestation and in active labor. She has just received an epidural and now complains of "an itchy feeling all over." Her vitals are as follows: HR 120, RR 12, BP 130/74, T 98.8, and O2 sat 98%. Which action should the nurse take first? Take no further action regarding the patient's complaints, as they are normal after epidural placement Call the health care provider regarding the patient's pruritus to order an antipruritic medication. Activate emergency response due to the patient's pruritus and tachycardia postepidural placement Call the anesthesiologist regarding the patient's oxygen saturation level.

Call the health care provider regarding the patient's pruritus to order an antipruritic medication. This is correct. Ninety percent of women who receive opioids in epidural have itching, and the health care provider should be notified so the correct medications can be ordered and administered to treat the pruritus.

A women has just arrived at the labor & delivery suite. To report the client's status to her obstetric provider, which of the following assessments should the nurse perform? SELECT ALL THAT APPLY. Contraction Pattern Urinalysis Biophysical profile Vital Signs Fetal Heart Rate

Contraction Pattern *Vital Signs Fetal Heart Rate

The nurse is administering Enalapril (Vasotec) to a patient with heart failure. Which of the following should be a consideration in relation to this medication? Select ALL that apply: Do not administer if the BP is less than 100 mm Hg systolic. It is contraindicated in clients with an ejection fraction of less than 40%. Teach the client how to prevent orthostatic hypotension. Monitor for hyperkalemia It can cause persistent dry cough

Do not administer if the BP is less than 100 mm Hg systolic. Teach the client how to prevent orthostatic hypotension. Explanation/Rationale: Ace inhibitors are indicated for clients with an EF of less than 40%. Enalapril can lower the blood pressure so the medication should not be administered if the BP systolic is below 100 mm Hg. Orthostatic hypotension is a side effect so clients should be advised to change position slowly. Hyperkalemia is a side effect of ace inhibitors. It can cause persistent dry cough Explanation/Rationale: Ace inhibitors are indicated for clients with an EF of less than 40%. Enalapril can lower the blood pressure so the medication should not be administered if the BP systolic is below 100 mm Hg. Orthostatic hypotension is a side effect so clients should be advised to change position slowly. Hyperkalemia is a side effect of ace inhibitors.

An adult patient with third degree AV block is admitted to the cardiac unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? A saw-tooth pattern to the ECG tracing. A PR interval that is constant Fewer QRS complexes than P waves An irregularly irregular rhythm

Fewer QRS complexes than P waves Explanation/Rationale:In third degree AV block, no atrial impulse is conducted through the AV node. A lower pacemaker usually ventricular , stimulates the ventricles. Therefore there are more P waves than QRS complexes due to the difference in the inherent rates of the sinus node and the purkinje system.

The obstetric nurse is assessing the laboring patient for pain. Which of the following should the nurse identify in a pain assessment? Select all that apply. Frequency and duration of contractions Presence of pain in the neck or back Presence of FHR with intermittent auscultation Intensity of contractions Signs of anxiety

Frequency and duration of contractions Intensity of contractions This is correct. In a pain assessment, the nurse should assess for intensity, location, pattern, and degree of distress. Presence of FHR with intermittent auscultation In a pain assessment, the nurse should assess for intensity, location, pattern, and degree of distress. Fetal heart tones are not part of a pain assessment. Fetal heart tones are not part of a pain assessment.

The nurse is caring for a client who had a 12-lead ECG done. The nurse notes that the leads differ from one another on the rhythm strip. How should the nurse best respond? Repeat the 12-lead ECG and instruct the patient to keep still. Inform the technician that the ECG equipment has malfunctioned. Recognize that the view of the electrical current changes in relation to the lead placement. Inform the physician that the patient is experiencing a new onset of dysrhythmia.

Repeat the 12-lead ECG and instruct the patient to keep still. Explanation/Rationale: Each lead offers a different reference point to view the electrical activity of the heart, hence the difference in the waveforms.

the nursing assessment findings reveal joint swelling and tenderness in the great toe of a client. What does the nurse suspect

Gout

A client who has been diagnosed with paroxysmal supraventricular tachycardia (PSVT) is being treated in the emergency department. During the episodes of PSVT the client becomes lightheaded but does not lose consciousness. Which intervention may be used to interrupt this dysrhythmia? Give the client warm water to drink Instruct the client to take quick shallow breaths. Tell the client to exercise vigorously. Have the client bear down.

Have the client bear down. Explanation/Rationale: Bearing down is a form of valsalva maneuver which stimulates the vagus nerve and can terminate PSVT.

The patient is having an unmedicated childbirth and has begun to bear down. She vocalizes, "The baby is coming!" Which action should the nurse take to facilitate fetal descent? Help the patient into a knee-chest position. Help the patient in a lithotomy position. Help the patient onto all fours. Have the patient assume a comfortable and upright position.

Have the patient assume a comfortable and upright position. This is correct. An upright position allows gravity to assist with the descent of the baby.

the nurse is teaching a client newly diagnosed with SLE about the condition. which statement by the client indicates teaching was effective

I should avoid prolonged sun exposure

A nurse is teaching a client about mitral stenosis and the effect on blood flow in the heart. What is the teaching point for this client, based on the disruption to the normal flow of blood through the heart from the mitral stenosis? atrial hypertrophy related to increased blood volume emptying into the left side of the heart Increased resistance caused by a narrowed orifice between the left atrium and the left ventricle pulmonary circulation congestion from incomplete left ventricular emptying inadequate left and right ventricle filling due to ventricular hypertrophy

Increased resistance caused by a narrowed orifice between the left atrium and the left ventricle Left atrial pressure increases because of the slowed blood flow into the LV through the narrowed orifice. The left atrium dilates and hypertrophies because of the increased blood volume. Pulmonary venous pressure rises, and the circulation becomes congested. As a result, the RV and right atrium become enlarged. Eventually, the ventricle fails.

A nurse is receiving a client from the OR after a permanent pacemaker insertion in the right subclavian vein. Which measure should the nurse do to prevent pacemaker lead dislodgement during the early post operative phase? Inspecting the incision site for bleeding and hematoma. Instructing the client to limit right arm movement and to avoid reaching above the shoulder. Asking the provider to order a chest X-ray to check placement of the pacemaker wire. Assisting the client with getting out of bed to ambulate using a walker.

Instructing the client to limit right arm movement and to avoid reaching above the shoulder. Explanation/Rationale: Avoiding excessive movement of the right arm especially reaching above the shoulder during the immediate post operative phase will help prevent dislodgement of the pacemaker lead.

A client admitted to the telemetry unit for unstable angina has several medications ordered. Upon interpretation of the rhythm strip the nurse notes a PR interval of 0.28 seconds. Based on this information, which medication should the nurse question administering to the patient? Rosuvastatin (Crestor) 10 mg once a day at bedtime Metoprolol (Toprol) 50 mg po once a day Isosorbide mononitrate ( Imdur) 20 mg po once a day. Hydralazine (Apresoline ) 25 mg po every 8 hours

Metoprolol (Toprol) 50 mg po once a day Explanation/Rationale: Beta blockers slow conduction through the A-V node (negative dromotropic effect) and can cause first degree A-V block (prolonged PR interval), so administration of this medication should be questioned.

A client admitted for a diagnosis of three-day onset of atrial fibrillation with a rapid ventricular response is complaining of shortness of breath. Vital signs are: BP 130/84; P156/min; R 28/min; O2 Saturation 90% on room air. The nurse anticipates that the medical provider will most likely order which of the following? SELECT ALL THAT APPLY: Immediate cardioversion Oxygen IV Heparin drip per nomogram Carotid sinus massage IV diltiazem (Cardizem) bolus followed by a drip

Oxygen Explanation/Rationale: Immediate cardioversion is indicated if the patient is hemodynamically unstable. It is not done if the onset of atrial fibrillation has been more than 48 hours due to the risk of embolism. IV Heparin drip is given to prevent thromboembolic events. Diltiazem will slow the ventricular response and Amiodarone will covert atrial fibrillation to RSR. Oxygen supplementation is indicated to increase the saturation to 94% or higher. Carotid sinus massage is done to convert PSVT not atrial fibrillation. IV Heparin drip per nomogram Explanation/Rationale: Immediate cardioversion is indicated if the patient is hemodynamically unstable. It is not done if the onset of atrial fibrillation has been more than 48 hours due to the risk of embolism. IV Heparin drip is given to prevent thromboembolic events. Diltiazem will slow the ventricular response and Amiodarone will covert atrial fibrillation to RSR. Oxygen supplementation is indicated to increase the saturation to 94% or higher. Carotid sinus massage is done to convert PSVT not atrial fibrillation. IV diltiazem (Cardizem) bolus followed by a drip Explanation/Rationale: Immediate cardioversion is indicated if the patient is hemodynamically unstable. It is not done if the onset of atrial fibrillation has been more than 48 hours due to the risk of embolism. IV Heparin drip is given to prevent thromboembolic events. Diltiazem will slow the ventricular response and Amiodarone will covert atrial fibrillation to RSR. Oxygen supplementation is indicated to increase the saturation to 94% or higher. Carotid sinus massage is done to convert PSVT not atrial fibrillation.

The nursing preceptor asks the nursing student how to best determine the intensity of contractions before placing the patient on an electronic fetal monitoring strip. How would the nurse assess this? Monitor the patients' vocalizations and facial expressions. Palpate the maternal abdomen during a contraction. Time the amount of time in between the ending of one contraction and the beginning of another. Palpate the maternal abdomen right after a contraction ceases.

Palpate the maternal abdomen during a contraction. This is correct. Intensity is evaluated by palpating the fingertips on the maternal abdomen.

While caring for a women in the transition phase of the first stage of labor, the nurse notes that the fetal monitor tracing shows moderate variability with a baseline fetal heart rate (FHR) of 142 bpm. What should the nurse do? Speed up the women's IV infusion. Change the women's position. Administer O2 via face mask. Provide caring labor support.

Provide caring labor support.

The nurse is providing care to a postpartum patient after an emergency cesarean due to eclampsia. The patient received spinal anesthesia prior to delivery. Magnesium sulfate is infusing 2 g/hr in 100 mL of IV fluid. Which assessment finding will cause the nurse to administer calcium gluconate to the patient via IV push? Patella reflexes are rated at zero. Urinary output remains at 30 mL/hr. Serum magnesium level is 10 mg/dL. Respiratory rate is 18 breaths/min.

Serum magnesium level is 10 mg/dL. This is correct. The therapeutic serum level of magnesium sulfate is 5 to 7 mg/dL, and the patient's laboratory result is 10 mg/dL. The nurse will give the antidote of calcium gluconate (5 to 10 mEq) by IV over a period of 5 to 10 minutes.

A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion? Hypertension A loud, blowing murmur Tachycardia Shortness of breath

Shortness of breath Chronic mitral regurgitation is often asymptomatic, but acute mitral regurgitation (e.g., resulting from a myocardial infarction) usually manifests as severe congestive heart failure. Dyspnea, fatigue, and weakness are the most common symptoms. Palpitations, shortness of breath upon exertion, and cough from pulmonary congestion also occur. A loud, blowing murmur often is heard throughout ventricular systole at the apex of the heart. Hypertension may develop when reduced cardiac output triggers the renin-angiotensin-aldosterone cycle. Tachycardia is a compensatory mechanism when stroke volume decreases.

The nurse is reviewing the purpose of a modified BPP for a patient at 38 weeks gestation. The nurse recognizes which determinations can be made through a modified BPP regarding fetal well-being? Select all that apply. The NST is an indicator of short-term fetal well-being. The test is normal if NST is considered to be nonreactive. An AFI of less than 5cm is indicative of fetal asphyxia. The AFI is an indicator of long-term placental function. The test is considered most predictive for perinatal outcomes.

The NST is an indicator of short-term fetal well-being. This is correct. The nurse recognizes the NST indicates short-term fetal well-being.

a client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms he doesn't need to take this medication any longer. What is the best response by the nurse

it is important that you continue to take your medication to avoid an acute exacerbation.

The nurse is assisting a patient who is pregnant to prepare for an MRI scheduled to assess fetal brain development. Which situation causes the nurse to notify the radiology department personnel? The patient reports having an iodine allergy. The patient has a permanent body piercing. The patient expresses concern about pain. The patient had breakfast before the test.

The patient has a permanent body piercing. This is correct. Part of the preparation for an MRI is to have the patient remove all metallic objects before the testing. The fact that the patient has a permanent body piercing will present a problem. The nurse needs to notify the radiology department for the situation.

The nurse notes that a patient in the third trimester of pregnancy feels unable to "mother" her unborn child. Which information about the patient helps the nurse identify the sources of the patient's ambivalence? Select all that apply. The patient asks about classes for baby care. The patient is estranged from her mother.is estranged from her mother. The patient's partner is excited about a baby. The patient expresses disgust about body changes. The patient expresses a loss of independence.

The patient is estranged from her mother. This is correct. Women who have a positive relationship with their own mothers more easily identify with the role of motherhood. A source of ambivalence for this patient is likely related to her estranged relationship from her own mother. The patient expresses disgust about body changes. This is correct. Acceptance of a pregnancy includes acceptance of the related body changes. The patient's expressed disgust about body changes is a likely source of ambivalence. The patient expresses a loss of independence. This is correct. When the patient expresses unresolved conflict about her loss of independence, which may relate to the demands of motherhood, the nurse identifies a source of ambivalence.

A nurse concludes that a woman is in the latent phase of the first stage of labor. Which of the following signs /symptoms would lead a nurse to that conclusion? The woman talks and laughs during contractions. The woman complains about severe back labor. The woman is thrashing from side to side in pain. The woman asks to go to the bathroom to defecate

The woman talks and laughs during contractions.

A student nurse who is preparing to give Enoxaparin (Lovenox) subcutaneously demonstrates correct understanding of the medication when the student verbalizes which statement about the medication? Vitamin K partially reverses the anticoagulation effect of this drug. The medication dose will be adjusted depending on the daily coagulation studies. The air bubble in the syringe must be expelled prior to administration. There is less risk for bleeding with Enoxaparin compared to unfractionated Heparin (UFH).

There is less risk for bleeding with Enoxaparin compared to unfractionated Heparin (UFH). Explanation/Rationale: Enoxaparin is a low molecular weight Heparin and can cause bleeding but not as much as unfractionated heparin. The air bubble in the syringe serves as an air lock and should not be expelled to ensure that the correct dose of the medication is administered. Protamine sulfate is the antidote, not Vit. K.

The nurse is reading the patient's chart, which indicates the patient has a "gynecoid pelvis." What finding is expected in this patient? Shorter diameter between her coccyx and ischium Smaller outlet Narrower pubic arch Wider outlet

Wider outlet This is correct. A gynecoid pelvis has a wider outlet, larger inlet, longer diameter between the coccyx and ischium and the pubic arch is wider than an android pelvis.

The nurse is performing a cardiac auscultation on a patient with mitral valve regurgitation. Which of the following heart sounds might the nurse expect to hear? a. a harsh diastolic murmur b. a prominent S4 c. a loud second heart sound d. a blowing systolic murmur

a blowing systolic murmur Mitral regurgitation will produce a blowing systolic murmur

a nurse is managing the care of a client with osteoarthritis. what is the appropriate treatment strategy the nurse will teach osteoarthritis.

administration of NSAIDs

A client with a history of heart disease is on telemetry. The ECG strip shows a regular rhythm, with normal intervals, normal P waves and QRS complexes. The rate is 45/min. The client is not experiencing any symptoms. The nurse continues to monitor the client closely for the development of which common consequence of this rhythm? premature ectopic beats asystole sinus arrest complete or third degree heart block

asystole Explanation/Rationale: Sinus bradycardia allows the lower level pacemakers to fire and produce premature ectopic beats

a client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout

elevated uric acid levels

the client with osteoarthritis is seen in the clinic. which assessment finding indicates the client is having difficulty implementing self care?

has a weight gain of 5 pounds