PN 102: Exam 2
Three process control fluid and electrolyte balance
Filtration, diffusion, and osmosis
Normal level of Mg Mg main function
1.5 - 2.5 Muscle relaxation
Cognition
A complex and integrative function of the nervous system to acquire and process knowledge for the purposes of reasoning, learning, memory formation, and decision making.
Depression
A mood disorder characterized by a sense of hopelessness and persistent unhappiness.
Fluid Volume Excess (FVE)
A.K.A. Hypervolemia-- Refers to isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water.
Which hormone regulates blood levels of calcium? A: Parathyroid hormone (PTH) B: Luteinizing hormone (LH) C: Thyroid-stimulating hormone (TSH) D: Adrenocorticotropic hormone (ACTH)
A: Parathyroid hormone (PTH) Parathyroid hormone (PTH) regulates the blood levels of calcium and phosphorus. LH stimulates the production of sex hormones, promotes the growth of reproductive organs, and also stimulates reproductive processes. TSH stimulates the release of thyroid hormones and the growth and functioning of the thyroid gland. ACTH promotes the growth of the adrenal cortex and stimulates the release of corticosteroids.
F.A.S.T
Acronym used for early detection of stroke symptoms (Face, Arms, Speech, Time).
Cerebrovascular Accident (CVA)
Also called a stroke, occurs when an area of the brain is deprived of blood flow, which causes damage to that area.
The nurse is reviewing the needs of a patient with cognitive impairment. What is the priority concern the nurse should address? A: Promoting at least 6 hours of sleep a night B: Encouraging an oral intake of 1200 calories per day C: Managing the patient's pain from arthritis D: Supervising medication administration
B: Encouraging an oral intake of 1200 calories per day
A patient injured in an earthquake today when a wall fell on his legs and was hemorrhaging received 9 units of blood an hour ago. Which laboratory value is priority for the nurse to check? A: Serum sodium B: Serum potassium C: Serum total calcium D: Serum magnesium
B: Serum potassium
For a disturbed client who is brought to the emergency department by the police, which assessments are priority? A: Recollection of past events and events preceding police involvement B: Previous history of incarceration or hospitalization for psychiatric disorders C: Current behavior, appearance, cognitive function, affect, and orientation D: Cultural background, family history, developmental level, and verbal skills
C: Current behavior, appearance, cognitive function, affect, and orientation
A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? A: "Don't worry; the patient should be fine once they are in a familiar environment." B: "I can make a referral for a home health aide to assist with the patient." C: "Once the dehydration is corrected, the patient's confusion should improve." D: "I can show you how to care for the patient once you return home."
C: "Once the dehydration is corrected, the patient's confusion should improve."
Which action would the nurse take to assess orientation to place of an older adult female who is brought to the clinic by a family member because of increasing confusion over the past week? A: Ask the client to explain a proverb. B: Ask the client in which state she was born. C: Have the client identify the name of the clinic's town. D: Have the client recall what was eaten for breakfast.
C: Have the client identify the name of the clinic's town.
Hypocalcemia
Deficient of calcium ( < 8.5)
Interstitial fluid (ISF)
Fluid between the cells of an organ or tissue
Anions
Negatively charged ions
Sundowning
Occurs in dementia patients and is characterized as worsening of agitation and confusion which occurs in the evening.
Fluid Volume Deficit (FVD)
Occurs when more water and fluids leave the body than enter it.
Fluid overload
Overhydration; an excess of body fluid. - It is a clinical indication of a problem in which fluid intake or retention is greater than the body's fluid needs.
Cations
Positively charged ions
Memory
Refers to the retention and recall of past experiences and learning.
Coping
The cognitive and behavioral efforts made to alleviate stress.
Oncotic Pressure
The pressure needed to stop movement of fluid in response to protein concentrations. - Albumin in the blood creates oncotic pressure that helps keep blood within the vessels of the circulatory system.
Hydrostatic pressure
The pressure within a blood vessel that tends to push water out of the vessel
Hypertonic dehydration
Water loss > Solute loss - Caused by excessive perspiration, hyperventilation, ketoacidosis, prolonged fever, diarrhea, early stage renal failure, and diabetes insipidus. - CELLS SHRINK - Replacement of water using hypotonic solutions
The nurse is teaching a patient with a new diagnosis of systemic lupus erythematosus (SLE) about the disease. The nurse recognizes that the patient understands the information when making which statement? A: "I need to avoid getting infections because they will increase the immune response in my body, which can make my SLE worse." B: "I need to be sure to take all the available immunizations to keep me from getting sick." C: "Because of my SLE, my immune system is already diminished, so I need to avoid people with the flu." D: "As long as I take all my prescribed medications, I won't have to make any lifestyle changes as a result of my SLE."
A: "I need to avoid getting infections because they will increase the immune response in my body, which can make my SLE worse." SLE is a hyperimmunity problem. Pathogens trigger the immune response in the body, which can exacerbate the SLE. Immunizations trigger the immune response in the body to help create antibodies. In patients with autoimmune diseases such as SLE, immunizations can exacerbate the disease. SLE is not the result of immunosuppression. Lifestyle changes are required with most chronic illnesses such as SLE. Patients cannot depend on medications alone.
A patient recently admitted to the hospital has been diagnosed with delirium. The family of the patient asks the nurse to explain what delirium is. How should the nurse respond? A: Delirium is reversible with treatment of the underlying cause. B: Delirium is progressive and has no known cure. C: Delirium affects a specific area of cognitive functioning. D: Delirium indicates the onset of a cerebrovascular accident
A: Delirium is reversible with treatment of the underlying cause.
The nurse is caring for a patient newly diagnosed with hyperparathyroidism. What findings should the nurse expect? A: Hypercalcemia, lethargy, and constipation. B: Hypercalcemia and positive Trousseau's sign C: Hypocalcemia, lethargy, and constipation D: Hypocalcemia and positive Trousseau's sign
A: Hypercalcemia, lethargy, and constipation.
A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to drink a glass of orange juice every day? A: Maintaining potassium levels B: Preventing increased sodium levels C: Limiting the medications' synergistic effects D: Correcting the associated dehydration
A: Maintaining potassium levels Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia. Digoxin toxicity can occur in the presence of hypokalemia. Neither medication increases sodium levels. Digoxin does not potentiate the action of furosemide; therefore the client should not experience dehydration. Orange juice will not prevent an interaction between digoxin and furosemide.
Which patient is at greatest risk for contracting a primary bacterial infection? A: A patient with newly diagnosed diabetes mellitus B: A patient whose lab results reveal leukopenia C: A patient receiving broad-spectrum antibiotics D: A patient following laparoscopic cholecystectomy
B: A patient whose lab results reveal leukopenia The patient with a decrease in the number of white blood cells (leukopenia) is at greatest risk for contracting a primary infection because of a weakened primary defense system. A patient with a diagnosis of diabetes mellitus is at greater risk for infection than a patient who does not have the disease but does not have the greatest risk of the four patients described. The patient receiving broad-spectrum antibiotics already has an infection and is at risk for a secondary infection. The patient who has undergone a surgical procedure is at risk for a bacterial infection but does not have the greatest risk of the patients described. Laparoscopy minimizes invasion and tissue impairment.
A client with dementia is trying to open the door and says, "I want to leave now." Which intervention would the nurse use? A: Ask the client where she or he is going and how she or he plans to get there. B: Invite the client to attend an activity program that she or he enjoys. C: Allow the client to leave; she or he has the right to refuse treatment. D: Explain that the family and doctor want her or him to stay for safety.
B: Invite the client to attend an activity program that she or he enjoys.
When hypokalemia is suspected, which diagnostic test will the nurse use to confirm the diagnosis? A: Complete blood cell count B: Serum potassium level C: X-ray film of long bones D: Blood cultures ×3
B: Serum potassium level
Electrolytes
Charged atoms or molecules (ions) that conduct electrical impulses across cells. -They carry a positive charge (cation) or a negative charge (anion), which should be equivalent.
Two types of FVD
Isotonic and Hypertonic
Osmotic Pressure
Pressure needed to stop fluid movement across a membrane created by concentration gradients. - When molecules cant move across a membrane, fluid will move to equilibrate the concentrations.
Cognition risk factors
Substance abuse Traumatic brain injury Congenital or genetic conditions Environmental exposures Chronic health conditions Psychotic disorders Neurocognitive disorders
Solutes
Substances that dissolve in a liquid
Colloids
Substances that do not easily dissolve into a liquid, i.e. protein.
Alzheimer's disease
The most common form of dementia that is characterized by a combination of deficits including loss of memory, language skills, visual perception, functional ability, focus, reasoning, and attention.
Sensation
The process by which our sensory receptors and nervous system receive and represent stimulus energies from our environment
Antidiruetic hormone (ADH)
This hormone is released from the posterior pituitary gland and acts on kidney nephrons, making them more permeable to water. As a result, more water is reabsorbed by these tubules and returned to the blood, decreasing blood osmolarity by making it more dilute.
Hyponatremia
Deficient of sodium ( < 135)
Hypermagnesemia
Excess of magnesium ( > 2.5)
Hypernatremia
Excess of sodium ( > 145)
Hypercalcemia
Excessive calcium ( > 10.5)
Hypotonic IV fluids
- 0.45% Saline (1/2 NS) - 0.225% Saline (1/4/ NS) - 0.33% Saline (1/3 NS)
Isotonic IV fluids
- 0.9% Saline - 5% dextrose in water (D5W) - 5% dextrose in 0.225% saline (D5W1/4NS) - Lactated Ringers (LR)
Hypertonic IV fluids
- 3% Saline - 5% Saline - 10% dextrose in water (D10W) - 5% Dextrose in 0.9% Saline - 5% Dextrose in 0.45% Saline - 5% Dextrose in Lactated Ringer's
Three hormones help control fluid and electrolyte balance
- Aldosterone - Antidiuretic hormone (ADH) - Natriuretic peptide (NP
Common causes of fluid imbalances
- Dehydration - Vomiting - Diarrhea - Fistulas - Severe wounds/burns - Long term NPO status
Hypotonic dehydration
- Electrolyte loss exceeds water loss - CELLS SWELL - Caused by chronic illness, excessive fluid replacement renal failure, chronic malnutrition - Treatment: replacement of electrolytes
Isotonic dehydration
- Proportionate loss of fluid and electrolytes - A.K.A. Hypovolemia - Not enough fluid intake, too much fluid loss - Causes a decrease in circulating blood volume, resulting in impaired perfusion.
In the body, water has many important functions including...
- Regulation of body temperature - Lubrication of joints - Serves as a shock absorber for internal organs - Transports nutrients and waste products throughout the body - Is the medium for metabolic reactions within cells
Extracellular fluid can be broken down into two groups.
1. Interstitial fluid (ISF) 2. Intravascular fluid (IVF)
Normal level of Na Na main function
135-145 mEq/L Extracellular excitation
Normal level of K K main function
2.5 - 4.5 Intracellular excitation
Intravenous (IV) fluid replacement of 7200 mL during the first 24 hours has been prescribed for a client with severe burns. Fifty percent of fluid replacement will be administered in the first 8 hours; then the remaining 50% given over the next 16 hours. How many milliliters per hour will the nurse infuse during the first 8 hours?
450 mL/hr Fifty percent of the total volume to be infused is 3600 mL (7200/2 = 3600). The total time of infusion for this volume is 8 hours. 3600 mL/8 hours = 450 mL/h.
Normal level of Ca Ca main function
8.5 - 10.5 Neuronal excitability
Defense mechanisms
A short term, unconscious, protective coping method that individuals apply in response to a perceived threat.
Traumatic brain injury (TBI)
A traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes.
The nurse is teaching a class of junior high school students about infection control through effective hand washing. Which statement made by a student indicates the need for further teaching? A: "Hand sanitizer works just as well as washing with soap and water." B: "If I sing the song "Happy Birthday" twice through while scrubbing my hands, that should be long enough." C: "I need to read the label on the hand sanitizer to be sure that it's at least 60% alcohol." D: "We should all wash our hands before eating lunch every day."
A: "Hand sanitizer works just as well as washing with soap and water." Hand sanitizer does not work as well as soap and water, because it is not effective against all pathogens or in all situations. For example, hand sanitizer should not be used when hands are visibly dirty. Repeating the song "Happy Birthday" twice takes about 20 seconds, which is how long hands should be rubbed together with soap. Hand sanitizer needs to be at least 60% alcohol to be effective. Hand washing before eating is recommended by the Centers for Disease Control.
Which organs are part of the immune system? (Select all that apply.) A: Adenoids B: Appendix C: Bone marrow D: Gallbladder E: Liver F: Thyroid gland
A: Adenoids B: Appendix C: Bone marrow
A 90-year-old patient is admitted to the hospital. Shortly after admission, the family notices that the patient is exhibiting disorientation and agitation. When the family asks the nurse about the behavior, the nurse states that the patient is at risk for developing which common complication of hospitalization in older adults? A: Delirium B: Dementia C: Alzheimer disease D: Sundowner syndrome
A: Delirium
Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. A: Diuretics B: Low-salt diet C: Daily weight checks D: Fluid restriction E: Intake and output F: Oxygen administration
A: Diuretics B: Low-salt diet C: Daily weight checks D: Fluid restriction E: Intake and output F: Oxygen administration Interventions for a client with heart failure who has sustained a 20-pound weight gain would be focused on decreasing fluid retention. Interventions could include diuretic administration to increase fluid removal; a low-salt diet with fluid restriction; daily weight checks and measuring intake/output; and oxygen administration, particularly if the client has fluid in the lungs.
The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) A: Do not use substances such as cannabis and alcohol. B: Wear helmets when riding bicycles and motorcycles. C: Complete a Mini Mental Status Exam (MMSE) yearly. D: Correct acid-base imbalances related to underlying disease processes. E: Wear a seat belt whenever riding in a motorized vehicle. F: Complete a Confusion Assessment Method (CAM) scale yearly.
A: Do not use substances such as cannabis and alcohol. B: Wear helmets when riding bicycles and motorcycles. E: Wear a seat belt whenever riding in a motorized vehicle.
A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? A: Leave a night light on in the room at all times. B: Leave the television on at night with the volume up. C: Restrain the patient to maintain safety during the confusion. D: Administer a sleeping medication to help the patient sleep.
A: Leave a night light on in the room at all times.
The nurse is caring for a patient experiencing a hyperimmune response. What role do the cytotoxic T cells play in this type of immune response? A: May kill healthy cells along with foreign antigens B: Are the most prevalent type of T lymphocyte C: Can suppress the immune response D: Diminish dendritic cell function
A: May kill healthy cells along with foreign antigens Cytotoxic T lymphocytes can kill healthy tissue along with antigens. Suppressor T cells help to keep cytotoxic T cells in check. Helper T cells are the most prevalent type of T lymphocyte, not cytotoxic cells. Cytotoxic T lymphocytes do not suppress the immune response but are a factor in optimal immune functioning. Suppressor T lymphocytes help to suppress the function of cytotoxic cells. Dendritic cell function enhances cytotoxic T lymphocyte functioning.
While caring for an older adult client, which symptom would require an immediate reassessment of the client's needs and plan of care? A: Memory loss or confusion B: Neglect of self-care C: Increased daily fatigue D: Withdrawal from usual activities
A: Memory loss or confusion
A community health nurse is preparing a course on protecting cognitive function. Which population group should the nurse target for teaching? A: Older male adults with diabetes B: Older female adults who are overweight C: Young adults living in school dormitories D: Adolescents attending summer camps
A: Older male adults with diabetes
An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient's confusion? A: Pain medication received earlier in the night B: The death of the patient's spouse 2 years ago C: The patient's history of diabetes D: The age of the patient
A: Pain medication received earlier in the night
Which is a primary contributing factor for the risk-taking behavior for school-aged children? A: Peer pressure B: Cognitive ability C: Chronological age D: Developmental stage
A: Peer pressure
Which developmental achievements distinguish preschoolers from school-aged children? Select all that apply. One, some, or all responses may be correct. A: Preschoolers have imaginary playmates. B: Preschoolers are able to relate events to their causes. C: Preschoolers are curious to know about their surroundings. D: Preschoolers understand that one object can exist in two shapes. E: Preschoolers believe that inanimate objects have lifelike qualities.
A: Preschoolers have imaginary playmates. E: Preschoolers believe that inanimate objects have lifelike qualities.
Transcellular fluid
Cerebrospinal, synovial, peritoneal, pleural, and pericardial fluids. Vitreous and aqueous fluid in the eye and bile and other digestive fluids are included in this category.
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? A: Shift of fluid into the interstitial spaces B: Weakening of the cell wall C: Increased intravascular compliance D: Increased intracellular fluid volume
A: Shift of fluid into the interstitial spaces Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathological reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.
Twenty minutes after an infusion of packed red blood cells begins, the client complains of chest pain, difficulty breathing, and feeling cold. Which is the first action the nurse will take? A: Stop the transfusion. B: Notify the health care provider. C: Provide several warm blankets. D: Assess vital signs.
A: Stop the transfusion. The client is experiencing an anaphylactic reaction and the infusion should be stopped immediately to prevent worsening problems. The vital signs should be assessed because they will need to be provided to the health care provider, who should be notified next. Providing blankets is not essential and may be done after essential actions are taken, if they are needed.
The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? (Select all that apply.) A. Extracellular fluid volume (ECV) excess B. Extracellular fluid volume (ECV) deficit C. Hypokalemia D. Hyperkalemia E. Hypocalcemia F. Hypercalcemia
B. Extracellular fluid volume (ECV) deficit C. Hypokalemia E. Hypocalcemia
Which degree of edema will result in a 6-mm deep indentation upon pressure application? A: 4+ B: 3+ C: 2+ D: 1+
B: 3+
A patient presents to the clinic with observable edema and erythema of the left forearm. A brief history reveals no exposure to potential irritating agents. On palpation, the nurse finds the area very warm and tender. What is the most likely cause of the patient's symptoms? A: An allergic reaction B: A complement cascade C: IgE reactions D: Clonal diversity
B: A complement cascade A complement cascade is responsible for the dilation of blood vessels and leaking of fluid from the vascular system to the area of insult, resulting in the swelling and redness associated with an inflammatory response. An allergic reaction can cause edema and erythema, but the question does not provide enough information to determine the specific cause of the swelling and redness. IgE is a specific immunoglobulin associated with signs and symptoms of allergic rhinitis. Clonal diversity refers to the maturation process of cells.
A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? A: An infant who is being fed reconstituted powdered formula B: A toddler living in an older home that is being remodeled C: A preschooler who attends a play group 3 days a week D: A school-age child who rides a school bus 5 days a week
B: A toddler living in an older home that is being remodeled
Osmosis
Diffusion of water through a selectively permeable membrane
When ammonia is excreted by healthy kidneys, which mechanism usually is maintained? A: Osmotic pressure of the blood B: Acid-base balance of the body C: Low bacterial levels in the urine D: Normal red blood cell production
B: Acid-base balance of the body The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance. Osmotic pressure of the blood and normal red blood cell production are not affected by excretion of ammonia. Ammonia is formed by the decomposition of bacteria in the urine; ammonia excretion is not related to the process and does not control bacterial levels.
A client who was diagnosed recently with early dementia is admitted to the hospital for acute pain in the hip, and a total hip replacement surgery is scheduled. The client is oriented, alert, and responds appropriately when interviewed. The client says, "I don't want to have that surgery." The client's spouse asks that the team proceed with the surgery to provide pain relief for the client. How would the nurse respond? A: Discuss feelings about having surgery with the client. B: Ask the client if a power of attorney for health care has been established. C: Continue with preparation for surgery as the spouse has requested. D: Continue with teaching, ensuring that the client understands the process.
B: Ask the client if a power of attorney for health care has been established.
A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? A: Sodium B: Calcium C: Potassium D: Phosphorus
B: Calcium
The nurse administers a parenteral preparation of potassium slowly to avoid which complication? A: Metabolic acidosis B: Cardiac arrest C: Seizure activity D: Respiratory depression
B: Cardiac arrest Too rapid an administration can cause hyperkalemia, which contributes to a long refractory period in the cardiac cycle, resulting in cardiac dysrhythmias and arrest. Although acidosis can cause hyperkalemia, hyperkalemia will not lead to acidosis. Hyperkalemia causes muscle flaccidity and weakness, not seizures. Respiratory depression can occur with too rapid intravenous (IV) magnesium administration, not potassium administration.
The client's intravenous (IV) site is tender with erythema, warmth, and mild edema. Which action will the nurse take? A: Irrigate the IV tubing. B: Change the IV site. C: Slow the rate of the infusion. D: Obtain a prescription for an analgesic.
B: Change the IV site. The clinical findings indicate the presence of inflammation; therefore, the IV catheter should be removed to prevent the development of thrombophlebitis. Irrigating the IV tubing and slowing the rate of the infusion do not address the underlying problem and may cause worsening irritation. Although an analgesic may relieve the discomfort, it is not an intervention that will resolve the problem.
A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What is the best response by the nurse? A: Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. B: Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. C: Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. D: Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.
B: Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively.
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/h. One hour later, the client begins screaming, "I can't breathe!" How would the nurse respond? A: Discontinue the IV and notify the health care provider. B: Elevate the head of the client's bed and obtain vital signs. C: Assess the client for allergies and change the IV to an intermittent lock. D: Contact the health care provider to request a prescription for a sedative.
B: Elevate the head of the client's bed and obtain vital signs. Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Discontinuing the IV access line is unsafe because IV medications may need to be administered and restarting the IV will cause unnecessary discomfort and expense; more information is needed before calling the health care provider. No information is available to support changing the IV to an intermittent lock. Not enough information is available to support requesting a prescription for a sedative; further assessment is required.
Which interventions would the nurse take to ensure the well-being of a community-dwelling older adult with dementia? Select all that apply. One, some, or all responses may be correct. A: Obtain the client's medication history and educate the older adult about safe medication storage. B: Foster human dignity and maintain the best possible functioning, protection, and safety. C: Teach the client to be cautious of false advertisements that promise a cure for the disease. D: Show the caregiver techniques to dress, feed, and toilet the older adult. E: Protect the client's rights and provide support to maintain the physical and mental health of family members.
B: Foster human dignity and maintain the best possible functioning, protection, and safety. D: Show the caregiver techniques to dress, feed, and toilet the older adult. E: Protect the client's rights and provide support to maintain the physical and mental health of family members.
A client with dementia is having trouble with person, place, and time. Which action by the nurse would be appropriate in this situation? A: Minimize environmental stress to reduce confusion. B: Let the client continue to think in his or her own way. C: Prompt the client to recognize the correct date and time. D: Ask the client to recall the past to understand the present situation
B: Let the client continue to think in his or her own way.
A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? A: "I should drink a lot of tap water today." B: "I need to take more calcium tablets today." C: "I should avoid fruits with potassium in them." D: "I need to drink liquids with some sodium in them."
D: "I need to drink liquids with some sodium in them."
Which cation regulates intracellular osmolarity? A: Sodium B: Potassium C: Calcium D: Calcitonin
B: Potassium A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.
The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse's best response? A: "Hormone therapy will reverse the condition." B: "Vitamin C and zinc will reverse the condition." C: "There is no treatment that reverses dementia." D: "Dementia can be reversed with diet, exercise, and medications."
C: "There is no treatment that reverses dementia."
A client with stage 1 Alzheimer begins to demonstrate aphasia. Which intervention will the nurse use? A: Give step-by-step instructions to accomplish dressing. B: Place a calendar and clock in the client's room. C: Allow extra time for client to verbalize needs and thoughts. D: Remind client to clean and wear prescription eyeglasses.
C: Allow extra time for client to verbalize needs and thoughts.
While palpating the skin of a client, the nurse observes pitting edema on the dorsum of the foot. Which condition could be a possible cause of this? A: Endocrine imbalance B: Excessive collagen production C: Fluid and electrolyte imbalance D: Autonomic nervous system stimulation
C: Fluid and electrolyte imbalance Fluid and electrolyte imbalance results in pitting edema of the skin. An endocrine imbalance may result in nonpitting edema. Excessive collagen production leads to increased skin thickness. Stimulation of the autonomic nervous system may result in an increase in skin moisture.
A patient is on contact isolation for a bacterial infection. Which interventions should the nurse implement for this patient? A: Prevent all visitors from entering the room at any time during hospitalization. B: Use personal protective equipment only when knowingly coming into contact with pathogens. C: Help to ensure adequate social interaction and support. D: Communicate with the patient over the call light whenever possible.
C: Help to ensure adequate social interaction and support.
An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or symptom would the nurse expect to be exhibited by the patient? A: Severe headache B: Flank pain C: Increased confusion D: Decreased blood glucose
C: Increased confusion
Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? A: Shut the client's door during the night. B: Apply a vest restraint when the client is in bed. C: Leave a dim light on in the client's room at night. D: Administer the client's prescribed as-needed sedative medication.
C: Leave a dim light on in the client's room at night.
The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? A: Decreased rate of glomerular filtration B: Excessive blood loss through the burned tissues C: Plasma proteins moving out of the intravascular compartment D: Sodium retention occurring as a result of the aldosterone mechanism
C: Plasma proteins moving out of the intravascular compartment
The nurse is reviewing new medication orders for several patients in a long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? A: The patient prescribed an antibiotic for a urinary tract infection B: The patient prescribed a cholinesterase inhibitor for early Alzheimer disease C: The patient prescribed a β-blocker for hypertension D: The patient prescribed a bisphosphonate for osteoporosis
C: The patient prescribed a β-blocker for hypertension
Hypomagnesemia
Deficient of magnesium ( < 1.5)
Which response would the nurse make to a client with schizophrenia who says, "I'm starting to hear voices"? A: "How do you feel about the voices, and what do they mean to you?" B: "You're the only one hearing the voices. Are you sure you hear them?" C: "The health team members will observe your behavior. We won't leave you alone." D: "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"
D: "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"
At 10:00 AM the nurse hangs a 1000-mL bag of 5% dextrose in water (D 5W) with 20 mEq of potassium chloride to be administered at 80 mL/h. At noon the health care provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion for infusion of the antibiotic? A: 15 minutes B: 30 minutes C: 45 minutes D: 60 minutes
D: 60 minutes An infusion of 1000 mL at 80 mL should take 12.5 hours. Because the primary infusion is interrupted for an hour while the antibiotic is infused, the primary bag will run an hour longer than if it were running uninterrupted. Minutes that are less than an hour are incorrect calculations.
Which occurrence can delay wound healing after surgery? A: Adequate arterial blood flow to the wound B: Supplemental oxygen therapy C: A healthy diet D: An increased hospital stay
D: An increased hospital stay An increased hospital stay increases the risk for hospital-acquired infections, which can delay wound healing. Adequate arterial blood flow improves, rather than delays, wound healing. Supplemental oxygen can increase wound healing. A healthy diet is important to wound healing.
Which relationship between a client's burned body surface area and fluid loss would the nurse consider when evaluating fluid loss in a client with burns? A: Equal B: Unrelated C: Inversely related D: Directly proportional
D: Directly proportional There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.
The nurse is caring for a patient with a diagnosis of multiple sclerosis (MS). The nurse should be aware of which associated response? A: Primary immunodeficiency B: Secondary immunodeficiency C: Optimal immune response D: Exaggerated immune response
D: Exaggerated immune response MS is an autoimmune disease, which is a form of exaggerated immune response. MS is not a problem of immunodeficiency, nor is it an optimal immune response.
Which information would the nurse include in client education regarding alcoholic blackouts? A: It is a fugue state resembling absence seizures. B: It is fainting spells followed by loss of memory. C: It is a loss of consciousness lasting less than 10 minutes. D: It is an absence of memory in relation to drinking episodes.
D: It is an absence of memory in relation to drinking episodes.
Which assessment finding in a client signifies a mild form of hypocalcemia? A: Seizures B: Hand spasms C: Severe muscle cramps D: Numbness around the mouth
D: Numbness around the mouth A numbness or tingling sensation around the mouth or in the hands and feet indicates mild to moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.
The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? A: Allow food selections from a menu with several choices. B: Schedule frequent field trips off the unit for cognitive stimulation. C: Plan for attendance at activities with several other patients on the unit. D: Plan for a structured daily routine of events and caregivers.
D: Plan for a structured daily routine of events and caregivers.
The nurse is establishing a therapeutic environment for a patient admitted with dementia and influenza. Which intervention would be important for the nurse to implement? A: Keep a radio on all the time to provide sound for the patient. B: Decrease patient confusion by limiting verbal interactions. C: Limit family visits to one person for 30 minutes per day. D: Provide a quiet environment in a private room
D: Provide a quiet environment in a private room
A 5-year-old boy with early flu symptoms is at school working with some math blocks. He sneezes into his hand and then continues working with his blocks. An unvaccinated teacher's helper cleans up the blocks when the child leaves them on the table. After touching the blocks, she rubs her nose with her hand. Which represents the most likely mode of transmission? A: The 5-year-old boy B: The unvaccinated teacher's helper C: The hand-to-nose contact D: The unwashed math blocks
D: The unwashed math blocks The boy has the flu and sneezes into his hand while at school. When he works with the math blocks, he leaves the flu virus on the toys. The teacher's helper picks up the virus with the blocks. When the teacher's helper touches her nose with her hand, the virus enters the susceptible host. The blocks act as the mode of transmission. The boy carries the pathogen, and his sneeze is the portal of exit. The teacher's helper is the susceptible host. The hand-to-nose contact is the portal of entry.
Hypotonic and Hypotonic solution
Fluid inside the cell has a lower osmolarity than the fluid outside of the cell-- Cellular shrinkage Excess water moves into the cells-- Cellular swelling.
Dehydration
Fluid intake or retention is les that what is needed to meet the body's fluid needs, resulting in a deficit of fluid volume, especially fluid volume.
Hypertonic and Hypertonic solution
Fluid outside of the cell has a higher osmolarity than the fluid inside the cell. A hypertonic solution pulls water from the cell to the extracellular fluid compartment, causing cellular shrinkage
Extracellular fluid (ECF)
Fluid outside of the cells
Intravascular fluid (IVF)
Fluid within blood vessels/Blood plasma
Intracellular fluid (ICF)
Fluid within the cells that contains electrolytes and glucose.
Lobes of the brain
Frontal, parietal, occipital, temporal
Scope of Cognition
Impaired cognition ------> Intact cognition
Aphasia
Impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).
Delireium
Reversible state of acute confusion. It is characterized by a disturbance in consciousness or a change in cognition that develops over 1 to 2 days and is caused by a medical condition
Isotonic solution
Solute concentration that is essentially equal inside and outside of the cell.
Crystalloids
Solute substance that dissolves easily into a liquid
Natriuretic peptides (NPs)
This hormone is secreted by special cells that line the atria of the heart and the ventricles of the heart. These peptides are secreted in response to increased blood volume and blood pressure, which stretch the heart tissue. Kidney reabsorption of sodium is inhibited at the same time that urine output is increased. The outcome is decreased circulating blood volume and decreased blood osmolarity.
Aldosterone
This hormone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are low. Aldosterone prevents both water and sodium loss. When aldosterone is secreted, it acts on the kidney nephrons, triggering them to reabsorb sodium and water from the urine back into the blood. This action increases blood osmolarity and blood volume. Aldosterone also promotes kidney potassium excretion.
