bstrandable NCLEX musculoskeletal and immune
Cast Care in first 24 hours after molding
-ice packs on the side for the first 24 hours because the cast is still wet -no indentations -use palms of hands for the first 24 hours when cast is still wet -Keep uncovered and allow for air dry -Do not rest cast on hard surface or sharp edge (use soft pillow, no plastic)
factors that precipitate relapse
-infx -stress -post-partum (relapse less common during pregnancy)
Brain stem includes
-mesencephalon, pons and medulla oblongata (extend from the base of the brain to the foramen magnum)
Relapsing-remitting disease
-months to years between initial episode and new symptoms or recurrence --Eventually there are relapses and incomplete remissions leading to progressive disability -Weakness, spasticity, ataxia of limbs -Late findings include •Optic atrophy, nystagmus, dysarthria •Pyramidal, sensory or cerebellar deficits in some or all of the limbs
S/S of fractures
-pain and tenderness -unnatural movement -deformity (possible) -shortening of the extremity (caused by muscle spasm) -crepitus (bones grating together) -swelling -discoloration -worry about compartment syndrome
What type of fractures do you see with fat embolisms?
-pelvic, long bones, crushing injuries
Is it ok to massage the stump?
-promotes circulation and decreases tenderness
Common areas for compartment syndrome
-quads -forearms
What is skin traction?
-used short term to relieve muscle spasms and immobilize until surgery -This is when tape or some type of material is stuck to the skin and the weights pull against it. The skin is NOT penetrated
Carpal tunnel
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Describe IQ related to MR.
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Discuss at risk population for PDD, Autism and Down syndrome.
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Discuss educational challenges in the care of the MR.
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Discuss health promotion techniques and teaching to be done for a patient and family with a seizure disorder.
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Discuss health promotion techniques for a patient taking anticonvulsants.
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Discuss nursing care of the child with MR.
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Discuss prenatal, perinatal, and postnatal causes of MR.
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Discuss safety measures for a patient in status epilepticus.
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Discuss techniques used to evaluate the credibility and usefulness of health related information.
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Discuss the differences among home care agencies.
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Examine safety measures for the child with seizures.
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Explain ketogenic diet.
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Coup-contrecoup
..., These injuries to the cerebrum occur when a blow to the head caused the brain to shift towards the area of impact and injure itself by hitting the inner surface of the skull, and then rebounding in the opposite direction and injuring itself again by hitting the skull on the opposite side of the skull where the original blow was delivered.
A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is a. You can plan to have a near-normal life since SLE rarely causes death b. it is difficult to tell because to disease is so variable in its severity and progression c. life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids d. most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage
B. it is difficult to tell because the disease is so variable in its severity and progression
The nurse teaches the patient with RA that one of the most effective methods of aerobic exercise is a. ballet dancing b. casual walking c. aquatic exercises d. low-impact aerobic exercises
C. aquatic exercises
Which of the following terms refers to a fracture in which one side of a bone is broken and the other side is bent? a) Avulsion b) Oblique c) Greenstick d) Spiral
Greenstick Explanation: A greenstick fracture is a fracture in which one side of a bone is broken and the other side is bent. A spiral fracture is a fracture twisting around the shaft of the bone. An avulsion is the pulling away of a fragment of bone by a ligament or tendon and its attachment. An oblique is a fracture occurring at an angle across the bone.
The nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient describes the condition as which of the following? A. Joint destruction caused by an autoimmune process B. Degeneration of articular cartilage in synovial joints C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes
Correct answer: B. Degeneration of articular cartilage in synovial joints Rationale: OA is a degeneration or breakdown of the articular cartilage in synovial joints. The condition has also been referred to as degenerative joint disease.
Describe postop residual lib care after amputation for the first 48 hours?
Elevate stump for first 24 hours. Do not elevate stump after 48 hours. Keep stump in extended position, and turn client to prone position three times a day to prevent flexion contracture.
Neglect Syndrome
The result of certain right parietal lobe lesions that leave a patient completely inattentive to stimuli to her left, including the left side of her own body.
A client is admitted to the nursing unit after a l BKA following a crush injury to the foot and lower leg. The client says "I feel my left foot itching". The nurse interprets this how?
a normal response, and indicates the presence of phantom limb sensation.
Fatigue
a sense of physical tiredness and lack of energy distinct from sadness or weakness Fatigue interferes with physical functioning
Doppler Ultrasound
a study that uses sound for detection of blood flow within the vessels; used to assess intermittent claudication, deep vein thrombosis, and other blood flow abnormalities
PET Scan
a visual display of brain activity that detects where a radioactive form of glucose goes while the brain performs a given task
A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need to have what?
a window cut in the cast. A window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains
Agnosia
any of many types of loss of neurological function associated with interpretation of sensory information
Care of pt during plasmapheresis
assess VS/Weight, CBC, platelet count, clotting studies. Check blood type & crossmatch, watchfor hypotension, dizziness. Monitor for infection, electrolyte loss,
Nursing care of pt w/ rhizotomy
assess corneal reflex, asses facial nerves ie) blow out cheeks, frown, wink etc. assess oculomotor muscles by following finger with eyes. assess motor portion by pt clenching teeth, apply ice pack, avoid rubbing eye on surgical side,
primary progressive MS
continuous neurological deterioration from onset of S&S
clonus
convulsion characterized by alternating contractions and relaxations
Glaucoma assessment findings
diminished accommodation, increased IOP
inactivated or killed vaccines
diptheria, pertussis, and tetanus (DTaP) are considered this type of vaccine that produces a weaker response and require regular boosters
polio
disease caused by a virus that affects CNS through mouth causing paralysis respiratory complications and death
Primary-progressive MS
disease progression occurs from the onset either without remissions or with occasional plateaus and temporary improvement
Cause of Huntington's disease
dominant autosomal trait causes localized death of neurons in basal ganglia. If parent has it, each kid has 50% chance of having it only need 1 gene for disease expression.
tetanus
lock jaw msucle spasms and rigidity causing possible death
during pregnancy, immuno compromised
must avoid MMR vaccine if patient has either of these
a client who sustained a crush injury to right lower leg c/o numbness and tingling of the affected extremity. right leg appears pale and pedal pulse is weak.
notify the hcp- this is signs of compartment syndrome
What is ALS's?
rapidly progressive, degenerative neurological disease defined by weakness, wasting of voluntary muscles w/o sensory changes. Fatal
Relapsing-remitting MS
relapses that occur with either full or partial recovery - the periods of relapses are characterized by a lack of disease progression
S&S of MS
sensory loss, visual deficits (blurring, diplopis, dimished visual fields, altered reaction to light, red-green color distortion), weakness, paresthesias, ataxia, vertigo. Fatigue.
Define neuromuscular disorder.
a disorder involving the relationship between nerves and muscles, and especially the weakening or dysfunction of muscles.
S&S of myasthenic crisis
tachycardia, tachypnea, severe resp distress, dysphagia, restlessness, impaired speech and anxiety.
Skin Testing
the admin of an allergen to the surface of the skin or into the dermis; admin by patch, scratch, or intradermally
A client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the can by holding it with the
the client is taught to hold the cane on the opposite side of the weakness. This will be the patient's left hand. The cane is placed 6 inches lateral to the fithe toe
HIV myelopathy
•Presents as weakness in the legs and incontinence •Spastic paresis and sensory ataxia are seen on physical exam •Late manifestation •Most pts have associated HIV encephalopathy •Diagnosis of exclusion •LP to ruleout CMV polyneuropathy •MRI to exclude epidural lymphoma
Non-pharmacologic types of Tx for degenerative motor neuron diseases?
•Treatment -Physical therapy - exercise of facial muscles -Braces or walker -Portable suction •Feeding tube gastrostomy •Cricopharyngomyotomy •Tracheostomy •Palliative care
characteristics of degenerative motor neuron diseases
•Weakness •No sensory Loss or sphincter disturbance •Progressive course •No identifiable cause other than genetic in familial cases (usually sporadic) •Onset between age 30 and 60
Explain nursing responsibilities included in the referral process.
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Explain the teaching plan for a patient taking anticonvulsants.
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List two community resources for individuals and families of persons with MR.
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Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
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Skeletal Traction
-Applied directly to the bone with pins and wires -Used with prolonged traction is needed
Continuous Passive Motion (CPM)
-Continuously flexes and extends the knee to prevent scar tissue from forming and increasing gradually
symptoms of overactive bladder?
-Having to urinate too often in small amounts -Problems emptying all the urine from the bladder -Loss of bladder control
Primary progressive disease
-Less commonly patients will have steadily progressive symptoms from the outset -Disability develops at a relatively early stage
More cast care points after the cast is dry
-Watch for breakthrough bleeding (mark the area, circle it, date, and sign site, notice if it is bigger) -cover cast close to groin with plastic once it is dry -neuro-vascular checks with the 5 P's
Which of the following blood types would the nurse identify as the rarest?
AB
Identify specific medications and usage for various sign/symptoms of MS.
ABC+R - Avonex, Betaseron, Copaxone. All for relapsing and/or reducing lesions.
Immunosuppressants for MS
Azathioprine (Imuran) Cyclophosphamide (Cytoxan)
Joint Replacement Hesi Hint #4
After hip replacement, instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting. This upward motion can pop the prosthesis out of the socket.
Discuss assessment methods used to identify changes in patient neurological status?
Ask family what the patient's baseline is Assess LOC, and orientation, if pt is unconcious use the Glascow Coma Scale Assess for numbness and tingling in extremeties Determine if pt has difficulty with sensory functions Assess strength of hands grip and movement of extremities Assess pupils using PEERLA Obtain past medical hx
Fracture Hesi Hint #6
Assess the 6 P's of neurovascular functioning: pain, paresthesia, pulse, pallor, paralysis, pressure.
Risk for Disuse syndrome for ALS
Assess, provide skin care, active ROM exercises, maintain pos Nitrogen balance & hydration. Monitor for infection
Which of the following is the priority nursing diagnosis for the patient who has undergone surgery for a spinal fusion? 1. Acute Pain 2. Impaired Mobility 3. Risk for Infection 4. Risk for Injury
Correct Answer: 2 Rationale: The priority nursing diagnosis for a patient who has undergone a spinal fusion is Impaired Mobility, due to the assessment of the ABCs (airway, circulation, breathing). Impaired mobility can affect the patient's circulation, therefore affecting tissue perfusion and causing a risk for skin breakdown. Acute Pain is the next priority since it is an active diagnosis. Diagnoses with "risk for" do not take priority over active diagnoses.
During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate a. increased RBCs b. decreased ESR c. decreased anti-DNA d. increased complement
C. decreased anti-DNA
A patient with OA uses NSAIDs to decrease pain and inflammation. The nurse teaches the patient that common side effects of these drugs include a. allergic reactions, fever, and oral lesions b. fluid retention, hypertension, and bruising c. skin rashes, gastric irritation, and headache d. prolonged bleeding time, blood dyscrasias, and hepatic damage
C. skin rashes, gastric irritation, and headacche
Laboratory findings that the nurse would expect to be present in the patient with RA include a. polycythemia b. increased IgG c. decreased WBC d. increased C-reactive protein (CRP)
D. increased C-reactive protein (CRP)
Avonex
Interferon Beta-1A
The client presents with an exaggeration of the lumbar spine curve. The nurse interprets these findings as indicative of: a) Dowager's hump b) Scoliosis c) Lordosis d) Kyphosis
Lordosis Explanation: Lordosis is an exaggeration of the lumbar spine curve.
Myxedema Coma Interventions
Maintain airway Hourly vitals Monitor body temp Cardiac monitoring continuously Hypertonic saline fluids, glucose Aspiration precautions
Myxedema Coma Priority
Maintain patent airway
How can a nurse best ensure the safety of a client who has a latex allergy?
Make sure that the latex allergy is properly documented.
Pin care
Monitor the site sterile technique remove crusts serous drainage is ok
Chronic complications of DM
Neuropathy, retinal impairment, cataracts, renal issues
Which of the following is the most numerous type of white blood cell (WBC)?
Neutrophil
is CSF helpful to dx MS?
No, elevated protien and lymphocytes, IgG are not specific to MS.
Global Aphasia
Nonfluent aphasia w/ impaired comprehension. Both Broca's and Wernicke's areas affected.
A client is brought to the ED in an unresponsive state, and a dx of HHNS Is made. The nurse would immediately prepare to initiate which of the following in anticipation of the MD order?
Normal Saline
The nurse observes the client and notes a shuffling gait. The nurse recognizes this finding is consistent with: a) Lower motor neuron disease b) Scoliosis c) Parkinson's disease d) Paget's disease
Parkinson's disease Explanation: Parkinson's disease is characterized by a shuffling gait.
Pedi HH #3
Pin sites can be sources of infection. Monitor for signs of infection. Cleanse adn dress pin sites as prescribed.
A nurse administers etanercept (Enbrel) by subcutaneous injection to a client with ankylosing spondylitis. Which action should the nurse take to prevent a needle-stick injury?
Place the uncapped needle in the designated puncture-resistant container.
3 P's for Hyperglycemia
Polyuria, Polydipsia, Polyphagia
Which factor is most important when planning care for a client with a bleeding disorder?
Prioritization
A nurse is caring for a client who is experiencing the end-stage of acquired immunodeficiency syndrome (AIDS) . What is the goal of treatment for this client?
Promoting client comfort
Hyperthyroid Drugs
Propranolol (beta-blocker) Radioactive Iodine PTU Tapazole Lithium
Skin Test: Postprocedure
Record site, date, and time of test; Record date, time of follow-up; inspect site for erythema, papules, vesicles, edema, or wheal; measure wheal if present
Discuss a teaching plan for the child with a head injury.
Teach patient/parent about: Dizziness, nausea vomiting, when to call HCP Visual disturbances; blurring, pupils Headaches LOC - Keep patient oriented, check pt at least every hour Avoiding contact sports
Cataract NSG Diagnosis
Disturbed sensory perception Risk for Injury Social Isolation Self-care deficit
S&S of cholinergic crisis
GI symptoms, severe muscle weakness, vertigo, resp distress. freq pt need ventilator assistance.
List normal findings in a neurovascular assessment.
Warm extremity, brisk capillary refill, free movement, normal sensation of the affected extremity, and equal pulses.
Fractures Hesi Hint #2
What type of fracture is more difficult to heal: an extracapsular fracture (below the neck of the femur) or an intracapsular fracture (in the neck of the femur)? The blood supply enters the femur below the neck of the femur. Therefore, an intracapsular fracture heals with greater difficulty, and there is a greater likelihood that necrosis will occur because the fracture is cut off from the blood supply.
What is Kennedy's syndrome?
X-linked bulbospinal neuronopathy that has a more benign prognosis
Fat embolism
This is a complication of a fracture, especially of the long bone, that can occur in the first 48-72 h after theinjury.
A client with blood type B needs a blood transfusion. Which type of blood can this client receive?
Type B or type O blood
A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300 mg by mouth daily. Before initiating iron therapy, the nurse reviews the client's medical history. Which condition would contraindicate the use of ferrous sulfate?
Ulcerative colitis
Polyarteritis nodosa
collagen disease and a form of systemic vasculitis that causes inflammation of the arteries in visceral organs, brain, and skin; middle-aged men affected; poor prognosis; renal d/o & cardiac involvement are most common cause of death
Dysphagia
condition in which swallowing is difficult or painful
Should contraction be intermittent or continuous?
continuous! Never relieve traction without a doc's order
A client seeks tx in er department for a lower leg injury. There is visible deformity to the lower aspect of the leg and injured leg appears shorte than the other. The area is painful, swollen, and beginnin to become ecchymotic. The nurse interprets that this cliet has experienced a
fracture
Paresis
a slight or partial paralysis. Use Light resistance training to treat.
Bivalving a cast involves what
splitting the cast along both sides to allow space for swelling, facilitate taking x rays, or make a half cast usae as intermittent splint
Dysdiadicokinesia
the inability to switch on and switch off antagonising muscle groups
pertussis
whooping cough respiratory distress, pneumonia, seizures, brain damage or death
client is to begin drug for osteomyelitis: what is included in educating client?
you will need to undergo treatment with iv antibiotics for several weeks
SE of adenocorticosteriods for MS
glucose intolerance, osteoporosis, cataract formation.
sub Q
how are polio, MMR, and varicella vaccine route
personal contact or from food
how can Hep A be spread
sub q
how is meningococcal vaccine route
11 - 64 years old
how old should person be to recieve Tdap one time only and a Td booster every 10 years
may be vaccinated
if severely ill avoid all vaccines, if common cold or minor illness - should they be given vaccine
If a nonplaster (fiberglass) gets wet the client can dry it how
if the cast gets wet, it can be dried with a hair dryer set to a COOL setting to prevent skin breakdown.
Humoral Response
immediate; protects agains acute, rapidly growing bacteria and viruses
Apraxia
impaired ability to carry out motor activities despite intact motor function
A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include: a) body-wide decrease in bone mass. b) inability to perform active movement and pain with passive movement. c) a growth in and around the bone tissue. d) inability to perform passive movement and pain with active movement.
inability to perform active movement and pain with passive movement. Explanation: With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor.
subQ
inactivated polio virus vaccine IPV is given via this route
caring for a client w an external fixator on the lower leg for a fractured tibia, complication
infection
trigeminal Neuralgia
intense paroxysmal neuralgia along the trigeminal nerve. results from demyelination of the sensory division of the trigeminal nerve and is characterized by stabbing short attacks of severe facial pain Eating, shaving or simply touching the face may elicit the response
Cerebral Arteriography
is a form of medical imaging that visualizes the arterial and venous supply of the brain. It was pioneered by Dr Egas Moniz in 1927, and is now the gold standard for detecting vascular problems of the brain.
A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Include what instructions for patien
keep cast and extremity elevate the cast needs to be kept clean and dry allow the wet cast 24 hours to 72 hours to dry
third stage of lyme disease
large joints become involved; arthritis progresses
In an individual with Sjögren's syndrome, nursing care should focus on:
moisture replacement.
Can you dx MS based on one lesion?
no.
Medications for GB
nothing to treat specifically GB, treat other sysmptoms ie) UTI due to stasis in bladder, morphine for muscle pain, anticoags to prevent DVTs.
Stabilizing stage of GB
occurs 2 to 3 weeks after initial onset. symptoms "level off", labile autonomic functions stabilize.
Pemphigus Interventions
oral hygiene, soothe oral lesions; increased fluids; soothing (oatmeal) baths as ordered; ATBs for secondary infections; corticosteroids and cytotoxic agents
Morning stiffness occurs in
osteoarthritis
nursing care of GB is focused on
pain control and risk for impaired skin integrity.
later S&S of ALS
paralysis, muscle mass decrease, progressive fatigue, atrophy of tongue & facial muscles= dysphagia/dysarthria. Emotional libility & loss of control. eventually patient will need total care and ventilatory support.
Food high in calcium include what
plain yougurt, diary products, seafood, sardines, green vegetables, calcium-fortified orange juics, and cereal
what helps with severe relapses that don't respond to corticosteroids?
plasmapheresis
Natural Immunity
present at birth; includes biochemical, physical, and mechanical barriers as well as the inflammatory respone
Recognize patient's response to SC injury (anger, grief, hopeless or suicidal) .
preventions: allow the client time to grieve or to express denial, depression, and anger over the changes in social, financial, and personal roles - the patient needs time to adjust to lifestyle changes. provide accurate information based on the physician's prognosis. include family and significant others to treat the client as normally as possible. refer the client and family to support groups.
what is a neurogenic bladder?
problem in which a perosn lacks bladder control d/t brain or nerve condition
Progressive-relapsing MS
progressive disease from the onset with acute relapses with or without full recovery
What is Huntington's disease
progressive, degenerative, inherited neurological disease= progressive dementia, and jerky, rapid involuntary movements. Onset is in 30's.
Why is limb shaping important post amputation?
prosthesis -you want the end to be shaped like a cone (smaller and rounded at the bottom)
symptoms of latex allergy
range from mild contact dermatitis to moderately severe sx of rhinitis, conjunctivitis, urticaria, and bronchospasm; possible anaphylaxis
Acquired immunity
received passively from mother, animal serum (vaccine), or antibodies from previous disease
goal of plasmapheresis for MG
remove antiacetylcholine receptor antibodies. decreases muscle weakness, fatigue etc
T-Cells
responsible for rejection of transplant tissues
Early S&S of HD
restlessness, fidgety, minor gait changes, freq falls, postural differences, protruding tongue, Slurred speech, decreased ability for ADL's, irritability, rage followed by euphoria, depression, suicide
pathologic fx
results from minimal trauma to a bone weakened by disease
Why must you study the foramen magnum?
rule out possibility of Arnold Chiari malformation (parts of cerebellum and lower brainstem are displaced inferiorly causing mixed pyramidal and cerebellar deficits in the limbs).
first stage of Lyme disease
s/s several days-months following bite; small red pimple develops, spreads to ring-shaped rash; rash may be large, small, or not occur at all; flu-like s/s occur
Nikolsky's sign
separation of the epidermis caused by rubbing the skin; present in pemphigus
anaphylaxis
serious and immediate hypersensitivity rxn with the release of histamine from the damaged cells; can be systemic or localized
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
"Avoid sharing such articles as toothbrushes and razors."
Dx of MS
-Involvement of different parts of the CNS at different times -MRI demonstrating multiple lesions -Must be multifocal (2 foci) -must relapse and remit (2 episodes) -Dx probable in patients with one lesion and two episodes or two lesions and one episode -in pts with single clinical episode who don't meet radiographic criteria, a dx of "clinically isolated syndrome" is made -these pts are at risk of developing MS and are given beta-interferon -Repeat MRI 6-12 months later looking for new lesions
Post-Op care for the hip replacement patient
-Neurovascular checks -Monitor drains (don't want fluid to accumulate in tissue) -Firm mattress (joints need support) -Over-bed trapeze to build upper body strength -isometric exercises while in bed -no weight bearing until ordered -hydrate! -stresses to the new hip joint should be minimal in the first 3-6 months -no sleeping on the operative side -do not give pain meds in the operative hip
Amputations (where are they performed?)
-at the most distal point that will heal -Doc tries to preserve the elbows and knees
Compare and contrast the different types of seizures in children.
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Discuss the adaptions the nurse makes to provide care in the home environment.
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Discuss the importance of early intervention for the child with PDD, Autism and Down syndrome.
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Discuss the nursing care of an individual with a seizure disorder.
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Nursing care for TN focuses on
Acute pain, altered nutrition.
The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
An above-normal anti-deoxyribonucleic acid (DNA) test
fatigue
Antdepressants, Ritalin, Antiviral agents (Symmetral)
A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?
Aplastic anemia
A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-Prone D. Trendelenburg
B. Semi-Fowler's -- The client lies supine with the head of the bed elevated approx. 30 degrees. This position is frequently used to prevent regurgitation and aspiration in clients who have difficulty swallowing. This is the safest position for the client receiving a tube feeding.
To preserve function and the ability to perform activities of daily living, the nurse teaches the patient with OA to a. avoid exercise that involves the affected joints b. plan and organize less stressful ways to perform tasks c. maintain normal activities during an acute episode to prevent loss of function d. use mild analgesics to control symptoms when performing tasks that cause pain
B. plan and organize less stressful ways to perform tasks
A 70-year old patient is being evaluated for symptoms of RA. The nurse recognizes that a major problem in the management of RA in the older adult is that a. RA is usually more severe in older adults b. older patients are not as likely to comply with treatment regimens c. drug interactions and toxicity are more likely to occur with multidrug therapy d. laboratory and other diagnostic tests are not effective in identifying RA in older adults
C. drug interactions and toxicity are more likely to occur with multidrug therapy
During the physical assessment of the patient with moderate RA, the nurse would expect to find a. hepatomegaly b. Heberden's nodes c. spindle-shaped fingers d. crepitus on joint movement
C. spindle-shaped fingers
Cataracts
Clouding and blurring of the lens Opacity Visual acuity is restricted No pain is assoc. with it
Hyperthyroid Interventions
Cool, quiet environment Promote sleep Cool showers & linen changes High calorie/protein diet Extra fluids, no caffeine or fiber Eye care
The nurse recognizes that the most common type of brain attack (CVA) is related to which of the following? 1. ischemia 2. hemorrhage 3. headache 4. vomiting
Correct Answer: 1 Rationale: Eighty percent of all strokes are caused by ischemia. Hemorrhagic strokes are less common than ischemic strokes. Headache and vomiting may be symptoms associated with CVA, but not common causes.
When caring for a patient admitted post-stroke (CVA) who has altered consciousness, the nurse should place the patient in which position? 1. side-lying 2. supine 3. prone 4. semi-Fowler's
Correct Answer: 1 Rationale: The side-lying position is the safest position to allow adequate drainage of fluids without aspiration.
The healthcare provider orders 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5 milliliter (mL) ampule containing 60 mg of ketorolac. How many milliliters of ketorolac does the nurse need to withdraw from the syringe?
Correct Answer: 1.25
A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? 1. "I will stop taking this medicine if I notice any bruising." 2. "I will not eat spinach while I'm taking this medicine." 3. "It will be OK for me to eat anything, as long as it is low fat." 4. "I'll check my blood pressure frequently while taking this medication."
Correct Answer: 2 Rationale: Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless by prescriber order. Low-fat foods do not interfere with warfarin therapy, which is not prescribed to affect the blood pressure.
A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which of the following? 1. increased episodes of hypoglycemia 2. possible episodes of hyperglycemia 3. no change in the patient's glycemic parameters 4. both hyper- and hypoglycemic episodes
Correct Answer: 2 Rationale: A common side effect of corticosteroids is hyperglycemia. Stress as well as the medication could cause this person to have periods of elevated blood sugars.
A lumbar puncture (LP) is done on a patient to rule out a spinal cord tumor. The cerebrospinal fluid (CSF) is xanthochromic, has increased protein, no cells, and clots immediately. What syndrome do these findings describe? 1. Glasgow's syndrome 2. Froin's syndrome 3. cord tumor syndrome 4. reflex syndrome
Correct Answer: 2 Rationale: Froin's syndrome is seen with spinal cord tumors. A lumbar puncture, x-rays, CT scans, MRI, and myelogram are all common tests that are used to diagnose a spinal cord tumor. Glasgow's syndrome, cord tumor syndrome, and reflex syndrome are not terms associated with the symptoms of spinal cord tumor described.
The nurse must be alert to complications in the patient who has suffered a ruptured intracranial aneurysm. The nurse should assess the patient for signs of which of the following? Select all that apply. 1. headache 2. hydrocephalus 3. rebleeding 4. vasospasm 5. stiff neck
Correct Answer: 2,3,4 Rationale: Headache is a sign of a probable rebleed. Hydrocephalus, rebleeding, and vasospasm are the three major complications that a nurse must anticipate following a ruptured intracranial aneurysm. Stiff neck is a manifestation of intracranial aneurysm, not a complication.
A patient is placed in ventilator support with the diagnosis of botulism and failure to thrive. Which nursing actions would be most appropriate for this patient? Select all that apply. 1. maintaining intravenous fluids at KVO (keep vein open) 2. assessing bowel sounds once a shift 3. referring the patient for a physical therapy consult 4. recording the patient's ongoing calorie count 5. assessing the patient's urinary output every hour
Correct Answer: 3,4,5 Rationale: Maintaining fluids at KVO is inappropriate since this patient will be placed on NPO (nothing by mouth) status while ventilated. It is important that the patient receive adequate fluids for hydration and nutrition since nothing will be consumed by mouth. The patient's bowel sounds need to be assessed more often than once a shift (every one to two hours while in the ICU) since the patient is at risk for a paralytic ileus. Physical therapy will be beneficial for maintaining ROM (range of motion) while the patient is immobile from ventilation and sedation. The nurse must closely monitor the patient's calorie intake to determine nutritional needs while NPO. Any time a patient is on maintenance intravenous fluids urinary output must be monitored closely. Additionally, this particular patient is at risk for urinary retention.
The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is which of the following? 1. diabetes 2. heart disease 3. renal insufficiency 4. hypertension
Correct Answer: 4 Rationale: Hypertension is the greatest risk factor for stroke, and should be controlled. Diabetes, heart disease, and renal insufficiency can all lead to stroke, however hypertension is the greatest risk.
A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia
Correct Answer: 4 Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.
The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which of the following findings would the nurse expect to be present on examination of the patient's knees? A. Ulnar drift B. Pain with joint movement C. Reddened, swollen affected joints D. Stiffness that increases with movement
Correct answer: B. Pain with joint movement Rationale: OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease.
Assessment data in the patient with osteoarthritis commonly include a. gradual weight loss b. elevated WBC count c. joint pain that worsens with use d. straw-colored synovial fluid
Correct answer: c Rationale: Osteoarthritis pain ranges from mild discomfort to significant disability. Joint pain is the predominant symptom, and the pain generally worsens with joint use.
Discuss the nursing implications for medications ordered for patients with a spinal cord injury.
Corticosteroids: reduces damage and improves functional recovery by protecting the neuromembrane from further destruction. Monitor for increased infection rate, hyperglycemia, GI bleeding. May also use osmotic diuretics, analgesics, antacids, anticoagulants, stool softeners, vasopressors. Histamine H2-receptor antagonists (ranitidine) are used to prevent stress-related gastric ulcers. Antispasmodics: baclofen, diazepam, dantrolene. they are used to control muscle spasm and pain associated with acute or chronic musculoskeletal conditions. they are not always effective in controlling spasticity resulting from cerebral or spinal cord conditions. assess the client's spasticity and involuntary movements. give with food to decrease GI symptoms. monitor for drowsiness and dizziness.
Characteristics of spondyloarthritides associated with HLA-B27 antigen include a. symmetric polyarticular arthritis b. an absence of extraarticular disease c. presence of rheumatoid factor and autoantibodies d. high level of involvement of sacroiliac joints and the spine
D. high level of involvement is sacroiliac joints and the spine
An important nursing intervention for the patient with ankylosing spondylitis is to teach the patient to a. wear roomy shoes with good orthotic support b. sleep on the side with the knees and hips flexed c. keep the spine slightly flexed while sitting, standing, or walking d. perform back, neck, and chest stretches and deep breathing exercises
D. perform back, neck and chest stretches and deep breathing exercises
A patient is seen at the outpatient clinic for a sudden onset of inflammation and severe pain in the great toe. A diagnosis of gout is made on the basis of a. a family history of gout b. elevated urine uric acid levels c. elevated serum uric acid levels d. the presence of sodium urate crystals in synovial fluid
D. the presence of sodium urate cystals in synovial fluid
Rheumatoid Arthritis
DESCRIPTION: Chronic, systematic, progressive deterioration of the connective tissue (synovioum) of the joints; characterized by inflammation. The exact cause is unknown but it is classified as an immune complex disorder, autoimmune. Joint involvement is bilateral and symmetrical. Severe cases may require joint replacement. NURSING ASSESSMENT: Fatigue; Generalized weakness; Weight loss; Anorexia; Morning stiffness; Bilateral inflammation of joints with: decreased ROM, joint pain, warmth, edema, erythema (rash). Joint deformity. DIAGNOSIS: Elevated erythrocyte sedimentation rate (ESR); Positive rheumatoid factor (RF). Presence of antinuclear antibody, positive (ANA). Joint-space narrowing indicated by arthroscopic examination, (provides joint visualization). **Spongy and boggy joints** Abnormal synovial fluid (fluid in joint) indicated by arthrocentesis. C-reactive protein (CRP) indicated by active inflammation. NANDA: Chronic pain r/t..... ** antidepressants usually ordered.** NURSING INTERVENTIONS: A. Pain relief measures: 1. Use moist heat. Warm, moist compresses, Whirlpool baths, Hot shower in the morning. 2. Use diversionary activities. Imaging, Distraction, Self-hypnosis, Biofeedback. 3. Administer meds and teach client about meds. B. Provide periods of rest after periods of activity: 1. Encourage self-care to maximal level. 2. Allow adequate time for the client to perform activities. 3. Perform activities during time of day when client feels most energetic. C. Encourage the client to avoid overexertion and to maintain proper posture and joint position. D. Encourage use of assistive devices to promote funtional ADL's: 1. Elevated toilet seat. 2. Shower chair. 3. Cane, walker, wheelchair. 4. Reachers. 5. Adaptive clothing and shoes with velcro closures. 6. Straight-backed chair with elevated seat. (remember you can build up a chair with pillows if needed). Develop a teaching plan to include the following: 1.Medication regimen. 2. Need for routine follow-up for evaluation of possible side effects. 3. ROM and stretching exercies tailored to specific client needs. 4. Safety tips and precaustions about equipment use and environment. ***Early diagnosis is better because DMAR's can be given to prevent joint deformity***
Conductive Hearing Loss
DESCRIPTION: Hearing loss in which sound does not travel well to the sound organs of the inner ear. The volume of sound is less, but the sound remains clear. If volume is raised, hearing is normal. Hearing loss is the most common disability in the U.S. It usually results from cerumen impaction or middle ear disorders.
Osteoarthritis (OA) AKA Degenerative Joint Disease (DJD)
DESCRIPTION: Noninflammatory arthritis. OA is characterized by a degeneration of cartilage, a wear-and-tear process. It usually affects on or two joints. It occurs asymmetrically. Obesity and overuse are predisposing factors. NURSING ASSESSMENT:Joint pain that increases with activity and improves with rest. Morning stiffness. Asymmetry of affected joints. **Crepitus (grating sound in the joint).** Limited movement. Visible joint abnormalities indicated on radiographs. Joint enlargement and bony nodules. NURSING INTERVENTIONS:(same as RF) Instruct in weight-reduction diet. Remind client that excessive use of the involved joint aggravates pain and may accelerate degeneration. Teach client to: Use correct posture and body mechanics. Sleep with rolled terry cloth towel under cervical spine if neck pain is a problem. Relieve pain in fingers and hands by wearing stretch gloves at night. Keep joints in functional position. Tylenol or NSAIDs
meds for TN
DOC=tricyclic anticonvulsant- carbamazepine (tegretol). other Dilantin, gabapentin or muscle relaxers- baclofen. SE= dizziness, N, Drowsiness. need to assess liver function, bone marrow and blood levels of meds.
What is compartment syndrome?
Damage to nerves and vasculature of an extremity due to compression.
Describe the adaptive equipment available for patient care.
Eating Devices • Nonskid mats to stabilize plates • Plate guards to prevent food from being pushed off plate • Wide-grip utensils to accommodate a weak grasp Bathing and Grooming Devices • Long-handled bath sponge • Grab bars, nonskid mats, handheld shower heads • Electric razors with head at 90 degrees to handle • Shower and tub seats, stationary or on wheels Toileting Aids • Raised toilet seat • Grab bars next to toilet Dressing Aids • Velcro closures • Elastic shoelaces • Long-handled shoe horn Mobility Aids • Canes, walkers, wheelchairs • Transfer devices such as transfer boards and belts
Diagnosis
Electromyography - To detect fasciculations Muscle biopsy - To rule out muscle disease Spinal tap - Reveals a higher protein level * motor impairment without sensory impairment**
A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? a) Maintaining the client on complete bed rest b) Elevating the stump for the first 24 hours c) Removing the pressure dressing after the first 8 hours d) Applying heat to the stump as the client desires
Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.
Which factor is most important when providing care for a client with hemophilia?
Ensuring client safety
Meneire's Disease
Episodic/incapacitating vertigo, tinnitus, fluctuating sensorineural hearing loss, aural fullness.
A client with a fracture develops compartment syndrome that requires surgical intervention. The nurse would most likely prepare the client for which of the following? a) Amputation b) Joint replacement c) Bone graft d) Fasciotomy
Fasciotomy Explanation: Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.
Pedi HH #1
Fractures in older children are common because they fall during play and are involved in MVAs. Spiral fractures (caused by twisting) and fx in infants may be related to child abuse. Fractures involving the epiphyseal plate can have serious consequences in terms of the growth of the affected limb.
Joint Replacement Hesi Hint #3
Fractures of bone predispose the client to anemia, especially if long bones are involved. Check H&H every 3-4 days to monitor erythropoiesis. Iron can be given PO with meals. (watch for constipation)
Discuss nursing care for the child with ICP.
Frequent assesment of vital signs Careful assement of neurological status Maintaining patent airway Maintaing fluid and electrolyte balance Assesing for s/s of bleeding Parental education and support Elevate HOB 30 degrees, keep head still Use logrolling Nutrition ROM - Mobility Avoid vaso Vagus stimulation Monitor lab values Assess for s/s of infection
What are some causes of conductive hearing loss?
Frequent episodes of ostitis media or otosclerosis
Identify terms describing level of consciousness (LOC).
Full: alert, oriented to time place, and person, pt fully understands written and spoken words. Confusion: unable to think rapidly and clearly; easily bewildered (confused) with short attention span and poor memory. Disorientation: disorientened to time, place, and person. Obtundation: appears drowsy and lethargic; responds to verbal and tactile stimuli but quickly drifts back to sleep. Stupor: generally unresponsive; may withdraw purposefully with vigorous or painful stimuli. Coma: unarousable, does not stir or moan in response to stimuli
PTU
GI irritation, skin rash, pruritis, agranulocytosis (report s/s of sore throat or fever) Results achieved in several weeks
Discuss conditions that result in increased ICP.
Head Injury Hematoma CVA Tumors Infections
Neuro s/s of anaphylaxis
Headache, dizziness, paresthesia, feeling of impending doom
don't give varicella vaccine
If pt. is HIV can they get the varicella vaccine
Fracture Hesi Hint #4
In clients with hip fractures, thromboembolism is the most common complication. Prevention includes passive ROM exercises, use of ted hose, elevation of the foot of the bed 25 degrees to increase venous return, and low-dose anticoagulation therapy (lovenox IM or xarelto PO). ****hip fx compare effected to unaffected side- it will be shorter and externally rotated**
RF Hesi Hint #2
In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflammation sets in. The result is deformity marked by: Immobility Pain Muscle spasm The prescribed treatment regimen is corticosteroids for the inflammation; splinting, immobilization, and rest for the joint deformity; and NSAIDS for pain.
A major symptom of Meniere's Disease is
Incapacitating vertigo
What causes Glaucoma?
Increase in IOP r/t ocular disease
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?
Infection
A 56-year-old client diagnosed with acquired immunodeficiency syndrome (AIDS) is admitted with a closed head injury after being found unconscious on the kitchen floor by her neighbor. The staff suspects domestic abuse, based on information supplied by the neighbor that the client has a restraining order against the husband, who repeatedly tries to visit the client. Which nursing action ensures client safety?
Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client.
Describe strategies and approaches to prevent a CVA.
Ischemic Stroke Modifiers: • Hypertension (Because HBP damages arteries throughout the body, it is critical to keep your blood pressure within acceptable ranges to protect your brain from this often disabling or fatal event.) • Atrial fibrillation • Hyperlipidemia • Diabetes mellitus (associated with accelerated atherogenesis) • Smoking • Asymptomatic carotid stenosis • Obesity • Excessive alcohol consumption Hemorrhagic Stroke Modifiers: Primary prevention of hemorrhagic stroke is the best ap- proach and includes managing hypertension and ameliorat- ing other significant risk factors. Control of hypertension, especially in people older than 55 years of age, reduces the risk of hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Stroke risk screenings provide an ideal opportunity to lower hemorrhagic stroke risk by identifying high- risk individuals or groups and educating patients and the community about recognition and prevention.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
Listen and show interest as the client expresses feelings.
live attenuated vaccine
MMR vaccine is this type of vaccine
What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition?
Notify physician stat, draw blood gases, administer O2 according to blood gas results, assist with endotracheal intubation and treatment of respiratory failure.
symptoms of underactive bladder?
-Bladder becomes too full and you may leak urine -Problems starting to urinate or emptying all the urine from the bladder -Unable to tell when the bladder is full -Urinary retention
Explain the nursing care for the patient receiving anticoagulant therapy.
-Monitor labs, monitor VS, monitor for signs of bleeding, reduce risk factors such as shaving (electric), etc. -Patients should be given the NPSA booklet (see guidance and resources) -On discharge, nurses should ensure patients know their drug dosage and arrange follow-up care -There is no evidence to suggest grapefruit juice should be avoided but cranberry juice can affect INR results. Foods rich in vitamin K can affect INR results if eaten in large quantities -Almost any drug can interact with oral anticoagulants, including herbal remedies. Most increase the effect but some reduce it. The INR should be closely monitored when a new drug is started or dose altered -Patients must know to seek medical attention for injuries, particularly head injuries, due to haemorrhage risk
Tx for degenerative motor neuron diseases
-Riluzole 50mg BID reduces the presynaptic release of glutamate, may slow progression of ALS -Monoclonal gammopathy (increased IgG) - may benefit from plasmapheresis or immunosuppression -Symptomatic treatment with anticholinergic drugs dries up oral secretions -Spasticity may be helped by Baclofen or Valium
Phantom Pain
-Seen more with AKA (above knee) -Diversional activity is the first thing to do -Usually subsides in 3 months
Complications with Fractures include:
-Shock (hypovolemic) -Fat embolism -compartment syndrome
What will you see on MRI for MS?
-T1-weighted lesions show hypointense "black holes" in the brain and cervical spinal cord - Likely areas of axonal damage -hyperintense lesions on non-contrast T1 scans have recently been correlated to disease severity and progression -Gadolinium-enhanced T1-weighted images highlight areas of inflammation with breakdown of BBB (newer lesions) -T2-weighted images provide information about disease burden and total number of lesions - typically high signal intensity
What do you do if your client complains of pain after the cast is dry?
-assess neurovascular -Most pain is relieved by elevation, cold packs, and analgesics (if these things do not relieve pain, think complication)
what to expect with tx for MS?
-at least partial recovery from acute exacerbations -relapses -no means of preventing progression -1/2 of pts are w/o significant disability even 10 yrs after onset of symptoms
Patho of Compartment Syndrome
-fluid accumulates in the tissue and impairs tissue perfusion -The muscle becomes swollen and hard and the client complains of severe pain that is not relieved with pain meds -Pain is unpredictable -Pain is disproportionate to the injury, if undetected, it may result in nerve damage and possible amputation
Elevation post amputation
-it is controversial, because of hip contractures -Only elevate for a short time to reduce swelling -Do not elevate on a pillow, elevate the foot of the bed
Positioning for post-op hip replacement
-neutral rotation-toes to the ceiling -limit flexion; want extension of the hip -Abduction -trochanter roll to promote external rotation -Avoid crossing legs and bending over
Things to remember post knee surgery
-never hyper extend or hyperflex the knee -neurovascular checks -pain relief
Initial presentation of MS
-numbness, weakness, tingling or unsteadiness in a limb -Spastic paraparesis -Retrobulbar optic neuritis -Diplopia -Dysequilibrium -Sphincter diturbance (urinary urgency or hesitancy) *Symptoms may disappear after a few days or weeks, but on exam there may be residual deficit
How do you toughen the stump?
-press into a soft pillow -then a firm pillow -then on the bed -then on a chair or wall
Other Notes to remember about traction
-weights should hang freely -keep patient pulled up in bed and centered with a good alignment -exercise non-immobilized joints -ropes should move freely and knots should be secure/tight -special air filled or foam mattress
Compare the symptoms of PDD, Autism and Down syndrome.
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Describe a nursing care for the patient with a brain tumor.
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Discuss community resources for home health care, meals, equipment, respite care, social services, professional or lay support, and shelters.
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Discuss factors that may contribute to brain tumor formation.
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Discuss local and national resources available to patients with Alzheimer's disease.
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Discuss nursing implications regarding lab values for the patient prescribed anticonvulsants.
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Discuss the local and national community resources available for patients with seizure disorders.
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Discuss the nursing care of the newborn and child with Down syndrome.
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Do not abruptly discontinue use of the antiparkinsonism drugs. Can cause malignant-like syndrome.
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Explain measures used to keep populations healthy.
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Gout: s/s, meds, manifests, dietary restrictions
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List two community resources for individuals and families of persons with CP.
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Describe nursing care to assist the patient with mobility, gait, strength, and motor skills.
1.Reposition the client on a regular schedule as dictated by individual situation. ® Allow proper blood circulation, prevents venous stasis and formation of decubitus ulcers 2.Place patient on moderate high back rest position with head at the midline ® allows greater lung expansion and prevent compression on the diaphragm from prolong bed rest. 3.Support body part especially the affected side using pillows or rolls ®Prevention from developing pressure ulcers particularly on bony prominences 4.Keep body aligned and place extremities in proper position ® Proper positioning and turning maintains joint function and prevents contractures. 5.Perform active range of motion on unaffected extremities and passive range of motion exercises on affected extremities every 4 hours. ®Active range of motion exercise improves muscle strength while passive range of motion exercise improves joint mobility 6.Encourage patient to perform certain movements according to ones capability such as moving left upper and lower extremities, moving tongue, and moving head. ®To maintain strength and integrity of the functioning body parts. 7. Raise the siderails and provide a responsible watcher. ®weakness and loss of body coordination are at risk for fall or accidents. 8.Provide enteral feeding via NGT ®Provision of nutrition for metabolic and energy demand. 9. Perform regular skin care. (e.i sponge bath,apply lotion) ®Maintains skin integrity and decreases risk for skin breakdown. 10.Schedule activities with adequate rest periods ®To reduce fatigue and decrease energy demand 11. Provide a positive atmosphere while acknowledging ones difficulty. ®Helps minimize frustration and rechannel energy.
Discuss the age related (pediatric) nursing care and interdisciplinary care for a head injury.
A child advocacy team or child protective services should be contacted if child abuse is suspected, the mechanism of injury is unknown or unexplained, or the history is inconsistent. NB shock is rarely due to isolated head injury except in young children and in patients with medullary injuries or large scalp lacerations. Pediatric head injury has unique issues that make patient management and outcome different from that of adult head injury. Age related aspects will determine a greater or lesser degree of craniocervical junction injuries (disproportionate cranial size to trunk in infancy and early childhood). Other factors are potential underlying congenital anomalies, physiological factors (cerebrovascular reactivity and blood flow), differing support systems needed from that of adults for neuro imaging and specialized medical, nursing and allied health care support. Pediatric rehabilitation and educational needs and goals are different to that of adult head injury. intubating a child is harder than intubating and adult The physical exam is frequently normal CT scan = significant radiation exposure children sometimes cannot talk but frequently vomit due to stress (instead of head injury) Brain is less myelinated, results in greater sensitivity to shearing forces Cranial bones thinner, resulting in greater transmission of a single force to brain Non-fused sutures makes skull easily deformable Children (particularly < 24 months old) are at increased risk of cerebral hypo-perfusion after TBI
A patient with OA asks the nurse whether he could try glucosamine and chondroitin for control of his symptoms. The best response by the nurse includes the information that a. some patients find these supplements helpful for relieving arthritis knee pain and improving mobility b. although these substances may not help, there is no evidence that they can cause any untoward effects c. these supplements are a fad that has not been shown to reduce pain or increase joint mobility in patients with OA d. only dosages of these supplements available by prescription are high enough to provide any benefit in treatment of OA
A. Some patients find these supplements helpful for relieving arthritis knee pain and improving mobilitiy
A patient taking ibuprofen (Motrin) for treatment of OA has good pain relief but is experiencing increased dyspepsia and nausea with the drug's use. The nurse consults the patient's primary care provider about a. adding misoprostol (Cytotec) to the patient's drug regimen b. substituting naproxen (Naprosyn) for the ibuprofen (Motrin) c. administering the ibuprofen with antacids to decrease the GI irritation d. returning to the use of acetaminophen, but at a dose of 5 g/day instead of 4 g/day
A. adding misoprostol (Cytotec) to the patient's drug regimen
The pathophysiology of systemic lupus erthematosus (SLE) is characterized by a. destruction of nucleic acids and other self-proteins by autoantibodies b. overproduction of collagen that disrupts the functioning of internal organs c. formation of abnormal IgG that attaches to cellular antigens, activating complement d. increased activity of T-suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency
A. destruction of nucleic acids and other self-proteins by autoantibodies
The post-amputation client is seen by the home health nurse. One client outcome included preventing exposure to infection. Which finding would indicate to the nurse that this outcome was met? a) Decreased need for pain medication b) Absence of fever c) Decreased activity tolerance d) Increased participation in self- care
Absence of fever Explanation: Fever would be an indication of infection.
Angle-closure Glaucoma
Acute Considered medical emergency
Hypothyroid interventions
Add fiber to the diet Rest periods Skin moisturizers Low cal diet Increase fluid intake Cough & deep breathe
Describe predisposing factors linked to Alzheimer's disease.
Alzheimer's effects cranial nerves, especially #19. patho 1. loss of nerve cells 2. reduce brain size 3. presence of neurofibrillary tangles 4. neuritic plaques by amyloid protein. Aging. One out of eight people over age 65 has Alzheimer's. Nearly half of people over age 85 have the disease. Family history and genetics Another risk factor is family history. Research has shown that those who have a parent, brother or sister with Alzheimer's are two to three times more likely to develop the disease. There appears to be a strong link between serious head injury and future risk of Alzheimer's. It's important to protect your head by buckling your seat belt, wearing your helmet when participating in sports and "fall-proofing" your home. Some evidence suggests that strategies for general healthy aging may also help reduce the risk of developing Alzheimer's. These measures include controlling blood pressure, weight and cholesterol levels; exercising both body and mind; eating a balanced diet; and staying socially active. Scientists don't know yet exactly how Alzheimer's and diabetes are connected, but they do know that excess blood sugar or insulin can harm the brain in several ways: Diabetes raises the risk of heart disease and stroke, which hurt the heart and blood vessels. Damaged blood vessels in the brain may contribute to Alzheimer's disease. The brain depends on many different chemicals, which may be unbalanced by too much insulin. Some of these changes may help trigger Alzheimer's disease. High blood sugar causes inflammation. This may damage brain cells and help Alzheimer's to develop.
Discuss the use of anti platelet drugs.
Anti platelet drugs prevent thrombus formation in the arterial system (as opposed to anticoagulants, that prevent thrombosis in the venous system). they work by decreasing the platelet's ability to stick together in the blood, thus forming a clot. Often prescribed prophylactically to pts with a-fib for risk of embolic strokes, but have no other warning signs or indicators of future stroke. Compared with antiplatelet therapy, oral anticoagulation significantly reduces stroke at an average follow-up of one to three years, but does not reduce mortality. Applied to all-comers with atrial fibrillation, aspirin reduces stroke by 20 percent, whereas warfarin (Coumadin) reduces it by 65 percent. But SEVERE Intracranial or extracranial hemorrhage is more common with anticoagulation and must be weighed against its therapeutic benefit.
Discuss nursing care of the patient with neuromuscular disorder.
Assess ability to swallow, chew, and taste Assess weight daily Assess bowel sounds Assess/monitor changes in vital signs Assess respiratory rate, character, and use of accessory muscle Administer oxygen as ordered Administer medications as ordered Teach patient about disease process
Which nursing intervention takes priority for a client infected with Pneumocystis carinii pneumonia?
Auscultating breath sounds
If a dislocation is not treated promptly, tissue death due to anoxia can occur. This would be documented as which of the following? a) Heterotopic ossification b) Osteomyelitis c) Subluxation d) Avascular necrosis (AVN)
Avascular necrosis (AVN) Explanation: If a dislocation is not treated promptly, AVN, tissue death due to anoxia and diminished blood supply, and nerve palsy may occur. Subluxation is a partial dislocation of the articulating surfaces. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Osteomyelitis is an acute or chronic inflammation of the bone caused by infection.
How can a nurse best protect herself after she experiences a minor allergic reaction to latex?
Avoid use of all latex products.
During treatment of the patient with an acute attack of gout, the nurse would expect to administer a. aspirin b. colchicine c. allopurinol (Zyloprim) d. probenecid (Benemid)
B. Colchicine
After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says, a. it is important for me to perform my prescribed exercises every day b. I should perform most of my daily chores in the morning when my energy level is highest c. an ice pack to a joint for 10 minutes may help relieve pain and inflammation when I have an acute flare d. I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints
B. I should perform most of my daily chores in the morning when my energy level is highest
A nurse is instructing a client who is postoperative about the sequential compression device the provider prescribed. Which of the following client statements should indicate to the nurse that the client understands the teaching. A. This device will keep me from getting sores on my skin. B. This thing will keep the blood pumping through my leg. C. With this thing on my leg muscles wont get weak. D. This device is going to keep my joints in good shape.
B. This thing will keep the blood pumping through my leg. (promotes venous return in the deep veins of the legs and thus helps prevent thrombus formation.
A patient recovering from an acute exacerbation of RA tells the nurse she is too tired to bathe. The nurse should a. give the patient a bed bath to conserve her energy b. allow the patient a rest period before showering with the nurses' help c. tell the patient that she can skip bathing if she will walk in the hall later d. inform the patient that it is important for her to maintain self-care activities
B. allow the patient a rest period before showering with the nurses' help
A patient with gout is treated with drug therapy to prevent future attacks. The nurse teaches the patient that is is the most important to a. avoid all foods high in purine, such as organ meats b. have periodic determination of serum uric acid levels c. perform active ROM of all joints that have been affected by gout d. increase the dosage of medication with the onset of an acute attack
B. have periodic determination of serum uric acid levels
COMMON TYPES OF FRACTURES
BURST: Characterized by multiple pieces of bone; often occurs at bone ends or in vertebrae. COMMINUTED: More than one fracture line; more than two bone fragments; fragments may be splintered or crushed. COMPLETE: Break across the entire section of bone, dividing it into distinct fragments; often displaced. DISPLACED:Fragments out of normal position at fracture site. INCOMPLETE:Fracture occurs theough only one cortex of the bone; usually nondisplaced. LINEAR: Fracture line is intact; fracture line is intact; fracture is caused by minor to moderate force applied directly to the bone. LONGITUDINAL:Fracture line extends in the direction of the bone's longitudinal axis. NONDISPLACED: Fragments aligned at fracture site. OBLIQUE: Break occurs at an angle across the bone. Occurs at approximately 45 deg angle across the longitudinal axis of the bone. SPIRAL: Break twists around the bone.Fracture line results from twisting force. STELLATE:Fracture lines radiate from one central point. TRANSVERSE: Break occurs across the bone. Fracture line occurs at a 90 deg angle to longitudinal axis of bone. AVULSION:Bone fragments are torn away from the body of the bone at the site of attachment of a ligament or tendon. COMPRESSION:Bone buckles an deventually cracks as the result of unusual loading force applied to its longitudinal axis. GREENSTICK: One side of a bone is broken; the other side is bent. COLLES':Fracture within the last inch of the distal radius; distal fragment is displaced in a position of dorsal and medial deviation. POTT'S: fracture of the distal fibula, seriously disrupting the tibiofibular articulation; a piece of the medial malleolus may be chipped off as a result of rupture of the internal lateral ligament. IMPACTED: Telescoped fracture, with one fragment driven into another.
Define "pill rolling" and "bradykinesia".
Bradykinesia: since the extrapyramidal system regulates posture and skeletal muscle tone, a result is the characteristic of bradykinesia of Parkinson's. It is a slowness of movement. Slowness in the execution of movement, not initiation (like akinesia). "Stone face". Pill Rolling: The Parkinson's tremor tends to more often affect the hands and causes a movement sometimes referred to as "pill rolling". This "pill rolling" 'tremor' involves the uncontrolled movement of the thumb and finger(s) in a back and forth motion. This may also appear as the thumb and fingers are rubbing together, hence the term "pill rolling" movement. These tremors are usually rhythmic and may occur between 4 to 5 cycles per second. It may only affect one side of the body, or one hand, but as the disease progresses, the tremor may become more generalized affecting many parts of the body.
A nurse is completing discharge teaching to a client who has COPD. The client verbalizes understanding of the orthopneic position when he states, "When I have difficulty breathing at night, I will A. lie on my back with my head and shoulders elevated on a pillow. B. lie flat on my stomach with my head to one side. C. sit on the side of my bed and rest my arms over pillows on top of my raised bedside table. D. lie on my side with my weight on my hips and shoulder with my arms flexed in front of me.
C. sit on the side of my bed and rest my arms over pillows on top of my raised bedside table. The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial to clients who have COPD.
tests use to evaluate HIV progression
CBC, lymphocyte screen, quantitative immunoglobulin, chem panel, anergy panel, Hep B surface antigen, blood cultures, CXR
In a patient with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which of the following complications do the assessments help the nurse to monitor in the patient? a) Compartment syndrome b) GI bleeding c) Ganglion cysts d) Carpal tunnel syndrome
Compartment syndrome Explanation: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a patient with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A patient with a dislocation does not experience an increased risk of complications such as GI bleeding, carpal tunnel syndrome, or ganglion cysts.
Myxedema Coma
Complication of Hypothyroidism Resp depression, reduced cardiac output, and cerebral hypoxia Life-threatening Bradycardia, hypoglycemia, Hypotension, Resp depression, stupor, Hypothermia.
Radioactive Iodine (sodium 1131)
Contraindicated for pregnant women Destroys thyroid Fast the night before Benefits may not be seen for 4-6 weeks Avoid contact with other ppl for 2-4 days Increase fluid intake to flush body Expect tenderness in neck Wash clothes, oral care, bathing separately.
A 13-year-old client is brought to the emergency department. The client's mother reports that the client was struck with a baseball bat on his upper arm while diving for a pitched ball. After diagnostic tests are completed, the physician reassures the mother that her son's humerus is not broken but he has suffered another type of injury. What type of injury would you expect the physician to diagnose? a) Sprain b) Strain c) Contusion d) Subluxation
Contusion Explanation: A contusion is a soft tissue injury resulting from a blow or blunt trauma.
Which of the following is a term used to describe a soft tissue injury produced by a blunt force? a) Sprain b) Hematoma c) Contusion d) Strain
Contusion Explanation: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling. A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion.
A nurse is caring for a client who has been sitting in a chair for 3 hours. Which of the following problems is the client at risk for developing? 1. Stasis of secretions 2. Muscle atrophy 3. Pressure ulcer 4. Fecal impaction
Correct -- 3 - Pressure ulcer Incorrect 1. Stasis of secretions -Sitting in a chair will help prevent stasis of secretions 2. Muscle atrophy - is a complication for a client on prolonged bed rest, not just sitting in a chair. 4. Fecal impaction - complication for a client on prolonged bed rest not just sitting in a chair for brief time.
A nurse is caring for a client who is post-operative. Which of the following nursing interventions reduce the risk of thrombus development.? (Select ALL that apply) 1. Instruct the client not to use the Valsalva maneuver. 2. Apply elastic stockings. 3. Review laboratory values for total protein level. 4. Place pillows under the client's knee's and lower extremities. 5. Assist the client to change position often.
Correct -->2. Apply elastic stockings.(promotes venous return and prevents thrombus formation) Correct --> 5. Assist the client to change position often. (prevents venous stasis) Wrong 1. Instruct the client not to use the Valsalva maneuver. (increases workload of heart, but it does not affect peripheral circulation) Wrong3. Review laboratory values for total protein level. (important for evaluating his ability to heal and prevent skin breakdown) Wrong4. Place pillows under the client's knee's and lower extremities. (further impairs circulation to lower extremities.)
Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team
Correct Answer: 1 Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.
A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure
Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.
A patient has the nursing diagnosis of Impaired Swallowing and complains of frequent heartburn. What is the most appropriate action by the nurse? 1. Assist the patient in maintaining a sitting position for 30 minutes after the meal. 2. Teach the patient the "chin tuck" technique when swallowing. 3. Check the patient's mouth for pocketing of food. 4. Assist the patient to a 90-degree sitting position, or as high as tolerated, during meals.
Correct Answer: 1 Rationale: Keeping the patient upright for a time after the meal will help prevent food from being regurgitated back into the esophagus. The position of the patient during the meals as well as teaching the "chin tuck" technique will assist with the swallowing mechanism, but will not help with regurgitation. Pocketing food does not cause regurgitation.
A patient whose status is post-stroke (CVA) has severe right-sided weakness. Physical therapy recommends a quad cane. Which of the following is proper use of the cane by the patient? 1. The patient holds the cane in the left hand. The patient moves the cane forward first, then the right leg, and then the left leg. 2. The cane is held in either hand and moved forward at the same time as the left leg. Then the patient drags the right leg forward. 3. The patient holds the cane in the right hand for support. The patient moves the cane forward first, then the left leg, and then the right leg. 4. The patient holds the cane in the left hand. The patient moves the left leg forward first, then moves the cane and the right leg forward together.
Correct Answer: 1 Rationale: Proper use of the cane is essential to fall prevention. The patient should hold the cane in the left hand. The patient should move the cane forward first, then the right leg, and then the left leg.
A patient is recovering following a carotid endarterectomy. The blood pressure has risen this morning to 168/60. The nurse should do which of the following? 1. Recheck the blood pressure and make sure the correct size cuff was used. Then compare the trend of blood pressure readings and call the physician now. 2. Recheck the blood pressure every hour and report this change to the physician when he or she makes rounds the next time. 3. Record the blood pressure and find out who took this reading. Have that staff member demonstrate his or her blood pressure procedure and offer tips to obtain more accurate readings. 4. Check the standing orders and see if there is a medication ordered p.r.n. for lowering blood pressure. If so, administer it and document the action.
Correct Answer: 1 Rationale: Take a blood pressure reading manually to check technique, compare the results to the last several blood pressures recorded, and call the physician to report this blood pressure. Physicians typically have a range for maintaining the blood pressure following carotid endarterectomy, with standing orders for higher or lower blood pressures. If the blood pressure becomes higher, it is a danger and should be reported to the physician and documented in the patient record along with orders received. Although the skill of the staff is important, it is a priority to notify the physician of the blood pressure reading so that treatment can begin. Antihypertensives may be ordered and administered p.r.n., but physician notification after verification of the reading is the priority, so that further evaluation can occur.
Prodromal manifestations prior to an intracranial aneurysm rupture could be recognized by the nurse as which of the following? Select all that apply. 1. visual deficits 2. headache 3. mild nausea 4. dilated pupil 5. stiff neck
Correct Answer: 1,2,4 Rationale: Often intracranial aneurysms are asymptomatic until rupture but patients can complain of headache and eye pain, and have visual deficits and a dilated pupil. Nausea and vomiting and stiff neck are not usually associated with the prodromal manifestations of an intracranial aneurysm, but may occur with leaking or rupture.
An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed? Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.
Correct Answer: 1,2,5 Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.
A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching? Select all that apply. 1. how to use a sign board 2. transfer techniques 3. information about impulse control 4. time adjustment to complete activities 5. safety precautions for transferring
Correct Answer: 1,2,5 Rationale: The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The patient also might display overcautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement.
The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. "I will have less pain if I use the halo device." 2. "The halo device will allow me to get out of bed." 3. "I am less likely to get an infection with the halo device." 4. "The halo device does not have to stay in place as long."
Correct Answer: 2 Rationale: A halo device will allow the patient to be mobile since it does not require weights like the Gardner-Wells tongs. The patient's pain level is not dependant on the type of stabilization device used. The patient does not have a great risk of infection with the Garnder-Wells tongs; both devices require pins to be inserted into the skull. The time required for stabilization is not dependant on the type of stabilization device used.
A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.
Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.
The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia
Correct Answer: 2 Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.
The family of a patient who has had a brain attack (CVA) asks if the patient will ever talk again. The nurse should do which of the following? 1. Explain that the patient's speech will return to normal with time. 2. Explain that it is difficult to know how far the patient will progress. 3. Tell the family that nurses cannot discuss such issues. Tell them to ask the physician. 4. Tell the family what they see today is all they can expect.
Correct Answer: 2 Rationale: Therapeutic communication is needed. It is important to allow hope but be honest by not promising progress, since no one knows how much the patient will improve. Progress may depend on the extent and the areas affected. The nurse does not know that speech will return in time. It is not therapeutic to tell the family to ask the physician, and it does not display a professional, caring attitude.
The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury for two cord segments above and below the affected level." 3. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."
Correct Answer: 2 Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.
An industrial nurse is conducting a class to teach methods to prevent back pain. What is the correct of steps for lifting heavy objects? Choice 1. Spread the feet apart to broaden the base of support. Choice 2. Use large leg muscles to push when lifting. Choice 3. Stand as closely as possible to the object to be moved. Choice 4. Rolling or pushing the obect insrtead of lifting.
Correct Answer: 2,3,1,4 Rationale: In teaching prevention of back injuries the nurse would incorporate principles of proper body mechanics, which are work as close to the object as possible, spread feet apart, use large leg muscles for leverage. Sometimes rolling or pushing will enable movement of a heavy object.
A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion
Correct Answer: 2,4,5 Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.
A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction
Correct Answer: 2,5 Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.
A patient hospitalized with a known AV malformation begins to complain of a headache and becomes disorientated. Which is the most appropriate action by the nurse? 1. Recommend to the family members that they start to look for a long-term care facility. 2. Prepare to give aspirin or a "clot buster." 3. Prepare the patient for surgery. 4. Document the changes and monitor closely.
Correct Answer: 3 Rationale: An AV malformation is a cluster of vessels, usually located in the midline cerebral artery, that, if ruptured, becomes a surgical emergency to cut the blood flow to the vessels or the patient will bleed out into the brain. Symptoms of rupture include headache,,change in level of consciousness,, nausea and vomiting, and neurological deficits symptoms that mimic any brain bleed. Giving medication to affect coagulation will only make the bleeding worse. Recommending long-term care and merely documenting the changes are not appropriate interventions for a medical emergency.
While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia
Correct Answer: 3 Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.
A school nurse is called after a student falls down a flight of stairs. The student is breathing, but unconsciousness. After calling the ambulance, which is the most appropriate action by the nurse? 1. Protect the patient's neck and head from any movement. 2. Place the patient on his side to prevent aspiration. 3. Immobilize the neck,,securing the head. 4. Try to rouse the patient by gently shaking his shoulders.
Correct Answer: 3 Rationale: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. If the patient vomits, the nurse should utilize the log-roll technique to turn the patient while keeping the head, neck, and spine in alignment. Rousing the patient by shaking could cause damage to the spinal cord.
A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a stroke (CVA). What is the nurse's priority intervention? 1. Move the patient to the critical care unit. 2. Assess blood pressure. 3. Assess the airway and breathing. 4. Observe urinary output.
Correct Answer: 3 Rationale: In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of highest priority and will continue to be. Blood pressure and output monitoring as well as ensuring appropriate level of care are important interventions, but assessment of the patient's ability to maintain an airway is the most vital.
Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury? 1. Fluid Volume Deficit 2. Impaired Physical Mobility 3. Ineffective Airway Clearance 4. Altered Tissue Perfusion
Correct Answer: 3 Rationale: Ineffective Airway Clearance is the priority nursing diagnosis for this patient. The nurse utilizes the ABCs (airway, breathing, circulation) to determine priority. With Ineffective Airway Clearance, the patient is at risk for aspiration and therefore, impaired gas exchange. Fluid Volume Deficit is the nurse's next priority (circulation), and then Altered Tissue Perfusion. If the patient does not have enough volume to circulate, then tissue perfusion cannot be adequately addressed. The last priority for this patient is Impaired Physical Mobility.
The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.
Correct Answer: 3 Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.
The nurse realizes that the goal of surgery for a patient with a secondary metastatic spinal cord tumor is 1. complete removal of the tumor and affected spinal cord tissue. 2. eradication of the tumor with excision and drainage. 3. tumor excision to reduce cord compression. 4. exploration to visualize the tumor and obtain a biopsy.
Correct Answer: 3 Rationale: The tumor can exert pressure on the spinal cord, which interferes with function. In the case of secondary metastatic spinal tumor (which means a second site of cancer) and the metastasis (spread of cancer) the patient outcome may be limited to preventing compression on the spinal cord and not totally removing the cancerous lesion. Complete removal along with affected spinal tissue or eradication by excision and drainage would not be likely due to the secondary nature of the tumor and the resulting disability. Biopsy can be accomplished without direct visualization.
A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient asks, "What is the most important thing for me to remember?" Which is an appropriate response by the nurse? 1. "Know your family history." 2. "Keep a list of your medications." 3. "Be alert for sudden weakness or numbness." 4. "Call 911 if you notice a gradual onset of paralysis or confusion."
Correct Answer: 3 Rationale: Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.
Of the following, which groups are the most at risk for bacterial meningitis? Select all that apply. 1. older adults 2. pregnant women 3. military recruits 4. college students 5. low-income
Correct Answer: 3,4 Rationale: Military personnel living on a base and young adults living in close proximity (such as college students living in a dormitory) are at a greater risk of contracting bacterial meningitis. The other populations are at lower risk.
Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy? 1. Provide the patient with an air mattress. 2. Place pillows under patient to help patient turn. 3. Teach the patient to grasp the side rail to turn. 4. Use the log roll to turn the patient to the side.
Correct Answer: 4 Rationale: A patient who has undergone a laminectomy needs to be turned by log rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.
A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which of the following? 1. impending brain death 2. decreasing intracranial pressure 3. stabilization of the patient's condition 4. increased intracranial pressure
Correct Answer: 4 Rationale: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician. This is an emergency situation that requires intervention as the patient's condition is becoming more unstable. Brain death is diagnosed by lack of brain waves and inability to maintain vital function.
A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.
Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.
The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient that the most beneficial measure to protect the joints is to do which of the following? A. Use a wheelchair to avoid walking as much as possible. B. Eat a well-balanced diet to maintain a healthy body weight. C. Incorrect Use a walker for ambulation to relieve the pressure on her hips. D. Sit in chairs that do not cause her hips to be lower than her knees.
Correct answer: B. Eat a well-balanced diet to maintain a healthy body weight. Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight.
A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."
Correct answer: C. "I'm hoping that surgery will be an option for me in the future." Rationale: SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.
The nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which of the following activity patterns? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C.A regular exercise program of walking D. Frequent rest periods with minimal exercise
Correct answer: C. A regular exercise program of walking Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis.
Which of the following patient statements most clearly suggests a need to assess the patient for ankylosing spondylitis (AS)? A. "My right elbow has become red and swollen over the last few days." B. "I wake up stiff every morning and my knees just don't want to bend." C. "My husband tells me that my posture has become so stooped this winter." D. "My lower back pain seems to be getting worse all the time and nothing seems to help."
Correct answer: D. "My lower back pain seems to be getting worse all the time and nothing seems to help." Rationale: AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.
The nurse is reinforcing general health teaching with a 64-year-old patient with osteoarthritis (OA) of the hip. Which of the following points would the nurse include in this review of the disorder (select all that apply)? A. OA cannot be successfully treated with any current therapy options. B. OA is an inflammatory disease of the joints that may present symptoms at any age. C.Joint degeneration with pain and disability occurs in the majority of people by the age of 60. D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling. E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.
Correct answer: D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling. E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication. Rationale: OA occurs with greater frequency with increasing age, but it usually remains confined to a few joints and can be managed with a combination of exercise, diet, and medication. OA can lead to significant disability.
Teach the patient with ankylosing spondylitis the importance of a. regular exercise and maintaining proper posture b. continuing with physical activity during flare-ups c. avoiding extremes in environmental temperatures d. applying cool compresses for relief of local symptoms
Correct answer: a Rationale: Patients with ankylosing spondylitis (AS) should exercise after pain and stiffness are managed. Postural control is important to minimize spinal deformity. The exercise regimen should include back, neck, and chest stretches. The nurse should educate the patient with AS about regular exercise and attention to posture, local moist-heat applications, and knowledgeable use of drugs. The nurse should discourage excessive physical exertion during periods of active flare-up of the disease. Proper positioning at rest is essential. The mattress should be firm, and the patient should sleep on the back with a flat pillow, avoiding positions that encourage flexion deformity. Postural training emphasizes avoiding spinal flexion (e.g., leaning over a desk), heavy lifting, and prolonged walking, standing, or sitting.
When administering medications to the patient with gout, the nurse would recognize which of the following as a treatment for chronic disease? a. Colchicine b. Febuxostat c. Sulfasalazine d. Cyclosporine
Correct answer: b Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of hyperuricemia in persons with chronic gout. Acute gouty arthritis is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).
In teaching a patient with chronic fatigue syndrome (CFS) about this disorder, the nurse understands that a. palpating tender points is an indicator of CFS severity b. many symptoms are similar to fibromyalgia syndrome c. definitive treatment includes low-dose hydrocortisone d. CFS is characterized by progressive memory impairment
Correct answer: b Rationale: Fibromyalgia syndrome (FS) and chronic fatigue syndrome (CFS) have several commonalities. Both occur in previously healthy, young, and middle-aged women; the cause of both includes an infectious trigger, dysfunction of the hypothalamic-pituitary-adrenal axis or an alteration in central nervous system; and common clinical manifestations are malaise and fatigue, cognitive dysfunction, headaches, sleep disturbances, depression, anxiety, fever, and generalized musculoskeletal pain. Both diseases have symptoms that fluctuate over time, and both disorders have no definitive laboratory tests or joint and muscle examinations. They remain diagnoses of exclusion. Treatment for both disorders is symptomatic and may include antidepressant drugs. Other measures are heat, massage, regular stretching, biofeedback, stress management, and relaxation training.
In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. the production of a variety of autoantibodies directed against components of the cell nucleus
Correct answer: d Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions characteristically are directed against constituents of the cell nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune complexes containing antibody against DNA are deposited in the basement membranes of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and inflammation occurs. The overaggressive antibody response is also related to activation of B and T cells. The specific manifestations of SLE depend on which cell types or organs are involved. SLE is a type III hypersensitivity response.
In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints are damaged by (select all that apply) a. bony ankylosis following inflammation of the joints b. the deterioration of cartilage by proteolytic enzymes c. the development of Heberden's nodes in the joint capsule d.. increased cartilage and bony growth at the joint margins e. invasion of pannus into the joint causing a loss of cartilage
Correct answers: a, e Rationale: Bony ankylosis is the union of the bones of a joint by proliferation of bone cells, resulting in complete immobility. Bony ankylosis occurs with advanced rheumatoid arthritis. Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding cartilage, ligaments, tendons, and joint capsule. Pannus (i.e., highly vascular granulation tissue) forms within the joint. It eventually covers and erodes the entire surface of the articular cartilage. The production of inflammatory cytokines at the pannus-cartilage junction further contributes to cartilage destruction. The pannus scars and shortens supporting structures such as tendons and ligaments, ultimately causing joint laxity, subluxation, and contracture.
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the lower left extremity, which of the following instructions should the nurse provide? (Select ALL that apply) 1 - Hold the cane on the right side. 2. Keep two points of support on the floor. 3. Place the cane 15 inches in front of the feet before advancing. 4. After advancing the cane, move the weaker leg forward. 5. Advance the stronger leg so that it aligns evenly with the cane.
Correct: 1 - Hold the cane on the right side. (hold cane on the uninjured side to provide support for injured leg) 2. Keep two points of support on the floor. (for stability) 4. After advancing the cane, move the weaker leg forward. (cane, weaker leg then stronger leg) Wrong: 3. Place the cane 15 inches in front of the feet before advancing. (s/b 6-10 inches) 5. Advance the stronger leg so that it aligns evenly with the cane. ( should advance the stronger leg past the cane)
A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select ALL that apply) A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 - 3 hours to flex and stretch joints and muscles.
Correct: A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. D. Use smooth movements when lifting and moving clients. Incorrect: C. Keep the knees slightly lower than the hips when sitting for long periods of time. Should be knees HIGHER in order to decrease strain on the lower back. E. Take a break from repetitive movements every 2 - 3 hours to flex and stretch joints and muscles. Nurses should take a break every 15-20 min
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer.
D. Assess the client's ability to help with the transfer. The first action the nurse would take using the nursing process is to assess/collect data from the client. The nurse should assess the client's ability to help with the transfers (balance, muscle strength & endurance). Then the nurse can proceed with a safe transfer of the client.
Fracture
DESCRIPTION: Any break in the continuity of the bone. Fractures are described by the type and extent of the break. Fractures are caused by a direct blow, crushing force, a sudden twisting motion, or a disease such as cancer or osteoporosis. Comple fracture breaks across the entire cross section of the bone. Incomplete fracture breaks only part of the bone. Closed fracture there is no break in the skin. Open fracture has broken bone that protrudes theough skin or mucous membranes and are much more prone to infection. **update tetanus toxoid, prophylactic antibiotics**. NURSING ASSESSMENT:Signs and symptoms of fracture include: Pain, swelling, tenderness. Deformity, loss of functional ability. Discoloration, bleeding at the site throguh an open wound. Crepitus-crackling sound between two broken bones. Fracture is evident on radiograph. Therapeutic management is based on: reduction of the fracture. Maintenance of realignment by immobilization. **Don't dislodge hematoma**. Restoration of function. Crutches: there should be 2-3 finger widths between the axilla and the top of the crutch. A three-point gait is most common. The client advances both crutches and the impaired leg at the same time. The client then swings the uninvolved leg ahead to the crutches. Cane: It is placed on the unaffected side. The top of the cane should be at the level of the greater trochanter. Walker: Strength of upper extremity and unaffected leg is assessed and improved with exercises, if necessary so that upper body is strong enough to use walker. Client lifts and advances the walker and steps forward.
Juevenile Rheumatoid Arthritis (JRA) or Juevenille Idiopathic Arthritis (JIA)
DESCRIPTION: Chronic inflammatory disorder of the joint synovium. Single or multiple joints may be affected. It may also have a systemic presentation. It occurs between ages 2-5 and 9-12. NURSING ASSESSMENT: Joint swelling and stiffness (usually large joints). Painful joints. Generalized symptoms: fever, malaise and rash. Periods of exacerbations and remissions. Varying severity: mild and self-limited or severe and disabling. Lab data: latex fixation test (usually negative) and elevated ESR. Poorest prognosis: Positive RF and Polyarticular systemic onset. NURSING PLANS AND INTERVENTIONS: Plan home program of prescribed exercise, splinting, and activity. Assist in identifying adaptations in routine (eg. Velcro fasteners, frequent rest periods). Support the maintaining of school schedule and activites appropriate for age. Teach about med regimen: combination drugs are used. Nonsteroidal antiinflammatory drugs: aspirin, Tolmetin sodium, Ibprofen, Naproxen. Antirheumatic drugs-gold salts. corticosteroids-prednisone. Cytotoxic drugs-methotrexate. Teach child and family about side effects and toxic effects of prescribed drugs. Inform child and family that the optimum antiinflammatory effects of drugs may take a month to achieve. Encourage periodic eye exams for early detection of iridocyclitis so to prevent vision loss. encourage family to allow child's independence.
CATARACTS
DESCRIPTION: Condition characterized by opacity of the lens. Aging accounts for 95% of cataracts. The remaining 5% result from trauma, toxic substances, or systemic diseases or are congenital. Safety precatuions may reduce the incidence of traumatic cataracts. Surgical removal is done when vision impairment interferes with ADL's. Intraocular lens implants may be used. Most operations are performed under local anesthesia on an outpatient basis. NURSING ASSESSMENT:Early signs: Blurred vision and decreased color perception. Late signs include: Diplopia (double vision). Reduced visual acuity, progressing to blindness. Clouded pupil, progressing to a milky-white appearance. DX Tests: Ophthalmoscope. Slit-lamp biomicroscope. NURSING PLANS AND INTERVENTIONS: Preoperative: Demonstrate and request a return demonstration of eye medication instillation from client or family member. Develop a postop teaching plan that includes: Warning not to rub or put pressure on eye. Teach that glasses or shaded lens should be worn during waking hours. An eye shield should be worn during sleeping hours. Teach to avoid lifting objects over 15lbs, bending, straining, coughing, or any other activity that can increase IOP. Teach to use a stool softener to prevent straining at stool. Teach to avoid lying on operative side. Teach the need to keep water from getting into eye while showering or washing hair. Teach to observe and report signs of increased IOP and infection (eg. pain, changes in vital signs). *Tylenol should control postop pain.* ***S/S****
Sensorineural Hearing Loss
DESCRIPTION: Form of hearing loss in which sound passes properly through the outer and middle ear but is distorted by a defect in the inner ear. It involves perceptual loss, usually progressive and bilateral. It involves damage to the 8th cranial nerve. (vestibulocochlear). It is detected easily by the use of a tuning fork. Common causes: Infections. Ototoxic drugs-aspirin, lasix, aminoglycasides, vancomycin Trauma Neuromas Noise Aging process- presbycusis NURSING ASSESSMENT: Inability to hear a whisper from 1-2 feet away. Inability to respond if nurse covers mouth when talking, indicating that client is lip reading. Inability to hear a watch tick 5 inches from ear. Shouting in conversation. Straining to hear. Turning head to favor one ear. Answering questions incorrectly or inappropriately. Raising volume of radio or tv. NURING PLANS AND INTERVENTIONS:The nurse should do the following to enhance therapeutic communication with the hearing impaired: Prior to starting conversation, reduce distraction as much as possible. Turn the tv or radio down or off, close the door, or move to a quieter location. Devote full attention to the conversation; do not try to do two things at once. Look and listen during the conversation. Begin with casual topics, and progress to more critical issues slowly. Do not switch topics abruptly. If you do not understand, let the client know. If the client is a lip reader, face them directly. Speak slowly and distinctly; determine whether you are being understood. Allow adequate time for the conversation to take place; try to avoid hurried conversations. Use active listening techniques. Be sure to inform the health care staff of the clients hearing loss. Helpful aids may include a d telephone amplifier, earphone attachments for the radio and tv, and lights or buzzers that indicate the doorbell is ringing, located in the most commonly used rooms of the house.
EYE TRAUMA
DESCRIPTION: Injury to the eye sustained as the result of sharp or blunt trauma, chemicals or heat. Permanent visual impairment can occur. Every eye injury should be considered an emergency. Protective eye shields in hazardous work environments and during athletic sports may prevent injuries. NURSING PLANS AND INTERVENTIONS:Position the client according to the type of injury; a sitting position decreases IOP. Remove conjunctival foreign bodies unless embedded. **Never attempt to remove a penetrating or embedded object. Do not apply pressure.** Apply cold compresses to eye contusion (black eye). After chemical injuries, irrigate the eye with copious amounts of water. Administer eye meds as prescribed. Explain that an eye patch may be applied to rest the eye. Reading and watching tv may be restricted for 3-5 days. Explain that a sudden increase in eye pain should be reported.
Joint Replacement (common for RF clients)
DESCRIPTION: Surgical procedure in which a mechanical device, designed to act as a joint, is used to replace a diseased joint. The most commonly replaced joints: Hip; Knee; Shoulder; Finger Accurate fitting is essential. Client must have healthy bone stock for adequate healing. Infection is the concern postoperatively. NURSING ASSESSMENT: Joint pathology: 1.Osteoarthritis 2. Rheumatoid arthritis 3. Fracture Pain not relieved by medication. Poor ROM in the affected joint. NURSING INTERVENTIONS:Provide postoperative care for wound and joint. Monitor incision site: assess for bleeding and drainage; assess suture line for erythema and edema; assess suction drainage apparatus for proper functioning; assess for signs of infection. Monitor functioning of extremity: check circulation, sensation, and movement of extremity disal to replacement; provide proper alignment of affected extremity. Client will return from the operating room with alignment for the initial postoperative period; Provide abductor appliance (hip replacement) or continuous passive motion (cpm) device if indicated; monitor I&O every shift, including suction drainage. Encourage fluid intake of 3L per day. Enourage client to perform self-care activities at maximal level. Coordinate rehabilitation: work closely with health care team to increase client's mobility gradually. Get client out of bed as soon as possible. Keep client out of bed as much as possible. Keep abductor pillow in place while client is in bed (hip replacement). Use elevated toilet seat and chairs with high seats for those who have had hip or knee replacements (prevents dislocation). Do not flex hip more than 90 degrees (hip replacement) Provide discharge planning that includes rehabilitation on an outpatient basis as prescribed.
Pediatric fractures
DESCRIPTION: Traumatic injury to bone. Fractures that occur in the epiphyseal plate (growth plate) may affect growth of the limb. ASSESSMENT: General condition: visible bone fragments. Pain, swelling, contusions. Child guarding or protecting the extremity. Possibility of being able to use fractured extremity due to intact periosteum. NURSING PLANS AND INTERVENTIONS:Obtain baseline data, and frequently perform neurovascular assessments. Report abnormal assessment promptly! Compartment syndrome may occur; it results in permanent damage to the nerves and vasculature of the injured extremity due to compression. Maintain traction if prescribed. Note bed position, type of traction, weights, pulleys, pins, pin sites, adhesive strips, ace wraps, splints and casts. Skin traction: force is applied to skin. Buck extension traction: lower extremity, legs extended, no hip flexion. Dunlop traction: two lines of pull on the arm. Russell traction: two lines of pull on the lower extremity, one perpendicular, one longitudinal. Bryant traction: both lower extremities flexed 90 degrees at hips (rarely used because extreme elevation of lower extremities causes decreased peripheral circulation). Skeletal traction: pin or wire applies pull directly to the distal bone fragment. 90 degree traction: flexion of hip and knee; lowr extremity is in a boot cast, can also be used on upper extremities. Dunlop traction may be used as skeletal traction. Maintain child in proper body alignment; restrain if necessary. Monitor for problems of immobility. Provide age-appropriate play and toys. Prepare child for cast application; use age-appropriate terms when exlpaining procedures. Provide routine cast care following application; petal cast edges. Teach home cast care to family: neurvascular assessment of casted extremity; not to get cast wet; not to place anything under cast; keep small objects, toys, and food out of cast. Teach family to modify diapering and toileting to prevent cast soilage. Teach that in the presence of a hip spica, family may use a Bradford frame under a small child to help with toileting; they must not use abduction bar to turn child. Teach to seek follow-up care with HCP.
DETACHED RETINA
DESCRIPTION:Hole or tear in, or separation of the sensory retina from, the pigmented epithelium. It can be result of increasing age, severe myopia, eye trauma, retiopathy (diabetic), cataract or glaucoma surgery, family or personal hx. Resealing is done by surgery. Cryotherapy (freezing). Photocoagulation (laser). Diathermy (heat). Scleral buckling (most often used). NURSING PLANS AND INTERVENTIONS: The client may be on bed rest. Place eye patch over affected eye. Administer meds to inhibit accommodation and constriction; cycloplegics (mydriatics and homatropine) are given to dilate pupil before surgery. Administer meds for potop pain: Tylenol, Demerol, oxycodone. If gas bubble is used, position client so bubble can rise against area to be reattached. *****S/S****
NSAIDs AKA Prostoglandin antagonists
DRUGS: Aspirin; Motrin; Indomethacin (RF, Gout); Toradol; Naproxen INDICATIONS: Used as antiinflammatory; antipyretic; analgesic; Can be used with other agents, may alternate with narcotics. ADVERSE REACTIONS: GI irritation, (slow GI bleeds shown by H&H); n/v, constipation. Elevated liver enzymes. Prolonged coagulation time; Tinnitus; thrombocytopenia; fluid retention; Nephrotoxicity; blood dyscrasias. NURSING IMPLICATIONS: 1.Teach to take with food or milk to reduce GI symptoms. 2. Therapeutic serum salicylates level 20-25 mg% 3. Teach to watch for signs of bleeding. 4. Teach to avoid alcohol. 5. Teach to observe for Tinnitus (aspirin toxicity). 6. Administer corticosteroids for severe rheumatoid arthritis. 7.NSAIDs reduce the effect of ACE inhibitors in hypertensive clients. 8. Encourage routine appointments to check liver/renal labs and CBC.
Corticosteroids:
DRUGS: Hydrocortisone; Prednisone; Dexamethasone INDICATIONS: Hormone replacement; Severe Rheumatoid Arthritis; Autoimmune disorders. *decrease the bodies inflammatory response, makes client more prone to infection but mask the signs of inflammation.* ADVERSE REACTIONS: Emotional lability, personality changes. Impaired wound healing, bruise easily. Skin fragility. Abnormal fat deposition. Hyperglycemia, bs increase. Hirsutism, moon face. Osteoporosis *remember steroids leech calcium from the bones*. NURSING IMPLICATIONS: Wean slowly (administer high dose then taper off).; careful monitoring is required during withdrawal (NO cold turkey). Monitor serum potassium (normal: 3.5-5), glucose (normal: 70-100) (can become diabetic), and sodium (normal:136-145). Weigh daily, report weight gain of more than 5lb per week *this could indicate water retention*. Administer with antiulcer drugs or food (zantac, pepsid, tagament) *ulcerogenic*. Use care to prevent injuries. Monitor bp and pulse closely, these can increase bp. *remember to replace calcium, supplement.*
What is the cause of sensoneural hearing loss?
Damage to the cochlear or vestibular nerves
Differentiate decorticate posturing; decerebrate posturing, and flaccid response.
Decorticate posture: an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type of posturing is a sign of severe damage in the brain Decerebrate posture: an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain. Flaccid response: quality of lack of tone of muscular or vascular organ or tissue.
D
Dementia is defines as a a. syndrome that results only in memory loss b. disease associated with abrupt changes in behavior c. disease that is always due to reduced blood flow to the brain d. syndrome characterized by cognitive dysfunction and loss of memory
A client who suffers an injury in a local high school hockey game presents with left shoulder pain. The client cannot move the left arm, and the left shoulder is lower than the right shoulder. The nurse recognizes the client most likely has a: a) Clavicle fracture b) Dislocated elbow c) Dislocated shoulder d) Cervical injury
Dislocated shoulder Explanation: Clinical manifestations of a dislocated shoulder include pain, lack of motion, feeling of an empty shoulder socket, and uneven posture.
A 39-year-old client has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicated intact but malpositioned bones, what would you expect the physician to diagnose? a) Fracture b) Strain c) Sprain d) Dislocation
Dislocation Explanation: In joint dislocation, radiographic films show intact yet malpositioned bones.
Clinical signs of Guillain-Barre Syndrome
Distal symmetrical motor weakness, Mild distal sensory impairments, Transient paresthesias, Weakness progresses from LE to UE, Symptoms peaks within two-four weeks, MM and respiratory paralysis, Absence of DTR, Inability to speak or swallow - Can be life threatening if respiratory system is compromised, 30% of acute on a respirator, Acute onset in 2-4 weeks, f/b 2-4 weeks of static symptoms, gradual recovery over weeks and years
Which of the following are general nursing measures for a patient with a fracture reduction? a) Promoting intake of omega-3 fatty acids b) Encourage participation in ADLs c) Examining the abdomen for enlarged liver or spleen d) Assisting with intake of immune-enhancing tube feeding formulas
Encourage participation in ADLs Explanation: General nursing measures for a patient with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the patient for self-care. Omega-3 fatty acids have no implications on the diet of a patient with a fracture reduction. The nurse should not examine the abdomen for enlarged liver or spleen since fracture reduction treatment does not affect these organs. It is unlikely that a patient with a fracture reduction will be prescribed immune-enhancing tube feeding formulas.
Discuss manifestations of autonomic dysreflexia and nursing care to prevent or relieve symptoms.
Exaggerated unopposed autonomic response to noxious stimuli for individuals with SCI at or above T6 (as low as T8). Nursing Interventions: bowel/skin care regimen, flushing catheter daily, monitor for distention, I&O, monitor VS for indicators of AD such as hypertension, pounding HA, bradycardia, blurred vision, nausea, nasal congestion, flushing and sweating above the level of injury. If AD is suspected, raise head 90 degrees to lower BP. Monitor BP q3-5min during hypertensive episode. Assess for the cause, implement measures for removing the noxious stimulus. Could be: Bladder distension, bowel constipation/impaction, skin problems (pressure, infection, injury, heat, pain, cold).
Glaucoma Hesi Hint #2
Eye drops are used to cause pupil constrictions **avoid mydriatics** because movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is commonly used. Caution client that vision may be blurred for 1-2 hours after administration of pilocarpine and that adaptation to dark environments is difficult because of pupillary constriction (the desired effect of the drug.)
The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects which complication? a) Fat embolism syndrome b) Hypovolemic shock c) Reflex sympathetic dystrophy syndrome d) Compartment syndrome
Fat embolism syndrome Explanation: Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion. With compartment syndrome, the patient complains of deep, throbbing, unrelenting pain. With hypovolemic shock, the patient would have a decreased blood pressure and increased pulse rate. Clinical manifestations of reflex sympathetic dystrophy syndrome include severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.
Discuss nursing responsibilities of neurological vital signs.
Full Vital Signs Assess LOC, and orientation, if pt is unconcious use the Glascow Coma Scale Assess strength of hands grip and movement of extremities Assess pupils using PEERLA
Joint Replacement Hesi Hint #5
Hazards of Immobility: Immobile clients are prone to complications: skin integrity problems; formation of urinary calculi (client's milk intake may be limited); and venous thrombosis (client may be on prophylactic anticoagulants).
Explain the emergency care for a patient experiencing a CVA.
Helping to determine what kind of stroke it is, and acting appropriately. If ischemic, determine if pt is candidate for thrombolytic therapy. If hemorrhagic stroke, measures to reduce bleeding and IICP should be taken. Ischemic: (If non-thrombolytic therapy is needed) Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (eg, mannitol), maintaining the partial pres- sure of carbon dioxide (PaCO2) within the range of 30 to 35 mm Hg, and positioning to avoid hypoxia. Other treatment measures include the following: • Elevation of the head of the bed to promote venous drainage and to lower increased ICP • Possible hemicraniectomy for increased ICP from brain edema in a very large stroke • Intubation with an endotracheal tube to establish a patent airway, if necessary • Continuous hemodynamic monitoring (the goals for blood pressure remain controversial for a patient who has not received thrombolytic therapy; antihyperten- sive treatment may be withheld unless the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg) • Neurologic assessment to determine if the stroke is evolving and if other acute complications are devel- oping; such complications may include seizures, bleeding from anticoagulation, or medication- induced bradycardia, which can result in hypotension and subsequent decreases in cardiac output and cere- bral perfusion pressure During the acute phase, a neurologic flow sheet is main- tained to provide data about the following important mea- sures of the patient's clinical status: • Change in level of consciousness or responsiveness as evidenced by movement, resistance to changes of po- sition, and response to stimulation; orientation to time, place, and person • Presence or absence of voluntary or involuntary movements of the extremities; muscle tone; body pos- ture; and position of the head • Stiffness or flaccidity of the neck • Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position • Color of the face and extremities; temperature and moisture of the skin • Quality and rates of pulse and respiration; arterial blood gas values as indicated, body temperature, and arterial pressure • Ability to speak • Volume of fluids ingested or administered; volume of urine excreted each 24 hours • Presence of bleeding • Maintenance of blood pressure within the desired pa- rameters
When evaluating for hypovolemic shock, the nurse should be aware of which of the following clinical manifestations? a) Hypertension b) Bradycardia c) Bounding pulse d) Hypotension
Hypotension Explanation: The nurse should be alert to a weak pulse (thread), decreased blood pressure, decreased urine output, rapid, shallow respirations, and elevated heart rate.
Discuss the nursing measures in a bowel/bladder training program.
I&O, q2hr offer bedpan or urinal, maintain skin integrity in the perineal area, promote daily intake of 2L, but limit intake at night, high-fiber diet, offer the bedpan/urinal at the same times each day, stool softeners as ordered, increase physical mobility as tolerated (increases peristalsis)
hypersensitivity and allergy interventions
ID specific allergen; management of sx with antihistamines, anti-inflammatory agents, or corticosteroids; ointments, creams, wet compresses, and soothing baths for local rxns; possible desensitization
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
Increased weight, hypertension, and insomnia
A 33-year-old client who tested positive for the human immunodeficiency virus (HIV) is admitted to the medical unit with pancreatitis. A nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director, who says that the client is her neighbor's son. What should the nurse do to protect the client's right to privacy?
Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart.
The nurse should include which intervention in the postoperative care plan? a) Keeping a pillow between the client's legs at all times b) Turning the client from side to side every 2 hours c) Maintaining the client in semi-Fowler's position d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift
Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.
Which of the following is the most common site of joint effusion? a) Elbow b) Knee c) Hip d) Shoulder
Knee Explanation: The most common site for joint effusion is the knee. If inflammation or fluid is suspected in a joint, consultation with a provider is indicated. The elbow, hip, and shoulder are not the most common site of joint effusion.
Describe seven signs and symptoms of increased intracranial pressure.
LOC: EARLY IICP: restleness, irritability, LATE IICP: coma, no response to stimuli Pupils: EARLY IICP: equal round and reactive to light. LATE IICP: sluggish response, progressing to fixed response, pupils may dilate only on one side. Vision: EARLY IICP: decreased visual acuity, blurred vision. LATE IICP: unable to assess Motor Function: EARLY IICP: weakness in on extremity or side. LATE IICP: decorticate or decebrate posturing. Speech: EARLY IICP: difficulty speaking. LATE IICP: cannot assess due to decrease in LOC. Blood Pressure: EARLY IICP: elevated blood pressure. LATE IICP: Cushing's Triad, increased systolic BP, wideining pulse pressure, bradycardia Pulse: EARLY IICP: slighty elevated. LATE IICP: widening pulse. Respiration: EARLY IICP: rate may increase. LATE IICP: decreased respiratory rate or cheyne-stokes breathing. Temperature: EARLY IICP: may be decreased or increased. LATE IICP: significantly elevated. Other sx: EARLY IICP: headaches worse on rising in the morning and with position changes, LATE IICP: Continual headache, projectile vomitiing. Loss of pupil, corneal, gag, and swallowing reflexes.
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
Lamb and peaches
Which of the following is a factor that inhibits fracture healing? a) Vitamin D b) Maximum bone fragment contact c) Local malignancy d) Exercise
Local malignancy Explanation: Factors that inhibit fracture healing include local malignancy, bone loss, and extensive local trauma. Factors that enhance fracture healing include proper nutrition, vitamin D, exercise, and maximum bone fragment contact.
The human body has 206 bones, which are classified into four categories. Which types of bones are located in the forearm? a) Short bones b) Irregular bones c) Long bones d) Flat bones
Long bones Explanation: Long bones are the type of bone that is located in the forearm, specifically, the ulna.
Would you expect the TSH level to be high or low in someone with hyperthyroidism
Low
NSG Interventions Meneire's
Low sodium, no caffeine, no alcohol Potassium foods Bedrest Antihistamines, Valium. Quiet environment, low lighting.
Progressive spinal muscular atrophy
Lower motor neuron deficit in the limbs due to degeneration of the anterior horn cells in the spinal cord
Tests for MS
MRI= lesions seen CT= atrophy & white matter lesions CFS analysis= increase of T lymphocytes w/ antigens Also increase in IgG
Discuss common causes of a head injury.
MVAs, falls, violent assaults, sports injuries, IEDs at war. the cause is what influences the kind of head injury they have.
Which nursing intervention is appropriate for minimizing muscle spasms in the client with a hip fracture? a) Assist the client with use of a trapeze. b) Maintain the internal fixator. c) Apply a soft compression dressing. d) Maintain Buck's traction.
Maintain Buck's traction. Explanation: Buck's traction decreases pain, muscle spasm, and external rotation by immobilizing the hip fracture.
Explain the differences between Medicare and Medicaid reimbursement.
Medicaid: U.S government sponsored program for low-income individuals and families to pay the cost of health care. Medicaid beneficiaries are low income families and individuals. Covers a wider range than Medicare: hospitalization, x-rays, laboratory services, midwife services, clinic treatment, pediatrics care, family planning, nursing services and in-home nursing facilities for 21+ years, medical and surgical dental care. In some states Medicaid beneficiaries are required to pay the provider a small fee (co-payment) of up to $30 per month for medical services. May require payment of deductibles and co-pay for certain services provided. Program is run by individual states so the type of coverage and policies may vary between states. But generally, patients usually pay no (or very little) part of costs for covered medical expenses. Medicare: U.S government sponsored health care program for people above 65 years of age, people under 65 with certain disabilities and all people with end stage renal disease. Medicare beneficiaries are senior citizens over the age of 65, end stage renal disease, and disabled eligible to receive social security benefits. Divided in to Part A which covers hospital care, Part B which covers medical insurance and Part D covers prescription drugs. May require payment of deductibles and co-pay for certain services provided., Medicare reserves the right to refuse to pay for treatments it deems unnecessary. Small monthly premiums are required for non-hospital coverage. Federally run so the program and coverage is uniform throughout the country. Run by the Health Care Financing Administration.
When joint manipulation is unsuccessful for a client, he is taken to surgery for surgical repair of his hip injury. He is brought to the ICU where you practice nursing for postoperative recovery. In addition to the regular assessments prescribed by policy, what assessment is completed every 30 minutes for several hours? a) Neurological b) Neurovascular c) Orientation d) Head-to-toe
Neurovascular Explanation: The nurse should perform neurovascular assessments every 30 minutes for several hours, and then at least every 2 to 4 hours for the next 1 or 2 days to detect complications.
Describe the role of the nurse in the community setting.
Nurses work in diverse community settings to provide primary nursing and health care across the lifespan. Traditionally community nurses meet a continuum-of-health needs that range from the management of specific disease/s to broader community development and public health promotion needs. Health promotion and intervention consciously centre on the client who is viewed holistically; thus, care also considers the social conditions and relationships that affect an individual or a population's health status. In recent years the community nurse's role has begun to shift, directing more attention to the provision of disease recovery nursing care for transitioning clients as they move out of the hospital environment and into the community context. Additionally, the community nurse's role has become more focused on the provision of early intervention measures to prevent exacerbations or complications for clients living with chronic illness/conditions to prevent unnecessary hospital (re)admission.
Nursing Plans and Interventions: The Blind Client
On entering room, announce your presence clearly and identify yourself; address client by name. Never touch client unless he or she knows you are there. On admission, orient client thoroughly to surroundings; Demonstrate use of the call bell; Walk client around the room and acquaint them with all objects, chairs, bed, tv, telephone, ect. Guide client when walking; Walk ahead of client, and place their hand in the bend of your elbow; Describe where you are walking, note whether passageway is narrowing or you are approaching stairs, curb, or incline. Always raise side rails for newly sightless persons. Assist with meal enjoyment by describing food and its placement in terms of the face of a clock. When administering meds, inform client of number of pills and give only a half glass of water to avoid spills.
A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone (Deltasone) daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
Osteoporosis
Risk factors for Osteoporosis
Over 60 Postmenopausal women Family History Thin body build Low calcium and Vit D Smoker Immobile
What are the classifications of the commonly prescribed eye drops for glaucoma?
Parasympathomimetic for pupillary constriction; beta-adrenergic receptor-blocking agents to inhibit formation of aqueous humor; carbonic anhydrase inhibitors to reduce aqueous humor production; and prostaglandin agonists to increase aqueous humor outflow.
Treatment of Glaucoma
Parasympathomimetics (mimics parasympathetic- rest/relaxation syndrome): Pilocarpine: this drug enhances papillary constriction they are myotic drops. Adverse reactions: Bronchospasm. N/V, diarrhea. Blurred vision, twitching eyelids, eye pain with focusing. Nursing Implications: Use cautiously with pregnancy, asthma, hypertension. Teach proper drop instillation technique. Need for ongoing use of the drug at precribed intervals.*** Blurred vision tends to decrease with regular use of this drug.*** Beta-Adrenergic Receptor Blocking Agents: Timolol/ Carteolol: Inhibits formation of aqueous humor. Adverse Reactions: Side effects are insignificant. Hypotension. Nursing Implications: use cautiously with- hypersensitivity, Asthma, Second or third-degree heart block, HF, Congenital glaucoma, Pregnancy. Teach proper drop instillation technique. Need for ongoing use of the drug at prescribed intervals. Blurred vision tends to decrease with regular use of this drug. Carbonic Anhydrase Inhibitors: Diamox-PO: reduces aqueous humor production. Adverse Reactions: numbness, tingling of hands and feet. Nausea and Malaise. Nursing Implications: Administer orally or IV. Produces diuresis. Assess for metabolic acidosis. Prostaglandin Antagonists: Lumigan: lowers IOP of gluacoma by increasing outflow of aqueous humor. Adverse Reactions: Local irritation. Foreign-body sensation. Increased brown pigmentation of iris. Increased eyelash growth.
Differentiate kinds of seizures by types and symptoms.
Partial seizures: simple partial seizures: uncontrolled jerking movements of a finger hand, foot, leg, or the face (jacksonian march). Complete partial seizures: repititive non-purposeful actions (lip-smacking) Generalized seizures: absence seizures: blank stare, blinking of the eyes, eyelid fluttering. Tonic-clonic seizures: sudden onset, most common seizure
Elderly clients who fall are most at risk for which injuries? a) Cervical spine fractures b) Pelvic fractures c) Wrist fractures d) Humerus fractures
Pelvic fractures Explanation: Elderly clients who fall are most at risk for pelvic and lower extremity fractures. These injuries are devastating because they can seriously alter an elderly client's lifestyle and reduce functional independence. Wrist fractures usually occur with falls on an outstretched hand or from a direct blow. Such fractures are commonly found in young men. Humerus fractures and cervical spine fractures aren't age-specific.
A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? a) Prevent internal rotation of the affected leg. b) Keep the hip flexed by placing pillows under the client's knee. c) Use measures other than turning to prevent pressure ulcers. d) Keep the affected leg in a position of adduction.
Prevent internal rotation of the affected leg. Explanation: The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.
Describe the criteria for determining dosage of anticoagulant drugs. (PT, INR, APTT)
Prothrombin time (PT) and the international normalized ratio (INR) are used to monitor the pts response to warfarin therapy. The daily dose is based on these labs. Therapeutic range of the PT is 1.2 to 1.5 times the control value (11-13 seconds, think "pre teen"). INR should be maintained between 2 and 3. The The Activated Partial Thromboplastin Time (APTT) determines the overall capacity of the blood to clot for pts on heparin. 1.5-2.5 the control value (25-45 seconds, think "prime teaching time"). The APTT needs to be drawn q6hrs, heparin has a short half-life and so the amount can vary greatly within a short period of time. If the numbers are too low, they are at risk for clots. If too high, then they are at risk for bleeding. There is a narrow therapeutic range for anticoagulants.
Describe the use of clinical pathway/care map to guide the care of the patient with a CVA.
Purpose: To reduce unnecessary utilization of hospital resources, to give the most efficient care possible (because time is of the essence). Clinical pathways are multidisciplinary plans (or blueprint for a plan of care) of best clinical practice for specified groups of patients with a particular diagnosis that aid in the coordination and delivery of high quality care.
Discuss nursing care for the child with CP.
ROM exercises to prevent contractures, use special appliances to help the child perform ADLs, provide protective head gear and bed pads to prevent injury, provide a high-calorie diet because the child will have a high metabolism rate due to high motor function, explain the disorder and treatment to the family and that efforts should be made to ensure that the child reaches the optimal developmental level possible.
Thyroid Storm
Rare, but fatal complication of hyperthyroidism Reduce body temp and heart rate Fever 100-106 Tachycardia >140 bpm Hot, flushed skin Anxious Diarrhea, nausea
Which nursing intervention is essential in caring for a client with compartment syndrome? a) Wrapping the affected extremity with a compression dressing to help decrease the swelling b) Starting an I.V. line in the affected extremity in anticipation of venogram studies c) Keeping the affected extremity below the level of the heart d) Removing all external sources of pressure, such as clothing and jewelry
Removing all external sources of pressure, such as clothing and jewelry Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Risk for injury
Recognize signs and symptoms of client's impaired cognition.
STAGE 1: 2-4 years after onset short term memeory loss; forgets locations and names of objects attempts to cover up memory loss has difficulty learning new information or making decisions decreased attention span can be angry or depressed antidementia meds are trying to prolong this stage. STAGE 2: 2-10 years after end of stage 1 unable to remember names of family members and gets lost in familiar locations easily agitated and irritable has difficulty using objects; reading, writing, and speaking cannot follow a conversation personal hygiene declines unable to make decisions (choose clothing) walks and unsteady gait, head down, shoulders bent, shuffles exhibits "sundowning" and wandering behavior STAGE 3: 1-3 years after stage 2 cannot recognize self or others inability to communicate has delusions and hallucinations bowel and bladder incontinence
Discuss the common drugs, side effects, and precautions when administering drugs prescribed for extra-pyramidal disorders.
Sinemet: Dopaminergics - carbidoma-levodopa mixture. Levodopa is converted to doapaimine in the brain and carbidopa prevents levodopa from being destroyed. Comtan is used in adjunct to Sinemet sometimes. Enhances Tasmar: last resort Dry mouth/difficulty swallowing, anorexia, nausea, diskinesia vomiting, abdm pain and constipation, increased hand tremor, headache and dizziness. Caution should be used in combination with opioids, antacids, anticonvulsantsm and tricyclic antidepressants. Choreiform movements and dystonic movements are the most adverse reaction to levodopa.
Pedi HH #4
Skeletal disorders affect the infant's or child's physical mobility and typical questions focus on appropriate toys and activities for the child who is confined to bed rest and is immobilized.
how is skeletal traction applied?
Skeletal traction is maintained by pins or wires applied to the distal fragment of the fracture.
A client sustains an injury to the ligaments surrounding a joint. The nurse identifies this as which of the following? a) Fracture b) Strain c) Sprain d) Contusion
Sprain Explanation: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.
A 45-year-old softball player arrives at the emergency department following his injury while sliding into a base during a game. After his examination and radiographs, the physician diagnoses muscle strain and prescribes appropriate treatment. What does the physician mean with the term "strain"? a) Stretched or pulled beyond capacity b) Subluxation of a joint c) Injuries to ligaments surrounding a joint d) Injury resulting from a blow or blunt trauma
Stretched or pulled beyond capacity Explanation: A strain is an injury to a muscle when it is stretched or pulled beyond its capacity.
Pt Education for hypothyroid Meds
Take early morning on empty stomach Take at least 4 hrs apart from other drugs: antacids, and iron. Take at the same time every day. Measure pulse twice weekly report if >100.
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide?
Take ferrous sulfate and the antacid at least 2 hours apart."
The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
Take piroxicam with food or an antacid.
Reinforce teaching to patient/family healthy lifestyle choices.
Talk about changing modifiers to prevent future TIAs or CVAs: controlling hypertension (stress, meds), reinforcing the benefits of anticoagulant therapy and other info about medications, low-cholesterol and low-fat diet to reduce arteriosclerosis, etc. when to seek medical care; complications such as aspiration, pneumonia, UTI, skin breakdown; safety measures to prevent falls; psychologic support.
Identify support systems available to patient and family.
Teach about psychological support, respite care, community resources such as home health agency, meals on wheels, elder care, sources for special adaptive equipment, support groups and stroke clubs.
To diagnosis diff between myasthenic crisis & cholinergic crisis
Tensilon test. Edrophomium chloride (ashort acting anticholinesterase) if symptoms abate for 5 mins, w/ improved muscle strength, then myasthenic crisis. NO imporvement= cholinergic.
Discuss Glasgow Coma scale.
The Glascow Coma Scale provides a quick guide for assesing LOC, It measures how well the pt responds to eye opening and verbal and motor responses.
A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. The nurse replies that the client will be able to bear weight on the cast when?
The client can bear weight within 20 to 30 minutes of application
Identify common drugs in the treatment of TIA.
The most frequently used anti-platelet medication is aspirin. Aspirin is also the least expensive treatment with the fewest potential side effects. An alternative to aspirin is the anti-platelet drug clopidogrel (Plavix). Also maybe Aggrenox, a combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce blood clotting. The way dipyridamole works is slightly different from aspirin. Ticlid is used when there is an aspirin allergy, are are used with aspirin in order to avoid clots from forming on coronary stents. Persantine is also an antiplatelet used. Anticoagulant drugs include heparin and warfarin (Coumadin). Heparin is used short term and warfarin over a longer term. These drugs require careful monitoring. If atrial fibrillation is present, may prescribe another type of anticoagulant, dabigatran (Pradaxa). Think +10 to differentiate PTT from PT. (C+O+U+M+A+D+I+N + 2. PT.) Vitamin K is the antidote for Coumadin, and Protamine is the antidote for heparin. Heparin should only be used parenterally. Lovenox is used instead of Heparin during pregnancy (does not pass the placenta) and is more long term than Heparin, although not as long-term as Coumadin unless in a LTC. It is a type of Heparin. All are used prophylactically for DVTs, PEs.
A nurse delegates the task of obtaining a blood sample to a nursing assistant trained in venipuncture. When delegating this task, the nurse should understand which delegation principle?
The nurse may delegate the task but she remains accountable for the delegated task.
Amputation Hesi Hint #1
The residual limb or stump should be elevated on one pillow. If the residual limb is elevated too high, the elevation can cause a contracture.
Glaucoma Hesi Hint #3
There is an increased incidence of glaucoma in older adult population. Older clients are prone to problems associated with constipation. Therefore, the nurse should assess these clients for constipation and postop complications associated with constipation and should implement a plan of care directed at prevention of and, if necessary, treatment for constipation. **fiber, fluids, exercise**
RF Hesi Hint #4
What activity recommendations should the nurse provide a client with rheumatoid arthritis? Do not exercise painful, swollen joints. Do not exercise any joint ot the point of pain. Perform exercises slowly and smoothly; avoid jerky movements.
Explain the difference between a TIA and a CVA.
While transient ischemic attack (TIA) is often labeled "mini-stroke," it is more accurately characterized as a "warning stroke," a warning you should take very seriously. TIA is caused by a clot; the only difference between a stroke and TIA is that with TIA the blockage is transient (temporary). TIA symptoms occur rapidly and last a relatively short time. Most TIAs last less than five minutes; the average is about a minute. Unlike a stroke, when a TIA is over, there's no permanent injury to the brain.
Describe common diagnostic tests for the patient with neurological manifestations.
X-rays CT Scans MRI Cerebral angiography: contrast material is injected and an combined X-ray and fluroscopy is performed. Myelography: X-ray of spinal cord and canal after contrast media is injected. PET: radioactive agent is injected and CT measures metabolic activity of the brain. Ultrasound Carotid duplex study: sound waves identify blood flow velocity to determine the presence of occlusive vascular disease. EEG EMG: needles inserted in muscles to record electrical activity. Evoked potentials: electrodes are placed on scalp and skin to record the visual or auditory stimulus along sensory pathways
A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? "Using proper body mechanics will prevent you from injuring yourself." "You are physically fit and at lesser risk for injury when transferring the client." "Use the mechanical lift and another person to transfer the client from the bed to the chair." "Use the back belt to avoid hurting your back."
Your Answer: "Use the mechanical lift and another person to transfer the client from the bed to the chair." Rationale: It is prudent for nurses to understand and use proper body mechanics at all times to decrease risk, while keeping in mind the importance of assistive devices and help from other staff. While it is generally accepted that proper body mechanics alone will not prevent injury, many work settings do not yet have "no manual lift" and "no solo lift" policies and resources in place. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? Exercises past the point of resistance. Performs each exercise one time. Performs each series of exercises once a day. Uses the same sequence during each exercise session.
Your Answer: Uses the same sequence during each exercise session. Rationale: When the client performs the movements systematically, using the same sequence during each session, the nurse can evaluate that the teaching was understood and is successful. When performing active ROM the client should exercise to the point of slight resistance, but never past that point of resistance in order to prevent further injury (option 1). The client should perform each exercise at least three times, not just once (option 2). The client should perform each series of exercises twice daily, not just once per day (option 3). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Evaluation.
Multiple Sclerosis
a chronic progressive nervous disorder involving loss of myelin sheath around certain nerve fibers. Onset 15-50 yrs old
Lhermitte's sign
a sign of posterior column damage in the spinal cord. Is characterized by flexion of the neck produces a sensation like an electric shock running down the spine and into the LE.
MRI
a technique that uses magnetic fields and radio waves to produce computer-generated images that distinguish among different types of soft tissue; allows us to see structures within the brain
Immune deficiency
absence or inadequate production of immune bodies; congenital or acquired; tx depends on inadequacy and primary cause
pemphigus tx goal
aimed at suppressing the immune response that causes blister formation
active immunity
antibody production is stimulated without causing clinical disease
Receptive Aphasia
aphasia characterized by fluent but meaningless speech and severe impairment of the ability to understand spoken or written words
Discuss the common causes of a CVA.
atherosclerosis of large cerebral arteries (thrombotic) a-fib, CHF, endocarditis, rheumatic heart disease, mitral valve disease (embolic) HTN (hemorrhagic) risk factors: male, over 65 years of age, african american, hypertension, DM, obesity, a-fib, atherosclerosis, smoking, high cholesterol diet, excessive use of alcohol, cocaine/heroin, oral contraceptives. Another common cause of intracerebral hemorrhage in the elderly is cerebral amyloid angiopathy, which involves damage caused by the deposit of beta-amyloid protein in the small and medium-sized blood vessels of the brain
Meds for HD: antipsychotics
block dopamine receptors in brain. Restore balance of neurotransmitters
SLE data collection
butterfly rash on face; dry, scaly, raised rash on upper body or face; fever, weakness, malaise, fatigue; anorexia and wt loss; photosensitivity; joint pain; erythema of the palms; anemia; + ANA test; Elevated sedimentation rate and C-reactive protein
Discuss functional abilities related to area of spinal cord injury.
c1-c3 = no movement or sensation below the neck; ventilator-dependent c4 = movement and sensation of head and neck; some partial function of the diaphragm c5= controls head, neck, and shoulders; flexes elbow c6 = uses shoulder, extends wrist c7-c8 = extends elbow, flexes wrist, some use of fingers T1-T5 = has full hand and finger control, full use of thoracic muscles T6-T10 = controls abdominal muscles, has good balance T11-L5 = flexes and abducts the hips; flexes and extends the knee S1-S5 = full control of legs; progressive bowel, bladder, and sexual function
diagnosis and monitoring for posttransplant pt
check renal/hepatic fxn; monitor CBC w/ differential to monitor for s/s of infection; assess all body secretions for blood
What is Myasthenia Gravis
chronic autoimmune neuromuscular disorder characterized by fatigue, weakness of skeletal muscle.
Osteoporosis
chronic metabolic disease characterized in which bone loss causes decreased density and increased fracture risk
Routes of latex allergy exposure
cutaneous-latex gloves, balloons; Percutaneous/parenteral-IV lines, catheters, dialysis equip; Mucosal-latex condoms, catheters, airways, nipples; Aerosol- powder from latex gloves
A nurse is assigned to care for a client with multiple trauma who is admitted to the hospital. The client has a leg fracture, and a plaster cast had been applied. In positioning the casted leg , the nurse should do what
elevate the leg on pillow continuously for 24-48 hours
A nurse is caring for a client with fresh application of a plaster leg cast. THe nurse plans to prevent the development of compartment syndrom by doing what?
elevating the limb and applying ice to the affected leg. Compartment syndrom is prevented by controlling edema. This is acheived most optimally with elevation and application of ice
Hyperpathia
exaggerated subjective response to a painful stimuli, w/ a continuing sensation of pain after the stimulation has ceased.
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
fat.
Interventions for individual with latex allergy
hx of latex allergy upon assessment; ID latex allergy risk factors; Use non-latex gloves, supplies; Keep latex-free cart in pt room; cloth barrier under BP cuff; Educate pt to always inform HCPs of allergy
you review the pts understanding of stapedectomy which concerns you
i cant wait to get back to my weight lifting class- no straining for at least three wks, water and air- 1 wk
during discharge a client with oteoporosis which statement needs more teaching?
i take ibprofen every morning as soon as i get up-dont take it on empty stomach! ulcerogenic drug
older than 5 years old
if healthy, pt might not need the HIB vaccine who is older than __
within 3-5 days
if pt. is exposed to varicella can the vaccine be given after.
dont restart series no matter how long previous dose
if pt. misses one of the series of Hep A vaccines could they be restarted
two doses 4-8 weeks apart
if pt. older than 13 has not had chickenpox require this dosage and frequency of vaccine
nutritional S&S of MD
inability to chew and swallow, decreased ability to move tongue, impairment of fine motor movements= inability to eat. complications: weight loss, dehydration, skin breakdown, aspiration,
Ataxia
inability to coordinate voluntary muscle movements
dyssynergia
inability to coordinate voluntary muscle movements
Optic neuritis
inflammation of the optic nerve
What is worn under the prosthesis?
limb sock
For pts with relapsing-remitting disease or secondary progressive, what helps to reduce the frequency of exacerbations?
long term beta-interferon or SQ glatiramer acetate
A client with allergic rhinitis is prescribed loratadine (Claritin). On a follow-up visit, the client tells the nurse, "I take one 10-mg tablet of Claritin with a glass of water two times daily." The nurse concludes that the client requires additional teaching about this medication because:
loratadine should be taken once daily for allergic rhinitis.
Describe a therapeutic environment for a patient with Alzheimer's disease.
make schedule of the client's daily activities, label drawers containing client's clothes and label rooms, use communication techniques to the client's level of ability, when the client is agitated re-direct attention, if pt wanders they need a MedicAlert, schedule rest periods or quite times throughout the day, set boundaries by placing red or yellow tape on the floor, assign the same caregivers as much as possible, music/art therapy, orient to person place and time if needed.
Polyarteritis nodosa data collection
malaise, low fever, severe abd. pain, bloody diarrhea, wt loss, elevated sedimentation rate
Single lesions may be...
malignant or congenital
A client with a sprain but not fracture should be told to do what before being sent home
patien should be taughts to rest, ice, compress, and elevate SPRIAN=RICE
Identify community care and resources to assist patient and family with chronic and long-term disabilities.
physical therapy will demonstrate assistive devices, social services can arrange referral to home health agency, transfer to rehab center, or job retraining program.
Explain interventions to prevent patient aspiration and assist with feeding a patient with a swallowing disorder.
place client in upright positon for meals and 30 minutes afterward. tild head slightly forward. do not feed client who does not have functioning gag reflex or has altered LOC. provide oral care before meals. serve thickened liquids and pureed or soft food and place foods on unaffected side of mouth. limit distractions at meal time. have suction equipment available during mealtimes.
Amyotrophic Lateral Sclerosis
progressive muscle atrophy caused by hardening of nerve tissue on the lateral columns of the spinal column (Lou Gehrig disease)Chronic Degenerative Disease UMN and LMN impairments. Rapid degeneration and demyelination of the giant pyramidal cells of the cerebral cortex
A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension tractions is primarily:
provides comfort by reducing muscle spasms and provides fracture immobilization
High-risk immunosuppressed pt
pt w/ hx of malignancy or premature malignancy have increased risk of malignancy when immunosuppressed; pt w/ recent infection or exposure to TB, chicken pox, have high risk for severe generalized disease
contraindications for anticholinesterase
pt w/ obstruction of intestinal/urinary tract. asthma, hyperthyriodism, bradycardia, peptic ulcer disease.
ocular/ facial S&S of MG
ptosis, diplopia, facial weakness, Dysphagia, dysarthria. complications: difficulty closing eyes, aspiration, impaired communication, impaired nutrition.
Goodpasture's syndrome data collection
pulmonary and renal involvement, SOB, hemoptysis, decreased UO, edema and wt gain, HTN and tachycardia
Lumbar Puncture
removal by centesis of fluid from the subarachnoid space of the lumbar region of the spinal cord for diagnostic or therapeutic purposes
Lyme disease interventions
remove tick, clean with antiseptic; after 4-6wks, blood test to check for presence of disease; if confirmed, ATBs;
observe the nursing assistant performing all of these interventions for the pt with CTS
replace the pts splint in hyperextension
Surgery for TN
rhizotomy- surgically severing nerve root. residual pain/numbness from surgery. can lose sensations on affected side of face, lose corneal reflex.
A client with diabetes mellitus has had a R BKA (right below knee amputation). The nurse should monitor for what?
separtion of wound edges. Client's with diabetes mellitus are more prone to wound infection and delayed healing because of the disease
What is a gallium scan
similar to a bone scan, but with an injection of gallium isotope instead of technetium-99m. Gallium is injected 2-3 hours before the procedure, which takes 30-60 minutes to perform. The client must lie still during procedure and there is no special aftercare
Describe four types of CP.
spastic (most common): the cortex is affected resulting in the child having a scissor-like gait where one foot crosses in front of the other foot. other s&s: underdeveloped limbs, increased deep tendon reflexes, contractures, involuntary muscle contraction and relaxation, flexion. athetoid: the basal ganglia are affected resulting in uncoordinated involuntary motion. other s&s: uncontrolled involuntary movements, drooling writhing, all extremities move with voluntary movement, difficulty swallowing, facial grimacing. ataxic: the cerebellum is affected resulting in poor balance and difficulty with muscle coordination. other s&s: wide-based gait, unsteadiness, clumsiness, poor balance, unnatural muscle coordination.
Kaposi Sarcoma interventions
standard precautions; protective isolation if immune system depressed; prep pt for chemo or radiation; admin immunotherapy to stabilize immune system
weakness and fatigue exacerbated by....
stress, fever, overexertion, and exposure to heat. relieved by rest.
Interventions for postransplant immunosuppressed pt
strict aseptic technique; teaching re asepsis and s/s of infection/rejection; psychosocial support; pt teaching re immunosuppressants
tx for spasticity, neurogenic bladder, and fatigue?
symptomatic therapy
List common signs and symptoms of head injury.
the most common general symptoms: Impulsive behavior Loss of memory Impaired perception Personality changes Loss of taste and smell Diminished concentration Hearing and balance disorders Cognitive fatigue Concussion Coma Epilepsy open head injury: open wound on head, no nerves receptors so patient might not even realize the extent of injuries. Most open head injuries expose the brain to the outside environment, leaving victims extremely susceptible to infection (meningitis). closed head injury: Loss of consciousness Dilated pupils Respiratory issues Convulsions Headache Dizziness Nausea and vomiting Cerebrospinal fluid leaking from nose or ears Speech and language problems Vision issues scalp injury: concussion: immediate loss of consciousness for <5min. drowsiness, confusion, dizziness, HA, blurred or double vision. contusion: varies with the size and location of injury. initial loss of consciousness;if LOC remmains altered, client may become combative. During unconsciousness, lies motionless; has pale, clammy skin; faint pulse; hypotension; shallow resps; altered motor responses. epidural hematoma: brief loss of consciousness followed by a short period of alterntess. the client rapidly progresses into coma with decorticate or decerebate posturing, ipsilateral pupil dilation, and seizures. subdural hematoma: acute - rapid deterioration from drowsiness and confusion to coma, ipsilateral pupil dilation and contralateral hemiparesis subacute - appear 48 hours - 2 weeks later; alert period followed by slow progression to coma chronic - develops within weeks/months after initial injury. slowed thinking, confusion, drowsiness; may progress to pupil changes and motor deficits intracerebral hematoma: decreased LOC; pupil changes and motor deficits.
killed or inactivated vaccine
what kind of vaccine is the Hep A vaccine
meningitis, epiglottitis, pneumonia, sepsis and septic arthritis
what serious diseases are vaccinated for with HIB vaccine
day care, immunosuppressed, cardiopulmonary illnesses, diabetes, SCA, asplenia pt.
what type of pt. are recommended for the pneumonia vaccine
Tdap
what vaccine is recommended for those who go to college and live in crowded conditions or work with infants less than 12 months old.
after 6 weeks and finish by 32 weeks
when should rotavirus be given to an infant and end the series of oral dose
4
which is the best response by the nurse if the client fails to follow the information or teaching provided? 1. give up because the client doesnt want to change 2. develop a tough approach 3. guide the client to create a plan of action 4. Remind the client of previous successes.
paresthesias
which is the feeling of pins and needles or numbness of the face, body and extremities.
Discuss alternative communication methods with an aphasic patient.
• Face the patient and establish eye contact. • Speak in a normal manner and tone. • Use short phrases, "yes" and "no" questions, and pause between phrases to allow the patient time to understand what is being said. • Limit conversation to practical and concrete matters. • Use gestures, pictures, objects, and writing. • As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. • Be consistent in using the same words and gestures each time you give instructions or ask a question. • Keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. • Ask them to nod the head or blink their eyes, provide pad and pencil, magic slate, flash cards, computerized talking board, and/or pictures boards to help with communication.
Progressive Bulbar Palsy
•Motor nuclei of the cranial nerves are most affected (lower motor neuron) •Patients often present with slurred speech and difficulty chewing and swallowing •Exam: drooping of palate, depressed gag, pooling of saliva, wasted, fasiculating tongue •All cranial nerves have bilateral innervation except: Half of CN7 & CN12
Myelopathy of HTLV-1
•Myelopathy develops in some infected pts after an initial latency period of several years •MRI, CSF, EP findings may mimic MS •Differentiated from MS by the presence of HTLV-1 antibodies in blood and CSF •Treatment with oral corticosteroids may be helpful •Prevention of transmission
types of degenerative motor neuron diseases
•Progressive Bulbar Palsy •Pseudobulbar Palsy •Progressive Spinal muscle atrophy •Primary Lateral Sclerosis •Amyotrophy Lateral Sclerosis
Osteoporosis Hesi Hint #1
Postmenopausal, thin white women are at highest risk for development of osteoporosis. Encourage exercise, a diet high in calcium and supplemental calcium. Tums are an excellent source of calcium, but they are also high in sodium, so hypertensive or edematous individuals should seek another souce of supplemental calcium.
Elevated sedimention rate, morning stiffness occure in
RA
Differentiate between RF and osteoarthritis in terms of joint involvement.
RF occurs bilaterally, Osteoarthritis occurs asymmetrically.
To Treat Spasticity
Stretching, Topical cold, Rotational movement to decrease tone
Examine health promotion techniques and available resources for the patient with a head injury.
Teaching prevention to avoid head injury is key.
D
The clinical diagnosis of dementia is based on a. CT or MRS b. brain biopsy c. electroencephalogram d. patient history and cognitive assessment
B
The early stage of AD is characterized by a. no noticeable change in behavior b. memory problems and mild confusion c. increased time spent sleeping on or in bed. d. Incontinence, agitation, and wandering behavior
Osteoporosis Hesi Hint #2
The main cause of fractures in older adults, especially women is osteoporosis. The main fracture sites seem to be hip, vertebral bodies, and Colles fracture of the forearm.
Recognize the patient/family's ability to adapt to role changes.
The middle-aged adult family member may become the care-taker for an older parent. An older adult may be unable to care for a spouse who has had a stroke. They may have to accept placement of the spouse into an LTC. Emphasize that physical function may continue to improve for up to 3 months, and speech may continue to improve even longer.
Explain the nursing care of the patient with a CVA.
The priority of care during the initial period is preserving functional brain cells and preventing acute complications. Once the client's condition is stable, problems of physical mobility, communication, sensory-perceptual deficits, bowel and urine eliminations, and swallowing present the major nursing challenges. Diags: Ineffective Tissue Perfusion: Cerebral, Risk for Ineffective Airway Clearance, Impaired Physical Mobility, Impaired Verbal Communication, Disturbed Sensory Perception, Impaired Urinary Elimination and Constipation, Impaired Swallowing, Self-Care Deficit
Fracture Hesi Hint #3
The risk for the development of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli, is greatest in the first 36 hours after a fracture. It is more common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The initial symptom of a fat embolism is confusion due to hypoxemia. Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is suspected, notify the physician stat, draw blood gases, administer O2, and assist with endotracheal intubation. ****Imobilization and stabilization of the long bones can help prevent fat emboli****
Describe common symptoms of a TIA.
The warning signs of a TIA are exactly the same as for a stroke. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause
Sinemet
This drug is given to Parkinson's Disease patients early in the disease course. It is very effective for the management of akinetic symptoms. Tremor and rigidity may also respond to this drug. After a few years of therapy the effectiveness of sinemet wears off and other drugs are prescribed.
Discuss the etiology of seizures.
This is a disorder that involves a sudden episode of abnormal, uncontrolled dis- charge of the electrical activity of the neurons within the brain. The patient may experience a variety of symptoms depending on the type of seizure and the cause.
The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour
Conjunctivitis Pt Education
Use of meds, washing hands, not touching eyes
3
Using maslow's framework which statement charecterizes the highest level of need? 1. Nurse my pain is severe. . . is it time for my shot? 2. I felt welcomed when i first joined the group and i look forward to the monthly meetings 3. Im very proud of recieving the employee of the month award 4. There have been home breakins with burglary in our neighborhood. we are thinking of moving.
C
Vascular dementia is associated with a. transient ischemic attacks b. bacterial or viral infection of neuronal tissue c. cognitive changes secondary to cerebral eschemia d. abrupt changes in cognitive function that are irreversibe
List three problems associated with immobility.
Venous thrombosis, urinary calculi, skin integrity problems.
Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Volkmann's contracture b) Callus c) Subluxation d) Whiplash injury
Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client?
Volume overload
Identify pain-relief interventions for clients with arthritis.
Warm, moist heat (compresses, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and meds.
Hyperthyroidism
Weight loss Tachycardia Insomnia Heat intolerance Diarrhea Finger clubbing Nervousness Tachypnea Flushed skin Exopthalmos
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
Western blot test with ELISA.
Cataract Hesi Hint #2
When the cataract is removed, the lens is gone, making prevention of falls important. When the lens is replaced with an implant, vision is better.
D
Which patient is most at risk for developing delirium? a. a 50 year old woman with cholecystitis b. a 19 year old man with a fractured femur c. A 42 year old woman having an elective hysterectomy d. A 78 year old man admitted to the medical unit with complications related to heart failure
When assessing a client's gait, which does the nurse look for and encourage? The spine rotates, initiating locomotion. Gaze is slightly downward. Toes strike the ground before the heel. Arm on the same side as the swing-through foot moves forward at the same time.
Your Answer: The spine rotates, initiating locomotion. Rationale: Normal gait involves a level gaze, an initial rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment.
Dyssynergic bladder
a problem with coordination between the bladder contraction and sphincter relaxation: results in urgency, increase in urinary frequency, hesitancy in initiating urine flow, nocturia, dribbling and incontinence
Systemic lupus erythematosus (SLE)
a progressive systemic inflammatory disease that can cause major organs and systems to fail; CT and fibrin deposits collect in blood vessels on collagen fibers and organs; deposits lead necrosis and inflammation of blood vessels, lymph nodes, GI tract and pleura
CT Scan
a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body.
Products that may contain latex
ace bandages, adhesive/elastic bandages, ambu bag, balloons, BP cuff, catheters, condoms, diaphragms, TEDs, EKG pads, feminine hygiene pads, gloves, IV components, Levin tubes, pads for crutches, prepackaged enema kits, rubber stoppers on med vials, stethoscopes, syringes
Discuss the primary characteristics of extra-pyramidal disorders.
akinesia (inability to initiate movement) and akathisia (inability to remain motionless), dystonia. relating to the part of the nervous system that affects body posture and promotes smooth and uninterrupted movement of various muscle groups.
Data collection for posttransplant immunosuppressed pt
assess for s/s of opportunistic infections; assess nutritional status; assess for s/s of rejection of transplant
5 and older
at what age can a child recieve a live attenuated flu vaccine via intranasal form
Goodpasture's syndrome
autoimmune d/o; autoantibodies made against glomerular basement membrane and alveolar basement membrane; primarily affects lung and kidneys
relapsing- remitting MS
characterized by periodic remissions and exacerbation of symptoms. Most common
patho of MS
destruction of myelin sheath (plaques) around axons in nervous cells, disrupting/ distorting the conduction of electrical impulses. Only nerves in CNS affected, no peripheral nerves. Early= inflammation/edema around plaques. Later in disease= scarring of glia and degeneration of axon
The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for:
diarrhea
Risk factors associated with osteoporosis
diet low in calcium sedentary lifestyle cigarette smoking long term alcohol assumption chronic illness longe term use of anticonvulsants and furosemide (Lasix)
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
diphenhydramine hydrochloride (Benadryl)
Diplopia
double vision, occurs when the mm that control the eyes are not well coordinated
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse's suspicions are:
drop in blood pressure and rise in heart rate.
A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which the followin as a high-risk area for pressure and breakdown
elbows if they are used for repositioning instead of trapeze, heel of good leg whih is used as a brace when pushing up in bed. ischial tuberosity, popliteal space, and schilles tendon
Discuss nursing care to promote independence with ADL's.
encourage the client to use the unaffected arm, teach family/client to put clothing on the affected extremity first and then dress the unaffected extremity, consult with occupational therapist to teach the client how to use assistive devices for eating, hygiene, and dressing.
In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
extent of immune system damage.
Plasmapheresis
filtration of the plasma to remove some of the proteins
pemphigus data collection
fragile, flaccid bullae lesions; partial thickness wounds that bleed, weep, and form crusts when bullae are disrupted; debilitation, malaise, pain; chewing/swallowing difficulties; leukocytosis, eosinophilia, foul-smelling discharge from skin
MS Problems w/ GU system
freq UTIs, urinary retention, incontinence, impotence. May have spastic bladder= anticholinergics May have flaccid bladder= cholinergics
MS Probs w/ Resp system
freq infections r/t inability to cough, move secretions, breath deeply
HD diagnosis made how?
genetic testing.
Immunomodulators given to who?
given to relasping/remitting. Prolongs onset of disability.
plasmapheresis for GB
helps if given during first 2 weeks of onset. Removes antibiodies and given immunosuppressive meds at same time.
Respiratory s/s of anaphylaxis
hoarseness, coughing, sensation of narrowed airway, wheezing, stridor, dyspnea, tachypnea, respiratory arrest
A nurse is checking the casted extremity of a client. The nurse would check for which of the following signs and symptoms indicative of infection 1.edema 2. no distal pulses 3.hot spot on the cast
hot spot on the cast which are areas of the cast that are warmer than others
neomycin, gelatin, or eggs
if allergy to these, must not get an MMR.
Nutrition for GB patient
may need enteral or TPN due to dysphagia. Need to positive nitrogen balance, hydrated, electrolytes balanced and sufficient calories
What is nursing care after bone biopsy
mointoy site for swelling, bleeding, and hematoma formation elevate site for 24 hours to reduce edem monitor vitals every four hourse for 24 hours. The client usually requires mild analgesics, more sever pain usually indicates that complication are arising
skin around pin site is swollen red and crusty with dried drainage
notify the hcp-indicates osteomalitis
Complications of ALS:
paralysis, decrease in ADL's, aspiration, loss of verbal communication, pneumonia, resp failure, malnutrition, depression.
What is the sign of mal-union?
persistent discomfort with moving (broken bones should not be moving under the cast)
Discuss the local and national community resources available for patients for home care.
psychological support, respite care, meals on wheels, sources for special adaptive equipment, support groups, social services
thymectomy
recommend for pts under 60. taped off steriods. give pyridostigmine given to prevent S&S during surgery. post op care focused on pulmonary hygiene,preventing complications from chest tube & pain control
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
myasthenic crisis
sudden exacerbation of motor weakness= resp failure/ aspiration. caused by undermedication/ infection.
which clinical manifest on a leg from which a cast has just been removed is abnormal finding
the bony prominences are excoriated; (restricted motion, smaller, atrophy, skin peeling wrinkled and dry are all normal findings)
A client who is learning to use a can if afraid it will slip with ambulations causing a fall. the nurse provides the client with the greatest reassurance by telling the client that:
the cane has a flared tip with concentric rings to provide stability
HA, photophobia, >liver enzymes, fever
what are 4 side effects to Hep B Vaccine
bacterial meningitis
what illness is caused by the pneumocoocal infection
stool
where can the Hep A virus be found
Prevalence
young adults and individuals in their 50's and 80's, more males than females, more Caucasians than African Americans
A client diagnosed with human immunodeficiency virus (HIV) infection states, "I'm afraid of gaining weight, so I always supplement my diet with vitamins." Which response by the nurse is appropriate?
"Eating a variety of healthy foods is the best source of vitamins."
The nurse is teaching the parents of a child with hemophilia about how to provide a safe home environment throughout the child's life. Which nursing instruction is most appropriate?
"Establish a written emergency plan that includes what to do in specific situations and the names and phone numbers of emergency contacts."
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
"I will receive parenteral vitamin B12 therapy for the rest of my life."
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
"I won't donate blood because I don't want to get AIDS."
In teaching a female client who is HIV-positive about pregnancy and the human immunodeficiency virus (HIV), the nurse would know more teaching is necessary when the client says:
"I'll need to have a C-section if I become pregnant and have a baby."
After being admitted to the hospital with sickle cell crisis, a client asks a nurse how he can prevent another crisis. Which response by the nurse is best?
"Make sure that you drink plenty of fluids."
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [Retrovir]), 200 mg by mouth every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
"Take zidovudine every 4 hours around the clock."
A 40-year-old client with mild dementia related to end-stage acquired immunodeficiency syndrome (AIDS) is preparing for discharge. She has decided against further curative treatment. Before discharge, she develops ocular cytomegalovirus (CMV). Her physician recommends treatment with a ganciclovir-impregnated implant (Vitrasert), which requires a surgical procedure. The client's husband feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which response best answers the husband's question while promoting client advocacy?
"The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult."
How should a nurse respond when asked by a family member of a client with human immunodeficiency virus (HIV) infection why she's performing passive range-of-motion (ROM) exercises on the client?
"These exercises help prevent contractures by keeping his joints mobile."
A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The nurse's most appropriate response to her would be:
"You seem angry. Would you like to talk about it?"
A 27-year-old client with end-stage acquired immunodeficiency syndrome (AIDS) is being cared for by his wife at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about advance directives. At the next visit, the client states that since he and his wife filled out the advance directive form he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client 's concerns?
"Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself."
(SELECT ALL THAT APPLY) The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions should the nurse include in the teaching plan?
(1) Stay out of direct sunlight., (3) Monitor body temperature., (4) Taper the corticosteroid dosage as ordered by the physician when symptoms are under control.
(SELECT ALL THAT APPLY) A client has undergone total gastrectomy due to stomach cancer. Which nursing interventions are necessary for this client immediately after surgery?
(3) Observe the wound for redness, swelling, and warmth, (4) Encourage incentive spirometry use every hour during the client's waking hours., (5) Administer opioid analgesics as prescribed.
(SELECT ALL THAT APPLY) The nurse is planning care for a client with human immunodeficiency virus (HIV). Which statement by the nurse indicates her understanding of HIV transmission?
(4) "I will wear a mask, gown, and gloves when splashing of bodily fluids is likely.", (5) "I will wash my hands after client care."
Steroid Hesi Hint**
**Many people take steroids for a variety of conditions, questions often focus on the need to teach clients the importance of following the prescribed regimen precisely. Clients should be cautioned against stopping the medications suddenly and should be informed that it is necessary to taper off the dosage when taking steroids.**
neomycin
what antibiotic causes the Hep A vaccine to be contraindicated
3-11 months
how long can pt. wait to receive immune serum globulin or blood products after varicella vaccine
avoid pregnancy for 3 months after vacine
how long should childbearer women avoid pregnancy after vaccine
2 under age of 12, one older than 12.
how many doses of flu vaccine be given for under 12 and over 12.
seizures, crying for 3 hours, or >105* temp
what are contraindications or side effects to DTaP or Tdap
pregnant or blleding disorder
what are contraindications to HPV
Why are fractures of the epiphyseal plate a special concern?
Fractures of the epiphyseal plate (growth plate) may affect the growth of the limb.
2 months to 4-6 years old
how old should child be for DTaP of five injections
hypersensitivity and allergy data collection
hx of exposure to allergen; itching, tearing, and burning of eyes and skin, rashes, nose twitching and nasal stuffiness
allergy to baker's yeast, or liver abnormalities
what are contraindications to the use of the 3 injections to Hep B vaccine
pregnant, immunocompromised, active TB, allergy to neomycin or gelatin
what are contraindications to varicella vaccine
siezure, pneumonia, fever UTI
what are some severe side effects for rotavirus vaccine
immuno globulin
what blood product can be given at the same time but in different sites
eggs
what food allergy causes the denial of the flu shot
genital warts
what is HPV
.01 ml/kg
what is epi 1:1,000 dose for anaphylaxis reaction to vaccine
AIDS s/s
flu-like sx; lymphadenopathy for @ least 3mo; presence of opportunistic infections; protozoal infections; Kaposi's sarcoma; Neoplasms; Fungal, viral, bacterial infections
gardisil or cervarix
what is name of the HPV vaccine
stimulate immunity
what is the purpose of a live attenuated vaccine
aspirin free pain reliever
what pain reliever is given to DTaP if fever or pain at injection site occured
autumn
what time of year is the flu shot to be given
wait until they recover
when should an severely ill person receive a Tdap or DTaP vaccine if they are sick
MS Gait Problems
Staggering, Wide BOS, Poor foot placement, Slow uncoordinated progression of LE, Poor ability to produce reciprocal movement
Nursing interventions for fatigue
Assess, arrange for rest periods, Prioritize activities, avoid temp extremes (hot showers), relieve pain. referrals to groups as needed
Nursing interventions for self-care deficit
Assess, suggest adaptive devices, teach intervetions r/t altered bowel/bladder function
Atherosclerosis
Associated with low TH levels Angina, heart failure, dysrhythmia, infarction, etc. Begin drug therapy in low doses and monitor for rapid HR, palpitations, and chest pain early in therapy.
LMN signs and symptoms
Asymmetric mm weakness, cramping, and atrophy in the hands, Mm fasciculations due to mm weakness, Mm weakness will continue throughout the body distal to proximal
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:
fluid replacement.
A client takes prednisone (Deltasone), as prescribed, for rheumatoid arthritis. The nurse should tell the client to look for common adverse reactions to this drug, such as:
fluid retention and weight gain.
Later Nursing care of HD
focuses on immobility, altered nutrition, impaired communication and self-care deficits.
Recovery stage of GB
may take months to 2 years. generally muscle strength and function return in descending order.
false negetive TB result
measles vaccine may cause this type of result
SLE precipitating factors
medications, stress, genetics, UV/sunlight, pregnancy
The edges of a cast can be petaled with tape to do what
minimize skin iritation
Identify two types of hearing loss.
Conductive (transmission of sound to inner ear is blocked) and sensorineural (damage to 8th cranial nerve).
A client is admitted to the medical-surgical floor with a suspected diagnosis of acute myeloid leukemia. A nurse discusses the client's condition in the hallway. This action by the nurse jeopardizes which of the following principles?
Confidentiality
Glaucoma Drug Therapy
Constrict the pupil. Reduce aqueous humor Beta-blockers Prostaglandin-agonist Adrenergic-agonist Cholinergic-agonist Carbonic inhibitors
Causes of SLE
cause unknown; thought to be due to a defect in the immunological mechanisms, possibly genetic origin
cholinergic crisis
caused by overdose of anticholinesterase meds.
wait 3 - 11 months
wait this long after a immune serum globulin or blood products before giving an MMR vaccine
Early Nursing care of HD
centered on teaching about disease, psych support, genetic counseling,
decorticate posturing
characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex.
dysphagia
condition in which swallowing is difficult or painful
thymus gland w/ MG
cont to produce antibodies . Possible source of autoantigen that triggers MG
resp S&S of MD
weakening of intercostal muscles. decrease in diaphra movement, dyspnea, poor gas exchange complications: decreased ability to walk, eat and ADL's, pneumonia
avoid pregnancy for at least 3 months
inform adolescent girls to avoid this after immunization of MMR
Evaluating degenerative motor neuron diseases via NCS you will see:
•Motor conduction is usually normal or slightly reduced •Sensory conduction is normal
Pedi HH #2
Skin traction for fx reduction should not be removed unless HCP prescibes its removal.
a,b,c,d,e
Social effects of a chronic neurologic disease include (select all that apply) a. divorce b. job loss c. depression d. role changes. e. loss of self esteem
Discuss drugs used to treat seizures by: name, action, adverse reactions and special precautions.
Sodium Luminal (Phenobarbital) Diphenylhdantin (Dilantin) Mephenytoin (Mesantoin) Valproic Acid (Depakene) Carbamazine (Tegretol)
What percent of ALS is familial?
10%
Diagnosis of MS requires
2 or + exacerbation separated by 1 mo and lasts +24 hrs. OR history of repeated exacerbation & remissions w/ or w/o recovery followed by increase in symptoms for 6 or + months. OR slow increase in symptoms for 6 months
Glaucoma
2 Types: Chronic open-angle glaucoma and Acute closed angle glaucoma. DESCRIPTION: Condition characterized by increased intraocular pressure (IOP). Glaucoma involves gradual, painless vision loss (peripheral lost). Glaucoma may lead to blindness if untreated. Glaucoma usually occurs bilaterally in those who have a family hx of the condition. Aqueous fluid is inadequately drained from the eye. It is generally asymptomatic, especially in early stages. It tends to be dx during routine visual examinations. It cannot be cured but can be treated with success pharacologically and surgically. NURSING ASSESSMENT: Early signs: Decreased accommodation or ability to focus. Late signs: Loss of peripheral vision. Seeing halos ar ound lights. Decreased visual acuity not correctable with glasses. Headache or eye pain that may be so severe as to cause n/v. ***acute closed-angle glaucoma-surgical emergency*** DX Tests: Tonometer, used to measure IOP. Electronic tonometer, used to detect drainage of aqueous humor. Gonioscopy, used to obtain a direct visualization of the lens. RISK FACTORS: Family Hx of glaucoma. Family Hx of diabetes. Hx of previous ocular problems. Medication use, glaucoma is a side effect of many meds eg. antihistamines, anticholinergics. It can also result from the interaction of meds. NURSING PLANS AND INTERVENTIONS: Administer eye drops as prescribed. Orient client to surroundings. Avoid nonverbal communication that requires visual acuity. Develop a teaching plan that includes the following: Careful adherence to eye-drop regimen can prevent blindness. Vision already lost cannot be restored. Eye drops are needed for the rest of life. Proper eye-drop instillation technique: Wash hands and external eye. Tilt head back slightly. Instill drop into lower lid, without touching the lid with the tip of the dropper. Release the lid, and sponage excess fluid from lid and cheek. Close eye gently, and leave closed 3-5 minutes. Apply gentle pressure on inner canthus to decrease systemic absorption. Safety measures to prevent injuries: Remove throw rugs. Adjust lighting to meet needs. Avoid activites that may increase IOP: Emotional upsets. Exertion like pushing, heavy lifting, shoveling. Coughing severely or excessive sneezing (get medical attention before upper respiratory infection worsens.) Wearing constrictive clothing eg tight collar or tie, tight belt or girdle. Straining at stool and constipation.
A client weighing 158 lb is ordered to receive 5 mg/kg of cyclosporine (Sandimmune) daily. How many milligrams should the client receive?
360
A nurse educator is teaching basic principles of proper lifting technique to a group of newly hired nurses. Use the ATI Active Learning template to complete this item. Under the section Underlying Principles, list 4 key elements of proper lifting technique.
4 Principles of Lifting 1. Use the major muscle groups to prevent back strain and tighten the abdominal muscles to increase support to the back muscles. 2. Distribute the weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and to avoid strain on the smaller muscles. 3. When lifting an object from the floor, flex the hip, knees & back. Get the object to thigh level, keeping the knees bent and the back straightened. Stand up while holding the object as close as possible to the body, bringing the load to the center of gravity to increase stability and decrease back strain. 4. Use assistive devices whenever possible, and seek assistance whenever it is needed.
Normal blood glucose
70-110
spasticity
Baclofen, Dantrium, Vallium, Zanaflex, Klonopin
The healthcare provider orders 2.5 mg IV of morphine sulfate (Morphine) to be administered to a patient with a ruptured interverterbral disk. The nurse has a 1 milliliter (mL) syringe containing 10 mg of morphine sulfate. How many milliliters of morphine sulfate does the nurse need to withdraw from the syringe?
Correct Answer: 0.25
Osteoporosis
DESCRIPTION: Metabolic disease in which bone demineralization results in decreased density and subsequent fractures. Many fractures in older adults occur as result of osteoporosis and often occur prior to the client's falling rather than as the result of a fall **pathologic fracture**. The cause of osteoporosis is unknown. Postmenopausal women are at highest risk **estrogen keeps calcium in bone** NURSING ASSESSMENT: Classic dowager's hump, or kyphosis of the dorsal spine. Loss of height, often 2-3 inches. Back pain, often radiating around the trunk. Pathologic fractures, often occurring in the distal end of the radius and the upper third of the femur. Compression fracture of spine- assess ability to void and defecate. NURSING PLANS AND INTERVENTIONS: Create a hazard-free environment **safety first**. Keep bed in low position. Encourage client to wear shoes or nonskid slippers when out of bed. Encourage environmental safety: adequate lighting, keep floor clear, discourage use of throw rugs, slean spills promptly, keep side rails up at all times. Provide assistance with ambulation: client may need walker or cane. Client may need standby assistance when initially getting out of bed or chair. Teach regular exercise program. ROM exercise several times a day, ambulation several times a day, use of proper body mechanics. Provide diet that is high in protein, calcium, and vitamin D; discourage use of alcohol and caffeine. Preventive measures for females: HRT has been used as a primary prevention straegy for reducing bone loss in the postmenopausal woman. Recent studies demonstrated that HRT may increase a woman's risk of breast cancer, cardiovascular disease, and stroke. If using HRT the benefits should outweigh the risks. Take prescribed meds to prevent further loss of bone mineral density (BMD). **Bisposphonates: inhibits osteoclast-mediated bone resorption, thereby increasing BMD. Common side effects are anorexia, weight loss, and gastritis. Instruct the client to take with full glass of water, take 30 minutes before food or other meds and remain upright for at least 30 minutes after taking**. Fosamax, Bonefos, Actonel. Selective estrogen receptor modulator: to mimmic the effect of estrogen on bone by reducing bone resorption without stimulating the tissues of the breast or uterus. The most common side effects are leg cramps, hot flashes, vaginal dryness. Evista High calium and vitamin D intake beginning in early adulthood. Calcium supplementation after menopause (Tums are an excellent source of calcium). Weight-bearing exercise. Osteopenia is defined as a bone loss that is more than normal and has a T-score less than or equal to a range of -1 to -2.5 but is not yet at the level for a dx of osteoporosis.
Amputation
DESCRIPTION: Surgical removal of a diseased part or organ. Causes for amputation include the following: Peripheral vascular disease, 80% (75% ar diabetics). Trauma. Congenital deformities. Malignant tumors Infection. Amputation necessitates major lifestyle and body-image adjustments. NURSING ASSESSMENT: Prior to amputation, symptoms of peripheral vascular disease include: Cool extremity. Absent peripheral pulses. Hair loss on affected extremity. Necrotic tissue or wounds: blue or blue-gray, turning black. Drainage possible with or without odor. Leathery skin on affected extremity. Decrease of pain sensation in affected extremity. Inadequate circulation is determined by: Arteriogram and Doppler flow studies. NURSING PLANS AND INTERVENTIONS:Provide wound care: Mark dressing for bleeding, and check marking at least every 8 hours. Measure suction drainage every shift. Change dressing as needed (physician usually performs initial dressing change): ****large tourniqiet at bedside for frank hemorrhage**** Maintain aseptic technique. Observe wound color and warmth. Observe for wound healing. Monitor for signs of infection: fever, tachycardia, redness of incision area. Maintain proper body alignment in and out of bed. Position client to relieve edema and spasms at residual limb (stump) site. ***Elevate stump for the first 24 hours postop*** Do not continually elevate stump after 48 hrs postop. (can cause contracture). Keep stump in extended position, and turn client to prone position three times a day to prevent hip flexion contracture. Be aware that phantom pain is real; it will eventually diappear, and it responds to pain meds. Handle affected ody part gently and with smooth movements. Provide passive ROM until client is able to perform active ROM. Collaborate with rehab team members for mobility improvement. Encourage independence in self-care, allowing sufficient time for client to complete care and to have input into care.
The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
Use the smallest needle possible for injections.
Skin s/s of anaphylaxis
Pruritus, angioedema, erythema, urticaria
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
Reduced sneezing
Drug therapy of hypothyroidism is usually...
lifelong
Evaluating degenerative motor neuron diseases via EMG you will see:
•Chronic partial denervation •Abnormal spontaneous activity at rest •Reduction in the number of muscle units under voluntary control
Emotional Lability
excessive emotional reposnisveness characterized by unstable and rapidly changing emotions
Client Education for Rehab after hip surgery
-best exercising is walking -Avoid flexion (low chairs, traveling long distances, sitting more than 30 minutes, lifting heavy objects, excessive bending or twisting, stair climbing)
Latex Allergy
source of the allergic rxn is thought to be due to the proteins in the natural rubber latex or the various chemicals used in the manufacturing process of latex gloves
types of tx for MS?
-corticosteroids can help with recovery from acute relapses -Prednisone 60-80mg daily x3-4wks -Long-term tx with corticosteroids = no benefit
Immunosupressants that help with MS?
-cyclophosphamide -azathioprine -methotrexate -cladribine -mitoxantrone
Avascular Necrosis (after hip surgery)
-death of tissue due to poor circulation
What is the purpose of traction?
-decrease muscle spasms -reduces (realigns) -Immobilizes
Fracture Healing Concerns
-delayed union (healing does not occur at a normal rate) -Non-union (failure of bone ends to unite; may require bone grafting) -Mal-union: deformity at the fraction site
S/S of fat emboli
-depends on where emboli goes petechia or rash over chest conjunctival hemorrhages snow storm on CXR young males first 36 hours of the fracture (after that it is the DVT)
MS is characterized by..
-episodic neurologic symptoms -under age 55 at onset -single pathologic lesion cannot explain the clinical findings -Multiple inflammatory foci best visualized on MRI
A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? a) "Apply ice packs for the first 24 to 48 hours, then apply heat packs." b) "Apply heat packs for the first 24 to 48 hours." c) "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." d) "Apply ice packs for the first 12 to 18 hours."
"Apply ice packs for the first 24 to 48 hours, then apply heat packs." Explanation: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
"Client will exhibit no signs or symptoms of aspiration."
The nurse is conducting the admission assessment for the client who is to undergo an arthrogram. What is the priority question the nurse should ask? a) "Are you claustrophobic?" b) "When did you last eat?" c) "When did you last urinate?" d) "Do you have any allergies?"
"Do you have any allergies?" Explanation: Many contrast dyes contain iodine. Therefore, it is essential for the nurse to determine whether the client has any allergies, especially to iodine, shellfish, and other seafood.
Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture? a) "Don't flex your hip more than 60 degrees, don't cross your legs, and have someone help you put your shoes on." b) "Don't flex your hip more than 120 degrees, don't cross your legs, and have someone help you put your shoes on." c) "Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." d) "Don't flex your hip more than 30 degrees,
"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." Explanation: Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.
A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? a) "The occupational therapist is showing me how to use a sock puller to help me get dressed." b) "I'll need to keep several pillows between my legs at night." c) "I need to remember not to cross my legs. It's such a habit." d) "I don't know if I'll be able to get off that low toilet seat at home by myself."
"I don't know if I'll be able to get off that low toilet seat at home by myself." Explanation: The client requires additional teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.
Immediate Post Op care for amputations
-Keep a tournaquette at the bedside -Extension to prevent hip/knee contractions -Inspect the residual limb daily to be sure that it lies completely flat on the bed
ANA results
+ test = 1:20 or 1:40; + in most with SLE; can produce false + in small % of normal population; + result does not confirm disease
Treatment of compartment syndrome
-Elevate extremity (get fluid away) -soft cast then rigid cast -Loosen the cast to restore circulation -Be careful in picking the answer to "remove the cast" -fasciotomy -cast cutters to remove the case (instruct them the cast saw does not touch the skin, but it does vibrate)
Treatment of Fractures
-Immobilize the bone ends plus the adjacent joints -support fracture above and below the site -move extremity as little as possible -splints help prevent fat emboli and muscle spasm
Secondary progressive disease
-In some MS patients, the clinical course changes from relapsing-remitting to a steady deterioration, unrelated to acute relapses
Should you relieve traction?
-Never relieve traction unless you've got a physician's order
Infection (after hip surgery)
-Prophylactic antibiotics -remove foley and drains as soon as possible
Complications post-op from hip replacement (4)
1. Dislocation 2. Infection 3. Avascular necrosis 4. Immobility problems
types of spinal muscular atrophies:
1. Werdnig-Hoffman dz 2. late childhood 3. Kugelberg-Welander syndrome 4. adult onset
Normal intraocular pressure
10-21 mm Hg
Retinal detachment assessment findings
19. Assessment findings are flashes of light, floaters, increase in blurred vision, sense of a curtain coming over eye, loss of portion of visual field, painless loss of central or peripheral vision.
after change of shift report which pt needs to be assessed first
28 yr old w fx complaining cast is tight
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? 1. Encourage isometric exercises. 2. Suction every 8 hours. 3. Give low-dose heparin 4. Promote incentive spirometer use.
4. Promote incentive spirometer use. -- helps keep the airways open and prevents atelectasis.
A nurse is planning to provide instructions to the client how to stand on crutches. In the written instructions, the nurse plans to tell the client to place the crutches:
6-10 inches in front and to the side of the client depending on the body size. This provides a base of support to the client and improves balance
charge nurse you are making assignments, pulled from pacu for the day
72 yr old with pagets disease returned from surgery tk replacement
Diet for a person with Meniere's Disease
: low sodium, restrict caffeine, restrict nicotine, restrict ETOH
C
A 65 Year old woman was just diagnosed with parkinson's disease the priority nursing intervention is: a. searching the internet for educational videos b. evaluating the home for environmental safety c. promoting physical exercise and a well balanced diet d. Designing an exercise program to strengthen and stretch specific muscles.
RF Hesi Hint #1
A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use, and which methods should not be used? Use: Inspection, Palpation, Stregnth testing Do NOT Use:ROM, this activity promotes pain because ROM is limited.
A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is sob and is restless. What does the client most likely have?
A fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever, and petechiae.
A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safe sex practices for persons with HIV is accurate?
A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.
a
A major goal of treament for the patient with AD is to: a. maintain patient safety b. maintain or increase body weight c. return to a higher level of self care d. enhance functional ability over time
c
A nurse and a primary care provider inform a client that chemotherapy is recommended for a diagnosis of cancer. Which nursing action is most representative of the concept of holism? a. Offer to come to the client's home to provide needed physical care b. Contact the client's spiritual advisor c. Inquire how this will affect other aspects of the client's life d. Provide the client with information about how to join a support group 1. ch 16
3
A nurse is planning a workshop on health promotion for older adults. Which topic will be included? 1. prevention of falls 2. cardiovascular risk factors 3. adequate sleep 4. how to stop smoking
After undergoing testing, a client comes to a physician's office for a follow-up appointment. During the appointment, the physician informs the client that she has systemic lupus erythematosus (SLE) . Which resource might be helpful for a nurse to recommend to this client?
A support group for clients with SLE
Discuss the discharge-teaching plan for anticoagulants (and anti-platelets).
A thorough review of the dosage regimen, possible adverse drug reactions, and early signs of bleeding tendencies help the patient cooperate with the prescribed therapy. Teach: -Follow the dosage schedule prescribed by the PHCP, and report any signs of active bleeding immediately. (gums bleeding, bruising, bloody stools, black and tarry stools, vomit that is bright red or looks like coffee grounds). If these are found, d/c the next dose and contact your PHCP immediately. -The INR will be monitored periodically. Keep all appointments, because dosage changes may be necessary. -Do not take or stop taking other drugs except on the advice of the PHCP. -Inform your dentist and other PHCP of therapy. -Take the drug at the same time each day. -Do not change brands of anticoagulants without consulting a physician or pharmacist. -Avoid alcohol unless use has been approved by the primary health care provider. -Be aware of foods high in vit-K, such as leafy green vegetables, beans, broccoli, cabbage, cauliflower, cheese, fish, and yogurt. Maintaining a healthy diet including these foods may help maintain a consistent INR value. -Keep in mind that anti-platelet drugs can lower all blood counts, including the WBC count. Patients may be at greater risk for infection during the first 3 months of treatment. -Use a soft toothbrush. -Use an electric razor when possible. -Wear or carry medical identification.
A clinical nurse specialist (CNS) is orienting a new licensed practical nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
A-positive blood to an A-negative client.
Teaching that the nurse will plan for the patient with SLE includes a. ways to avoid exposure to sunlight b. increasing dietary protein and carbohydrate intake c. the necessity of genetic counseling before planning a family d. the use of no pharmacologic pain interventions instead of analgesics
A. ways to avoid exposure to sunlight
A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements by a newly nurse indicates a need for further teaching? A. My line of gravity should fall outside my base of support. B. The lower my center of gravity, the more stability I have. C. To broaden my base of support, I should spread my feet apart. D. When I lift an object, I should hold it as close to my body as possible.
A. My line of gravity should fall outside my base of support. (Not correct, line of gravity will fall with IN base of support )
Adenocorticosteriod therapy in MS
ACTH, Prednisone, Methylprednisolone. Used to sustain remission and treat exacerbation. used to suppress immune system.
Which of the following terms refers to moving away from midline? a) Inversion b) Adduction c) Abduction d) Eversion
Abduction Explanation: Abduction is moving away from midline. Adduction is moving toward midline. Inversion is turning inward. Eversion is turning outward.
What are the signs and symptoms of compartment syndrome?
Abnormal neurovascular assessment: cold extremity, severe pain, inability to move the extremity, and poor capillary refill.
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Discuss the teaching plan for the patient with an extra-pyramidal disorder.
Actions of medication Continued support and counseling
This is considered a medical eye emergency
Acute closed angle glaucoma Retinal detachment
Describe nursing and interdisciplinary care for a patient with a spinal cord injury.
Acute phase: Aggressive respiratory therapy. Above C5 injury are intubated/ventilator. Intermittent positive-pressure breathing (IPPB) are used to prevent atelectasis. Foley catheter, surgery/immobilization, tracheotomy if long-term ventilation is needed. Parentreal nutrition and fluids until the GI tract starts functioning. A diet high in protein and fiber. Bowel program during spinal shock: manual disipaction and small-volume enemas. PT and OT therapy: passive ROM and then aggressive rehab long term. Chronic phase: orthostatic hypotension prevention, dietary management (weight gain likely), skin care/turning, respiratory management.
Guillain-Barre Syndrome
Acute polyneuropathy, Temporary inflammation and demyelination of the peripheral nerves' myelin sheaths, Results in motor weakness in a distal to proximal fashion with sensory impairment and possible respiratory paralysis. Thought to be an autoimmune response. Recovery is slow and can last 3-12 months.
What is the priority nursing intervention used with clients taking NSAIDs?
Administer or teach client to take drugs with food or milk.
Which nursing intervention is appropriate for a client diagnosed with idiopathic thrombocytopenia purpura (ITP)?
Administering stool softeners, as ordered, to prevent straining during defecation
Which action takes priority for a client who is experiencing a hypersensitivity reaction to latex?
Administering supplemental oxygen
Risk factors for Cataracts
Age-related Trauma Toxins Diabetes
Explain the surgical treatment for a TIA.
Angioplasty In selected cases, a procedure called carotid angioplasty, or stenting, is an option. This procedure involves using a balloon-like device to open a clogged artery and placing a small wire tube (stent) into the artery to keep it open. If you have a moderately or severely narrowed neck (carotid) artery, your doctor may suggest carotid endarterectomy (end-ahr-tur-EK-tuh-me). This preventive surgery clears carotid arteries of fatty deposits (atherosclerotic plaques) before another TIA or stroke can occur. An incision is made to open the artery, the plaques are removed, and the artery is closed. Carotid endarterectomy is often not done until several months after a TIA, but a large study showed that people benefit most from the surgery if it is done within 2 weeks of a TIA. Delaying surgery longer than 2 weeks increases the risk for stroke, because a person is more likely to have a stroke in the first few days and weeks after a TIA. Each person must carefully weigh the benefits and risks of surgery and compare them with the benefits and risks of using medicine to reduce the risk of TIA or stroke. The success of either treatment will depend on the amount of blockage you have and which medicine you use. Risks of surgery depend on your age, your health status, the skill and experience of the surgeon, and the experience of the medical center where the surgery is done.
Describe two classifications of drugs used to treat a TIA.
Anti-platelet drugs. These medications make your platelets, one of the circulating blood cell types, less likely to stick together. When blood vessels are injured, sticky platelets begin to form clots, a process completed by clotting proteins in blood plasma. Anticoagulants. They affect clotting-system proteins instead of platelet function.
The nurse would include which of the following in a neurological assessment? a) Palpate the dorsalis pedis pulse. b) Capillary refill of the great toe. c) Inspect the foot for edema. d) Ask the client to plantar flex the toes.
Ask the client to plantar flex the toes. Explanation: A neurological assessment evaluates sensation and motion. Assessing plantar flexion of the toes would be included in a neurological assessment. Capillary refill, palpation of pulses, and inspecting for edema would be included in a vascular assessment.
Describe the phases of a tonic-clonic seizure.
Aura: bright light Tonic phase: muscles are rigid with the arms extended and jaws clenched Clonic phase: movements are jerky as the muscles alternately contract and relax Postictal phase: the pt is unconscious for 30 minutes and then regains conciousness slowly
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
Autoimmune disorders include connective tissue (collagen) disorders.
Goodpasture's syndrome etiology
most common in males and young adults that smoke; exact cause unknown
Muscle relaxants for MS
Baclofen, dantrolene (may affect muscle strength & hepatoxic), diazepam. used to treat muscle spasms.
4
Based on the life changes index which individual would have an increased possibility of illness in the near future? 1. A 25 year old man who recently married his high school sweetheart 2. 1 35 year old man fired from his job 3. a 40 year old woman beginning a nursing program 4. 50 year old woman whos husband died a month ago
Describe nursing care for the client who is experiencing phantom pain after amputation.
Be aware that phantom pain is real and will eventually disappear. Administer pain meds; phantom pain responds to meds.
Explain the use of emergency equipment for patients with a seizure disorder.
Bite stick Suction O2
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
Bluish urine
Cataract assessment findings
Blurred vision, decreased color perception: early; diplopia, reduced visual acuity, absence of red reflex; pain and eye redness are associated w late forms
The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction?
Bronchospasm
What is the most famous type of skin traction?
Buck's (used most often with hip and femoral fractures) Must do a good skin assessment with these
Pre-op notes about Total Hip Replacement: what type of traction is used?
Buck's is frequently used
After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when the patient says, a. heat treatments should not be used if muscle spasms are present b. cold applications can be applied for 15-20 minutes to relieve joint stiffness c. I should use heat applications for 20 minutes to relieve the symptoms of an acute flare d. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain
D. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relive the pain
Diagnostic Tests
CSF examination: look for elevated gamma globulin MRI: look for demyelinating plaques Evoked Potential Testing: the presence of demyelinating lesions on sensory pathways can be confirmed by visual, auditory, or somatosenory evoked potentials. CT Scan: for areas of different densities
42. Hypoparathyroidism can lead to a decreased level in this electrolyte?
Calcium
A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
Compatible blood and tissue types
This drug should be kept at the bedside of a patient who had a thyroidectomy to prevent tetany?
Calcium gluconate
Write four nursing interventions for the care of the blind person and four nursing interventions for the care of the deaf person.
Care of the blind: announce presence clearly, call by name, orient carefully to surroundings, guide by walking in front of client with their hand in your elbow. Care of deaf: reduce distraction before beginning conversation, look and listen to client, give client full attention if they are a lip reader, face client directly.
What discharge instructions should be included concerning a child with a spica cast?
Check clid's circulation. Keep cast dry. Do not place anything under cast. Prevent cast soilage during toileting or diapering. Do not turn child using an abductor bar.
Which assessment findings would cause the nurse to suspect compartment syndrome after casting of the leg? a) Warm, pink foot and ability to move toes of affected leg b) Low-grade fever, dyspnea, tachycardia, and crackles c) Increased capillary refill and bounding pulses in affected leg d) Complaints of numbness and tingling in toes of affected leg
Complaints of numbness and tingling in toes of affected leg Explanation: Numbness and tingling indicate nerve ischemia and edema, suggesting development of compartment syndrome.
Discuss common drugs used in the treatment of Alzheimer's disease.
Cholinesterase inhibitor drugs, such as Cognex (40-80mh 4x/day, admin 1hr before or 2hr after meal), Aricept (5-10mg/day bedtime), and Exelon (1.5-6mg b.i.d), Reminyl (4-12mg b.i.d), and Namada (5-10mg b.i.d) block the breakdown of acetylcholine. Slows cognitive decline. Monitor ALT levels with cognex, elevated levels may indicate hepatoxicty Adverse Reactions: N/V/D, HA, confusion, upset stomach. SSRIs such as Prozac treat depression. Risperdal or Seroquel is used to control behavioral symptoms.
NSG Dx Osteoarthritis
Chronic pain Impaired physical mobility Activity intolerance Self-care deficit Disturbed body image
Fracture Hesi Hint #5
Clients with fractures or edema in or casts on the extremities need frequent neurovascular assessment distal to the injury. Skin, color, temp, sensation, capillary refill, mobility, pain, and pulses should be assessed. (CMS)
Performance of activities of daily living (ADLs) and active range of motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. Elbow flexion with eating and bathing. Elbow extension with shaving and eating. Wrist hyperextension with writing. Thumb ROM with eating and writing. Hip flexion with walking.
Correct Answers: Elbow flexion with eating and bathing. Thumb ROM with eating and writing. Hip flexion with walking. Rationale: Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension (option 2). Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint (option 3). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation.
When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which of the following statements? A. "I should take the Celebrex as prescribed to help control the pain." B. "I should try to stay standing all day to keep my joints from becoming stiff." C. "I can use a cane if I find it helpful in relieving the pressure on my back and hip." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."
Correct answer: B. "I should try to stay standing all day to keep my joints from becoming stiff." Rationale: It is important to maintain a balance between rest and activity to prevent overstressing the joints with OA.
When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply) a. avoiding the consumption of high-purine foods b. strategies for good dental hygiene and mouth care c. protecting the extremities from hot and cold temperatures d. maintaining joint function and preserving muscle strength e. performing mouth excursion (yawning) exercises on a daily basis
Correct answers: b, c, d, e Rationale: Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. The nurse should include the following in the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and gingival problems); protection of hands and feet from cold exposure and possible burns or cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures (they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint movement occurs); use of assistive devices as appropriate and organization of activities to preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open mouth) (helps maintain temporomandibular joint function).
acute exacerbations
Corticosteroids - methylprednisilone, prednisone, dexamethasone
JRA HH#1
Corticosteroids are used in the short term in low doses during exacerbations. Long term use is avoided because of side effects and their adverse effects on growth.
A client presents to the emergency department with an open fracture. What is the first action the nurse should take? a) Assess the client's vital signs and determine allergies. b) Cover the exposed bone with sterile dressing. c) Perform a neurovascular assessment of the affected extremity. d) Assist the physician with reduction of the fracture.
Cover the exposed bone with sterile dressing. Explanation: The exposed bone should be covered with a sterile dressing to protect the deeper tissues from contamination.
GI s/s of anaphylaxis
Cramping, abdominal pain, n/v/d
The basic pathophysiologic process of rheumatoid arthritis (RA) is a. destruction of joint cartilage and bones by an autoimmune process b. initiated by a viral infection that destroys the synovial membranes of joints c. the presence of HLA-DR4 antigen that causes inflammatory responses throughout the body d. an immune response that activates complement and produces inflammation of joints and other organ systems
D. an immune response that activates complement and produces inflammation of joints and other organ systems
A 60-year-old woman has pain on motion in her fingers and asks the nurse whether this is just a result of aging. The best response by the nurse includes the information that a. joint pain with functional limitation is a normal change that affects all people to some extent b. joint pain that develops with age is usually related to previous trauma or infection of the joints c. this is a symptom of a systemic arthritis that eventually affects all joints as the disease progresses d. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age
D. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age.
Nurse is reviewing the effects of immobility on various body systems. List at least 2 effects on respiratory system.
Decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange Stasis of secretions and decreased and weakened respiratory muscles, resulting in atelectasis and hypo-static pneumonia. Decreased cough response.
Explain the importance of frequent neuro vital signs in the early phase of neurological injury.
Frequent vitals allows the LPN to report and changes in the vitals immediately to HCP. It also allows nurse to identify the types of interventions the patient may need.
A client with anemia has been admitted to the medical-surgical unit. Which data collection findings are characteristic of iron-deficiency anemia?
Dyspnea, tachycardia, and pallor
Osteoarthritis Dx Tests
ESR: elevated due to synovitis Radiograph: structural changes
A client with human immunodeficiency virus (HIV) infection is preparing for discharge from the hospital when he complains to a nurse that he continually feels weak. How should the nurse intervene?
Explain to the client that he should schedule periods of rest throughout the day.
Osteoporosis: risk for ____________
Fractures
Secondary Symptoms
Falls, UTI,Incontinence, Anxiety, Contractures, Skin Breakdown, Depression
The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
Following safe-sex practices
What are the common side effects of salicylates?
GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation.
Discuss components of a nutritional plan for a patient with Alzheimer's disease.
Ginko Biloba seems to improve memory. Antioxidants such as Vit-C, Vit-E, and coenzyme 10 may slow progression. Huperzine A, a traditional Chinese medicine, acts as an acetylcholinesterase inhibitor, encourage fluids and fiber.
Copaxone
Glatiramer (MS, immunomodulator)
Glaucoma Hesi Hint #1
Glaucoma is often painless and symptom free. It is usually picked up as part of a regular eye examination.
Diagnosis of MG
H&P, tensilon tests, nerve stimulation studies and analysis of antiacetycholine receptor antibodies.
human papillomavirus infection
HPV stands for
Lab results for Hyperthyroid
Increased T3 & T4 Decreased TSH
List three of the most common joints that are replaced?
Hip, knee, finger
Lab results for Hypothyroid
Increased TSH Decreased T3 & T4
Interventions for Diabetic Neuropathy
I/O, monitor BUN/Creatinine, maintain normal blood glucose, restrict dietary protein, sodium, potassium
Which immunoglobulin is specific to an allergic response?
IgE
Patho of Glaucoma
Increased intraocular pressure resulting from inadequate drainage of aqueous humor from the canal of Schlemm or overproduction of aqueous humor
Compartment Syndrome
Increased pressure within a limited space
Triggers of Thyroid Storm
Infection (pulmonary) Sepsis Diabetes Stress Trauma or surgery Abrupt withdrawal from thyroid meds
Safety interventions for hypoparathyroidism
Initiate seizure precautions, place a trach set at the bedside, administer ca gluconate, VS, monitor for tetany
Type 1 Diabetes Treatment
Insulin, diet
Cerebellar dysfunction
Intention tremors, Vary from mild to massive involuntary movements Tremors can impose significant limitations in activity
Betaseron
Interferon Beta-1B
Immunomodulators for MS
Interferon beta-1a (Avonex=IM weekly)/ (Rebif= subq 3x week) Interferon beta-1b (Betaseron= subq every other day) Glatiramer acetate (copaxone, copolymer-1= subq daily) Natalizumab (tysabri= IV monthy)
Describe symptoms that may indicate a change in LOC.
Irritability Restlessness Personality changes Short-term memory changes Disorientation to place, time, and person
A 39-year-old softball player has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would you expect the physician to perform? a) Analgesia and immobilization b) Joint manipulation and immobilization c) Heat and immobilization d) Ice and immobilization
Joint manipulation and immobilization Explanation: The physician manipulates the joint or reduces the displaced parts until they return to normal position, then immobilizes the joint with an elastic bandage, cast, or splint for several weeks.
Osteoarthritis S/S
Joint pain & stiffness Pain with ROM Crepitus Herberden's nodes Inflammation
A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? a) Keeping a pillow between the client's legs at all times b) Maintaining the client in semi-Fowler's position c) Turning the client from side to side every 2 hours d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift
Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.
Which of the following is an inaccurate clinical manifestation of a fracture? a) Lengthening b) Deformity c) Pain d) Crepitus
Lengthening Explanation: Clinical manifestations of a fracture include crepitus, deformity pain, shortening, and loss of function.
Discuss nursing interventions for a patient having a seizure.
Loosening of clothing around the neck Turn client to side Suction at bedside O2 as ordered Record symptoms during seizure Pad side rails Bed in low position Fall pads on floor
Which of the following deformity causes a exaggerated curvature of the lumbar spine? a) Lordosis b) Steppage gait c) Kyphosis d) Scoliosis
Lordosis Explanation: Lordosis is an exaggerated curvature of the lumbar spine. Scoliosis is a lateral curving deviation of the spine. Kyphosis is an increased forward curvature of the thoracic spine. Steppage gait is not a type of spinal deformity.
Homonymous Hemianopia
Loss of vision in half of the visual field on the same side of both eyes
Discuss prenatal, perinatal, postnatal, causes of CP.
May be caused prenatally by the mother contracting rubella or other infection, malnutrition, abnormal attachment of the placenta, toxemia, radiation, or medication. Perinatally, it may be caused by a difficult birth, prolapsed umbilical cord, or multiple births. Postnatally, an infant might develop it as a result of trauma and result in prolonged anorexia or decreased circulation to the brain.
This disease is characterized by abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac causing endolymph to accumulate in the membranous labyrinth.
Meniere's Disease
Compare and contrast four inflammatory neurological conditions.
Meningitis: inflammation of the meninges of the brain and spinal cord. Enchephalitis: an acute inflammation of the white and gray matter of the brain. Brain abscess: collection of purulent material within the brain.
Cataract Post-Op Care
Mild itching is normal, pain is a problem. Reduce IOP Prevent infection Assess for bleeding Teach pt to report any changes in vision to dr Avoid activities that can increase IOP Proper eye drop admin
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
Monitor body temperature.
Discuss the nursing interventions are for the patient with Parkinson's disease.
Monitor neuro status for changes, monitor respiratory status for changes, encourage self-care, allow patient extra time, encourage exercise; assist with passive ROM if necessary, weigh patient; I&O; explain importance of following med schedule as well as effects of medication wearing off; reduce falls at home.
Interventions for Thyroid Storm
Monitor temp frequently Cooling blankets Tylenol, NO ASA. Higher dose of drugs & fluids Assess LOC frequently Restful environment Airway & Oxygen (resp failure) Vitals & cardiac monitoring
A licensed practical nurse (LPN) is coassigned with a registered nurse (RN) for the care of a client with hemophilia. The physician prescribes a blood transfusion for this client. Which task associated with blood transfusion is the responsibility of the LPN?
Monitoring the client during the transfusion
Differentiate between MS, Myasthenia, and ALS.
Multiple Sclerosis (MS) starts in ages 20-50 usually, in females more than males. It is due to a demylization of the myelin sheaths of neuron cells in the CNS. Symptoms include extreme fatigue, dizziness, muscle twitching/spasms, numbness, tingling, loss of concentration, sensory and/or visual and/or speech impairment., depression. Myasthenia Gravis starts in ages 20-30 usually, and in females more than males. Autoantibodies from the thymus gland directed at acetylcholine receptor sites impair transmission of impulses across the myoneural junction. This reduces the number of receptor sites. The difference (from MS) is that M. Gravis does not affect the CNS, but instad the nerve-muscle communication point of the PNS. Symptoms include at first diplopia (double vision) and ptosis (dooping of eyelids), and often are accompanied by facial muscle weakness, speech and swallowing impairment, and generalized weakness of the muscles. It is purely a motor disorder and has no effect on sensation or coordination Amyotrophic Lateral Sclerosis (ALS) is a fatal disease of known cause. Death usually occurs as a result of infection, respiratory failure, or aspiration with an avg. time from onset of 3 years. There is a loss of motor neurons in the brain and spinal cord, which decreases function of all smooth and skeletal muscles. The muscles eventually atrophy. Symptoms depend on the location of the affected motor neurons, because spefic neurons activate specific muscle fibers Chief complaints are fatigue, progressive muscle weakness, craps, fasciculations (twitching), and incoordination.
Name two signs of hypocalcemia?
Muscle and abd cramps, positive chvostek's and trousseau's sign
List the common signs and symptoms of Parkinson's diseases.
Muscle rigidity Pin rolling Bradykinesia Stooped posture, and shuffling gait Difficulty swallowing
Discuss the community resources available to the patient with a neuromuscular disorder.
Muscular Dystrophy Association (MDA) Outpatient Therapy Support Groups
Identify the categories of drugs commonly used to threat arthritis.
NSAIDs, of which salicylates are the cornerstone of treatment, and corticosteroids (used when arthritic symptoms are severe).
anti-dsDNA antibody results
Negative: <70units by ELISA; Borderline: 70-200units; Positive: >200units
anticholinesterase/cholinesterase inhibitors
Neostigmine, ambenonium, Pryridostigmine,. enhances effects of acetylcholine at remaining skeletal muscle sites, increases muscle contractions.
A 17-year-old high school junior was involved in a motor-vehicle collision and brought to the ED via squad. His left arm was severely traumatized in the accident and he was taken immediately to surgery. He is admitted to the ICU where you practice nursing and the physician has ordered close monitoring for compartment syndrome. What musculoskeletal structure does compartment syndrome affect? a) Nerve b) All options are correct c) Bone d) Ligament
Nerve Correct Explanation: Compartment syndrome affects nerve innervation, leading to subsequent palsy (decreased sensation and movement).
Primary Lateral Sclerosis
Purely an upper motor neuron deficit in the limbs -the tract involved is the Lateral Corticospinal Tract
Describe assessment findings: nuchal rigidity, photophobia, opisthotonus, Kerning's sign, and Brudzinksi's sign.
Nuchal rigidity: neck stiffness Photophobia: intolerance of bright light Opisthotnus: A type of spasm in which the head and heels arch backward in extreme hyperextension and the body forms a reverse bow Kerning's sign: is positive when the leg is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful Brudzinski's sign: is the appearance of involuntary lifting of the legs when lifting a patient's head.
Discuss the nursing care for patients with Alzheimer's disease.
Nursing care focuses on assisting the client and caregiver to maintain the highest quality of life. Diags: Disturbed Thought Process, Self-Care Deficits, Caregiver Role Strain
UMN symptoms
Occur due to loss of inhibition of mm - Spasticity, clonus, (+) Babinski, Dysarthria, dysphagia, emotional lability. Fatigue, Oral motor impairment, Fasciculations, spasticity, motor paralysis, Respiratory paralysis, Bowel and bladder remain untouched
Joint Replacement Hesi Hint #2
Questions about joint replacement focus on complications. A big problem after joint replacement is infection.
Type 2 Diabetes Treatment
Oral meds, insulin, diet, exercise
Joint replacement Hesi Hint #1
Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device usually accompanies the client to the postoperative floor. Check drainage often. **200-400 ml in a 24 hr time frame is normal**
Nurse is reviewing the effects of immobility on various body systems. List at least 2 effects on cardiovascular system.
Orthostatic hypotension Less fluid volume in the circulatory system Stasis of blood in the legs Diminished autonomic response Decreased cardiac output leading to poor cardiac effectiveness, which results in increased cardiac workload Increased oxygenation requirement Increased risk of thrombus development
Treatment for spasticity
PT= stretching, gait training, braces Muscle relaxers/ anticholergics for spastic bladder
The nurse is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when collecting data on the client?
Pallor, tachycardia, and a sore tongue
Explain the etiology of each extra-pyramidal disorder.
Parkinson's Disease: chronic progressive degenerative neurologic disease that alters motor coordination. Myasthenia Gravis: chronic autoimmune disorder. MS: chronic degenerative disease that damages the myelin sheath aurrounding the axons of the CNS Huntington's disease: progressive neurologic disease. ALS: rapidly progressive, fatal neurologic disease.
List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems.
Passive ROM exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return.
The physician prescribes didanosine (ddI [Videx]), 200 mg by mouth every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine, AZT [Retrovir]). Which condition in the client's history warrants cautious use of this drug?
Peripheral neuropathy
A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia. Good oral hygiene also is essential to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drugs falls into this category?
Phenytoin (Dilantin)
What measures should the nurse encourage female clients to take to prevent osteoporosis?
Possible estrogen replacement after menopause; high calcium and vitamin D intake beginning in early adulthood; calcium supplements after menopause; and weight-bearing exercise.
Pemphigus
Potentially fatal; a group of related d/o including vulgarism, vegetans, foliaceus, and erythematosus; rare autoimmune disease that occurs b/w middle and old age; cause unknown
Discuss the precautions to teach when instructing a patient on anticoagulants.
Precautions: in pts with fever, heart failure, diarrhea, diabetes, malignancy, HTN, renal/hepatic disease, psychoses, depression, or spinal procedures. Interactions: aspirin, acetaminophen, NSAIDS, penicillin, aminoglycosides, tetracyclines, cephalosporins, beta blockers, loop diuretics, oral contraceptives, vitamin-K, barbiturates Contraindicated: hemorrhagic diseases, TB, leukemia, uncontrolled HTN, GI ulcers, recent surgery of eye or CNS, aneurysm. Use during pregnancy can cause fetal death. May be contraindicated with a hypersensitivity to pork products.
What care is indicated for a child with juvenile rheumatoid arthritis?
Prescribed exercise to maintain mobility; splinting of affected joints; and teaching about medication management and side effects of drugs.
Fracture Hesi Hint #1
Questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a nonwheeled walker, the client should lift an dmove the walker forward and then take a step into it. The client should avoid scooting the walker or shuffling forward into it; these movements take more energy and provide less stability than does a single movement.
Discuss the nursing care for the patient with increased ICP.
Prevent IICP, and avoid the complications of IICP (ie; ineffective breathing patterns, cerebral edema, IICP, coma, brain herniation)
Discuss nursing care of patients with neurological infection or inflammatory disorder.
Preventing injury Monitor for decreased cerebral tissue perfusion. Preventing increased temperature Reducing headache Decreases enviornmental stimulation
Osteoarthritis
Progressive loss of joint function characterized by pain
Hearing Loss Hesi Hint #2
Questions often focus on communicating with older adults who are hearing impaired. Speak in a low-pitched voice, slowly and distinclty. Stand in front of the person, with the light source behind the client. Use visual aids if available.
Which nursing intervention takes priority for a client with human immunodeficiency virus (HIV) infection?
Protecting the client from infection
Which action should the nurse take when a client diagnosed with human immunodeficiency virus (HIV) infection refuses treatment?
Recognize that the client might not be ready to make treatment decisions.
Only kind of insulin can be given IV
Regular
Two days after a client undergoes splenectomy, a nurse changes his abdominal dressings according to the physician's order. How should the nurse proceed with the dressing change?
Remove the soiled dressings using clean gloves.
AIDS interventions
Respiratory support; psychosocial support; Fluid/electrolyte balance; Prevent and monitor infection; Standard precautions; Meticulous skin care; Nutritional support
A nurse is preparing a teaching plan for a client with sickle cell disease. She includes periods of rest in her plan. Why is this point important to include?
Rest relieves stress, which may precipitate sickle cell crisis.
Pharmacolgocial intervention For ALS
Rilutek (stop progression) Anti-depressants Antispasticity
medcations of ALS
Riluzole: antiglutamate. Inhibits presynaptic release of glutamic acid in CNS and protect neurons. Monitor for liver function, blood count, alkaline phosphatase.
A client is admitted to an acute care facility with a myocardial infarction. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to assist in formulating which nursing diagnosis?
Risk for impaired skin integrity
After an extensive diagnostic workup, a client is diagnosed with systemic lupus erythematosus (SLE). Which statement about the incidence of SLE is true?
SLE tends to occur in families.
List three symptoms which may be present in CP.
Seizures, poor sucking, difficulty feeding.
Which type of gait correlates with Parkinson's disease? a) Shuffling b) Scissors c) Steppage d) Spastic hemiparesis
Shuffling Explanation: A variety of neurologic conditions are associated with abnormal gaits, such as spastic hemiparesis gait (stroke), steppage gait (lower motor neuron disease), and shuffling gait (Parkinson's disease). Scissors gait is seen in cerebral palsy.
Types of Skeletal traction
Steinman pins Crutchfield Gardner-Wells tongs Halo vest
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
Strawberries
Skull sutures are an example of which type of joint? a) Amphiarthrosis b) Synarthrosis c) Diarthrosis d) Aponeuroses
Synarthrosis Explanation: Skull sutures are considered synarthrosis joints and are immovable. Amphiarthrosis joints allow limited movement, such as a vertebral joint. Diarthrosis joints are freely movable joints such as the hip and shoulder. Aponeuroses are broad, flat sheets of connective tissue.
RF Hesi Hint #3
Synovial tissues line the bones of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction. Often the disease goes into remission. Decreasing the amount of bone and joint destruction reduces the amount of disability.
Hearing Loss Hesi Hint #1
The ear consists of three parts: the external ear, the middle ear, and the inner ear. Inner ear disorders, or disorders of the sensory fibers going to the CNS, often are neurogenic in nature and may not be helped with a hearing aid. External and middle ear problems, (conductive) may result from infections, trauma or wax buildup. These types of disorders are treated more successfully with hearing aids.
Dysmetria
The inability to control the range of a movement and the force of muscular activity.
Cataract Hesi Hint #1
The lens of the eye is responsible for projecting light onto the retina so that images can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred.
D
The nurse assesses that an 87 year old woman with alzheimers disease is continually rubbing, flexing, and kicking out her legs throughout the day. THe night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to: a. ask the physician for a daytime sedative for the patient b. request soft restraints to prevent her from falling out of her bed. c. ask the physician for a nightime sleep medication for the patient d. assess the patient more closely, suspecting a disorder such as restless legs syndrome
A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600 mg by mouth every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?
Tinnitus
This should be available at the bedside of a client who had a thyroidectomy?
Trach kit
Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Subluxation b) Callus c) Volkmann's contracture d) Whiplash injury
Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.
Cataract Pt Education
Wear sunglasses outside Smoking cessation Eliminate oral/inhaled corticosteroids
Hypothyroidism
Weight gain Bradycardia Fatigue Cold intolerance Constipation Cool skin Dyspnea Muscle weakness Non-pitting edema Slow response & speech
Describe techniques to promote independence for the patient with impaired cognition.
a daily routine that they can count on, everything familiar to them has one place inside of their room, encourage as much self-care as possible, demonstrate use of equipment, modify clothing with Velcro and lay out daily clothing, encourage "finger foods" during meals.
B
Which of the following statements accurately describes mild cognitive impairment. (select all that apply) a. always progresses to AD b. Caused by variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that if treated will delay progression to AD c. Patient is usually not aware that there is a problem with his or her memory.
3
Which one of the followin is an example of the emotional component of wellness? 1. the client chooses healthy foods 2. a new father decides to take parenting classes 3. A client expressess frustration with her partner's substance abuse 4. A widow with no family decides to join a bowling league
2
While hospitalized a client is very worried aboiut business activities. The client spends a great deal opf time on the phone and with collegues instead of resting. Which principle of need therapy applies to this client? 1. his higher level need cannot be met unless the lower level physicological need is met 2. His lower level physiological needs are being deferred while higher need are addressed. 3. The higher need takes precedence and the lower need no longer must be met. 4. It is necessary for someone else to meet his higher level needs so he can focus on the lower level needs.
Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? "Going up, the strong leg goes first, then the weaker leg with both crutches." "Going down, the weaker leg goes first with both crutches, then the strong leg." "The weaker leg always goes first with both crutches." "A cane or single crutch may be used instead of both crutches if held on the weaker side."
Your Answer: "The weaker leg always goes first with both crutches." Rationale: Although the crutches (or cane) are always used along with the weaker leg, the weaker leg should go down the stairs first. The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation.
Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? Activity Intolerance. Risk for Activity Intolerance. Impaired Physical Mobility. Risk for Disuse Syndrome.
Your Answer: Activity Intolerance. Rationale: Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not "at risk for," as in option 2. There is no evidence that the client requires assistance (impaired mobility, option 3), or is immobile (disuse syndrome, option 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Diagnosis.
The client is ambulating for the first time after surgery. The client tells the nurse, "I feel faint." Which is the best action by the nurse? Find another nurse for help. Return the client to her room as quickly as possible. Tell the client to take rapid, shallow breaths. Assist the client to a nearby chair.
Your Answer: Assist the client to a nearby chair. Rationale: Placing the client in a safe position is the best maneuver. Leaving the client creates unsafe conditions because the client may faint before being able to return to her room (options 1 and 2). Rapid, shallow breathing (hyperventilation) may increase the dizziness (option 3). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? Heart rate 86 Reddened area on sacrum Nonproductive cough Urine output of 50 mL/hour
Your Answer: Reddened area on sacrum Rationale: The reddened area of the skin can lead to skin breakdown. The other options are within normal limits. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment.
To increase stability during client transfer, the nurse increases the base of support by performing which action? Leaning slightly backward. Spacing the feet farther apart. Tensing the abdominal muscles. Bending the knees.
Your Answer: Spacing the feet farther apart. Rationale: A key word in the question is base, and the feet provide this foundation. Leaning backward actually decreases balance (option 1), and tensing abdominal muscles alone (option 3) or bending the knees (option 4) does not affect the base of support. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation.
Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. Increase muscle tone and improve circulation. Increase blood pressure. Increase muscle mass and strength. Decrease heart rate and cardiac output. Maintain joint range of motion.
Your Answers: Increase muscle tone and improve circulation. Increase muscle mass and strength. Maintain joint range of motion. Rationale: Isotonic exercise increases muscle tone, mass, and strength, maintains joint flexibility, and improves circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body (option 4). Little or no change in blood pressure occurs (option 2). Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Planning.
allergy
abnormal, individual response to certain substances that normally do not trigger such an exaggerated rxn
Dyesthesias
abnormal, unpleasant sensation [burning, numbness, pins and needles, tingling]
Exacerbation
action that makes a problem or a disease (or its symptoms) worse
Scleroderma interventions
activity as tolerated, constant room temp, small frequent meals, with no spicy food, if esophagus involved, remain sitting for 1-2hrs after eating, corticosteroids for inflammation, emotional support
diptheria
acute contagious infection tha can cause repiratory obstruction
what is Guillian-Barre syndrome
acute inflammatory demyelinating disorder of PNS, characterized by acute motor paralysis accompanied w/ paresthesias/numbness (usually ascending)
patho of ALS
affects anterior horn cells of spinal cord, motor nuclei of brain stem, and upper motor neurons of cerebral cortex. Cells die= axonal degeneration, demyelination, glial proliferation and scarring along corticospinal tract. Cells try to grow new attachments to muscle, but that eventually fails.
Remission
an abatement in intensity or degree (as in the manifestations of a disease)
A client who is hospitalized with scleroderma signs a document that provides instructions concerning the provision of care if he is unable to make his own treatment decisions. The document is known as:
an advance directive.
Imuran
an immunosuppressive drug (trade name Imuran) used to prevent rejection of a transplanted organ
scotoma
an isolated area of diminished vision within the visual field
Patho of Myasthenia Gravis
antibiodies destroy or block neuromuscular junction receptor sites, decreasing the number of acetylcholine receptors. Net result is decrease in muscles ability to contract.
to treat dysphagia w/ MG
anticholinesterase 30 mins prior to meals.
A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:
autonomy.
Educational pts after cataract surgery
avoid eye strain, avoid rubbing eyes, contact MD about decrease in vision, severe eye pain, increase in eye discharge, take measures to prevent constipation; mild itching is normal
Diagnosis of ALS
based on S&S and test results for other disorders were negative.
diagnosis of GB
based on S&S, history of recent infection, elevated CSF protein, EMG studies show decreased nerve conduction.
S&S of MG
based on which muscle group involved
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
bilateral hearing loss.
When evaluating degenerative motor neuron diseases via biopsy, CSF, and CK... what will you see?
biopsy = chanes of denervation atrophy CSF= normal CK= slightly elevated, but not as high as in muscular dystrophies
anti-dsDNA antibody test
blood test done specifically to identify/differentiate DNA antibodies found in SLE; monitors disease activity, response to tx, and establishes prognosis for SLE
autoimmune disease
body unable to recognize its own cells as a part of itself; can affect collagenous tissue
SE of immunosuppressant for MS
bone marrow depression, increase risk of cancer. Hepatitis W/ Imuran. Cytoxan SE= hemorrhagic cystitis, sterility, stomatitis.
S&S of TN
brief, repetitive episodes of sudden severe facial pain. pain is experienced on surface of skin. begins one side of mouth, rises towards ear, eye, or nose on same side of face. can have remissions. less likely to as you age, dull ache present between attacks.
For the diagnosis of ALS or SMA, the EMG should show changes in what 3 areas? (there's 4 total, but you need to see changes in atleast 3 areas to make the dx).
bulbar, cervical, thoracic, lumbosacral
Scleroderma (systemic sclerosis)
chronic CT disease similar to SLE that is characterized by inflammation, fibrosis, and sclerosis; causes fibrotic changes involving the skin, synovial membranes, esophagus, heart, lungs, kidneys, GI tract; Tx directed toward forcing disease into remission
What is MS?
chronic demyelination of CNS. onset 20-40 yrs old. Mostly Northern European ancestry, those living in Northern Climates.theory= immune response to protein in CNS
what is trigeminal neuralgia
chronic disease of Cranial Nerve 5 causes unilateral excruciating facial pain.
Dislocation (after hip surgery)
circulatory/nerve damage S/S: shortening of leg, abnormal rotation, can't move extremity, PAIN
which of the follow should be immediately reported to hcp
curtain-like shadow across visual field- detached retina surgical emergency
A client with a dx of DKA is being treated in an ED. Which finding would a nurse expect to note as confirming this dx?
d. Elevated blood glucose level and low plasma bicarbonate level
Skin Test: Preprocedure
d/c corticosteroids/antihistamines 5 days before test; Obtain Informed Consent; Be prepared for anaphylactic shock for scratch test
Expressive Aphasia
damage to Broca's area can cause this condition in which person cannot talk, though understand speech
Immunomodulators SE
decreased ANC, increase liver enzymes, anxiety, confusion, depression, increase suicide. flu-like symptoms,
vomitting and or diarrhea
delay rotavirus vaccine if infant is experiencing these two problems
Cellular response
delayed response; protects agains slow growing bacteria; involved in autoimmune response, allergic run, and rejection of foreign cells
Describe s&s of a spinal cord injury.
depends on the location of the injury and other unique factors. general complications include hypotonia, autonomic dysreflexia, spinal shock, orthostatic hypotension, bradycardia, DVT, pressure ulcers, pain, limited chest expansion, pneumonia, stress ulcers GI, urinary incontinence, neurogenic bladder, UTIs, impotence, decreased vaginal lubrication, join contractures, muscle spasms, muscle atrophy, pathologic fractures, hypercalcemia spinal shock: temporary loss of reflex activity below the level of spinal cord injury, this usually happens 30-60 min after a complete SCI. There is loss of motor function, sensation, spinal reflexes, and autonomic function. other manifestations include bradycardia, hypotension, loss of sweating and temp control, bowel/bladder dysfunction, flaccid paralysis, loss of ability to perspire. could last from days to months before reflex activity returns. within the first year of injury even, the patient is at risk for spinal shock whenever they are moved.
patho of Guillain-Barre syndrome
destruction of meylin sheaths in axons of PNS= poor conduction of nerve impulses=sudden muscle weakness, loss of reflex response. result of humoral and cell-mediated immunologic responses.
Discuss the nursing care for a patient experiencing increased intracranial presure.
drugs - osmotic/loop diuretics, elevate HOB 30 degrees, midline position, o2 as ordered, avoid hip flexion and abdominal distention (stool softeners as ordered), monitor temp q2hrs for hyperthermia (no rectal temps), reduce stimulation of environment, turn client gently, limit fluid over 24hr period. barbiturates is used to induce coma, reduces (glucose) metabolism to decrease continued damage to the brain surgical interventions include burr holes (to evacuate hematoma or remove blood clot), craniotomy (relieves pressure of brain tumor), and a brain flap may be removed (to allow room for the brain to expand). post-op care is important, especially relating to IICP and respiratory function. For Head Injuries: tetanus immunization status should be checked and updated, especially when lacerations or contaminated wounds are present. Anticonvulsants may be needed to control or provide prophylaxis for seizure activity. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for minor pain control. Beta-blockers can be prescribed for patients with trauma-induced migraines. hypotension is a indicative of morbidity
Early S&S of ALS
dysfunction of upper motor neurons= spastic weak muscles w/ increased deep tendon reflexes. dysfunction of lower motor neurons= muscle flaccidity, weakness, paralysis, atrophy. slurred speech.
Nursing interventions after cataract surgery
elevate hob 30-45 degrees, maintain eye patch, orient to environment, side rails, assist w ambulation
anaphylaxis interventions
estab. patent airway; prep for admin of epinephrine, benadryl, or corticosteroids; control shock; emotional support; teach pt how to use EpiPen for future rxn
How can you detect small lesions?
evoked potentials.
Immune deficiency: data Collection
factors that decrease immune fxn; frequent infections; nutritional status; med hx (corticosteroid long-term use); hx of alcohol or drug abuse
spinal muscular atrophies are... and what chromosome is effected?
familial *chromosome 5.
What is a fasciculation
fine muscle twitches that are not normally present
Recognize changes in neurological status.
glasgow's coma scale, A&O x3, widening pulse pressure, abnormal body posturing, cushing's triad, cranial nerve checks, confusion, hallucinations, out of control emotions diagnostic tests for head injuries blood glucose, ABGs, tox screen, creatinine, BUN, liver function tests, CBC + diff, CT, MRI, LP, cerebral angiography, xray of the brain will be able to determine where the injury is, how big it is with an LP, encourage fluid intake - CSF reproduces after 24h hours when an LP is done, there is a space in the spinal column. pat may complain of HA because the air from that space naturally goes upwards, in this case towards the head. to test to see if leakage is CSF, check for glucose - see halo on gauze.
secondary progressive MS
gradual deterioration w/ or w/o relapses.
progressive- relapsing
gradual progression of neurological deterioration w/ super-imposes relapses.
Nutrition for ppl w/ MS
have tendency to be overweight due to immobility & depression. Goal to stay at normal weight. Adjust for disphagia,
Describe nursing measures in response to unexpected negative response (bleeding).
hold next dose immediately, call PHP if bleeding will not stop after 10min of pressure if external, be prepared to administer antidote, FFP, or other drugs as ordered by PHP.
individuals at risk for latex allergy
health care workers, rubber industry workers, pt having multiple surgeries, individuals with spina bifida, people who frequently wear gloves, people allergic to kiwi, banana, avocado, tropical fruits, potatoes, hazelnuts, water chestnuts
AIDS high risk groups
heterosexual/homosexual contact with high-risk individuals; IV drug abusers; People receiving blood products; health care workers; babies born to infected mothers
diseases associated w/ MG
hyperthryoidism, rheumatoid arthritis, lupus erythematosus,
cardiovascular s/s of anaphylaxis
hypotension, dysrhythmias, tachycardia, cardiac arrest
A nurse witnesses a client sustain a fall and suspects that the client's lef may be fractures. Which action is the priotiry
immobilize the leg before moving the client
passive immunity
immune globulins are used so antibodies are already formed and conferred from breastmilk
nursing care for MG focused on....
ineffective airway clearance, impaired swallowing, PREVENTION of fatigue. keep pt in constant temp. teach to avoid changes in temp.
Lyme Disease
infection caused by Borrelia brugdorferi, acquired from a tick bite; stimulates inflammatory cytokines and autoimmune mechanisms
Secondary Progressive MS
initial relapsing-remitting disease course followed by disease progression at varying rates - minor remissions and plateaus may occur during this progression
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse s response is based on the understand that this could result in
injury to the brachial plexus nerves
Nystagmus
involuntary movements of the eyeballs
Aricept (donepezil)
is a cholinesterase inhibitor block cholinesterase the enzyme responsible for breakdown of ach in the synaptic cleft.
During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
joint abnormalities.
Distinguish the characteristics of right and left hemiplegia.
left hemisphere lesion: right hemiplegia, right visual field deficits, aphasia both expressive and receptive, agrahia - difficulty writing, alexia - reading problems, aware of deficits, impaired intellectual ability, no memory deficits, no hearing deficits, deficits in the right visual field as reading, problems and inability to discriminate words and letters, behavior slow cautious and disorganized, anxious when attempting new task, depression, sense of guilt, quick anger and frustration, feeling of worthlessness, worries over the future right hemisphere lesion: left hemiplegia, left visual deficits, disoriented to time place and person, cannot recognize faces, spatial - perception deficits, neglect of left side, patient unaware of paralyzed side, loss of depth perception, impulsive - easily distracted, unaware of neurological deficits, confabulates, euphoric impaired sense of humor, constantly smiles, denies illness, poor judgement, overestimates ability, loss of ability to hear tonal variations
B cells
lie dormant until specific antigen enters the body, then they multiple for defense
anesthesia
loss of bodily sensation with or without loss of consciousness
What assessment is most important with fractures?
neuro-vascular checks -Pulse, Color, Movement, Sensation, Cap refill, and temp
A clietn has had a bone scan procedure. What is the after care
no specific aftercare. Encourage client to drink large amounts of water for 24-48 hours to flush the radiosotope from the system. There are no hazards to the clietn or staff from the minimal amount of radioactivity of the isotope
Discuss the nursing implications for medications ordered for a patients with a head injury.
osmotic diuretics (Mannitol) expel large amount of h2o and electrolytes - may have to switch to loop diuretic. Corticosteroids reduce inflammation. Zantac, Protonix, or antacids are given to prevent GI irritation. Antemetics are used to prevent vomiting. Anticonvulsants (Dilantin, Valium, phenobarbital). Barbituates are given to induce coma, last resort, reduces metabolism and slows brain death. Nursing Implications:
patient/family teaching for GB
paralysis isn't permanent, rationals for interventions to increase compliance
UMN lesion
paresis, spasticity, brisk tendon reflexes, involuntary flexor or extensor spasms, clonus,a babinski sign
decerebrate posturing
posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe.
other meds for MG
prednisone, immunosupressants (cyclosporine/Imuran)
Immune deficiency interventions
prevent infection; promote balanced diet; strict aseptic technique for all procedures; psychosocial support; educate ways to prevent infection
active acquired immunity
produced from immunization
suffered a fx femr
pt appears confused-fracture of a long bone early manifestiation of fat emboli
A nurse is evaluating the pin sites of a client in skeletal traction. THe nurse is least concerned with 1. inflammation 2.serous drainage 3.pain at pin site 4.purulent drainage
serous drainage. A small amount of serous oozing is expected at pin insertion sites.
second stage of Lyme disease
several weeks following the bite; joint pain, neuro complications, cardiac complications
Acute stage of GB
severe/rapid weakness, loss of muscle strength, progresses to quadriplegia & resp failure. decrease in DTRs, paresthesias, numbness, pain esp at night, facial muscle involvement. Involvement of Autonomic nervous=bradycardia, sweating, fluctuating BP. LAST 2 WEEKs
Late S&S of HD
severely altered gait, uncontrolled movements, facial grimacing, dysphagia, unintelligible speech, impaired diaphragm, immobility, aspirations, poor O2 sats, cachexia, loss of memory and cognitive skills, total dependence of care
Scleroderma Data collection
skin is taught, hard, thick, and shiny, with a loss of elasticity and it adheres to underlying structures; decreased ROM, joint contractors; Stiffness and muscle weakness
Kaposi's Sarcoma
skin lesions that primarily occur in individuals w/ compromised immune system; slow growing tumor that appears as a raised, oblong, purplish-reddish-brown lesion that may or may not be tender
For the patient in Buck's extension traction which is applied to a leg, the nurse can provide counteraction by:
slighltly elevating the foot of the bed
What to do with open fractures
sterile-dressing covering
A client has slight weakness in the right leg. Based on this information, teh nurse determines that the client would benifit most from the use of a
straight-leg cane is useful for the client with slight weakness in one leg
meds for HD: antidpressants
supplement counseling, but doesn't replace.
Goodpasture's syndrome interventions
suppression of the immune system and plasmapheresis to remove autoantibodies; supportive tx for pulmonary/renal involvement
Dysarthria
the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system
dysarthria
the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system
rotavirus
this infection is leading cause of gastroenteritis (vomit and diarrhea) among children
A nurse is evaluating the client's use of a cane for left sided weakness. The nurse would interven if the client moves the cane with witch side as the right leg is moved?
the nurse would interven and correct if the patient moves the cane when the righ leg is moved. The cane is held 6 inches lateral to the fifth great tow. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through
A nurse is planning to teach the client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion would the nurse include in the teaching plan
the shoulder of a casted arm should be lifeted over the head perodically as a prevenetive meausre.
haemophilus influenzae type B
this is the most common cause of meningitis in children over one month of age
Explain the use of thrombolytic drugs in the treatment of a CVA.
thrombolytic drugs dissolve blood clots that have already formed within the walls of a blood vessel. is prescribed after an ischemic stroke has occurred, within 3 hours of onset this therapy is given. 0.9mg/kg, 10% given IV bolus over one minute, the rest given over 60 minutes. criteria for receiving thrombolytic drugs: • Age 18 years or older • Clinical diagnosis of ischemic stroke • Time of onset of stroke known and is 3 hours or less • Systolic blood pressure <185 mm Hg; diastolic <110 mm Hg • Not a minor stroke or rapidly resolving stroke • No seizure at onset of stroke • Not taking warfarin (Coumadin) • Prothrombin time <15 seconds or INR <1.7 • Not receiving heparin during the past 48 hours with elevated partial thromboplastin time • Platelet count >100,000/mm3 • No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm • No major surgical procedures within 14 days • No stroke, serious head injury, or intracranial surgery within 3 months • No gastrointestinal or urinary bleeding within 21 days assess q 15min for first hour, then every 15-30 minutes for the next 8 hours, then at least q4hrs. bleeding and IICP are side effects to monitor for. draw CBC before starting thrombolytics patients is critical and cared for in ICU for 48 hours used as soon as possible after formulation of clot
two injections at same time in different extremities
to reduce pain and anxiety associated with injections - use correct needle, distract child, pressure on site for 10 seconds before injection, and if you have two injections to give -
Polyarteritis nodusa interventions
well-balanced diet; corticosteroids/analgesics; emotional support; initiate support services
2-23 months
what age should the pneumococcal conjugate vaccine be given
medications for HD: tetrabenzine
treat chorea (jerky movements). increased depression/suicide. DO NOT take w/ levodopa
9-26
what ages are recommended for HPV vaccine
antinuclear antibody (ANA) Titer
used in the differential dx of rheumatic diseases and to detect antinucleoprotein factors and patterns associated with certain autoimmune d/o
cognex
used in treatment of mild to moderate dementia associated with Alzheimer's disease. Increases level f ACH in the CNS by inhibiting its breakdown
Late S/S
varying neurological deficits, typically severe in nature
Causes of trigeminal neuralgia
vascular compression and demeylination of nerve caused by trauma, infection of jaw/teeth, aneurysm, tumor, MS.
AIDS
viral disease caused by HIV that destroys T cells, increasing susceptibility to infection and malignancy; clinically manifests by opportunistic infection and unusual neoplasms; incubation period is long, up to 10+yrs;
Early S/S
visual disturbances, paresthesias, incontinence, weakness and fatigability
musculoskeletal S&S of MD
weakness, fatigue, decreased function, comlplications; decrease ability to preform ADL's, immobility, myasthenic and cholinergic crisis
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:
wear gloves when providing mouth care.
Choice Multiple question - Select all answer choices that apply. A bone graft may be used for which of the following reasons? Select all that apply. a) Improvement of motion b) Defect filling c) Stimulation of bone healing d) Joint stabilization e) Reduction of a fracture
• Joint stabilization • Defect filling • Stimulation of bone healing Explanation: A bone graft is used for joint stabilization, defect filling, or stimulation of bone healing. Tendon transfer is used for improving motion. Either closed or open reduction may be used to reduce a fracture.
Pseudobulbar Palsy
•Bilateral involvement of motor cranial nerves •Similar presentation to Progressive Bulbar Palsy in terms of symptoms •Exam: tongue is spastic and contracted, cannot move quickly from side to side •Upper motor neuron dysfunction •"Pseudobulbar affect" - uncontrollable and inappropriate laughing or crying
What do you know about neuromyelitis optica (Devic disease)?
•Characterized by optic neuritis and acute myelitis with MRI changes that involve at least three segments of the spinal cord (brain MRI usually does not show white matter involvement but if present it does not rule out this dx) •Isolated myelitis or optic neuritis may occur •Specific antibody marker (NMO-IgG) •Treatment is long-term immunosupression
Facts about MS
•Common neurologic disorder •Likely autoimmune; Genetic susceptibility •More common in Western-European descent who live in temperate zones (unheard of in the tropics, but they have more parasites) •Focal, often perivenular lesions of demyelination with reactive gliosis are found in the white matter of the brain, spinal cord and optic nerves •Axonal damage
Wernicke Encephalopathy
•Confusion, ataxia, nystagmus leading to ophthalmoplegia (LR) •+/- Peripheral neuropathy •Due to Thiamine deficiency •Occurs in alcoholics (AIDS, hyperemesis, bariatric surgery) •If suspected, do not delay treatment waiting for confirmatory labs •Thiamine 50mg IV, then IM daily until improvement •IV glucose prior to supplement -> worsen pt
Subacute combined degeneration of the spinal cord
•Due to vitamin B12 deficiency (pernicious anemia, megaloblastic anemia) •Predominant pyramidal and posterior column deficits plus -Polyneuropathy -Mental changes -Optic neuropathy •Treatment is with vitamin B12 100mg IM daily x 1 week, weekly for 1 month, then monthly forever
Amyotrophic Lateral Sclerosis
•Mixed upper and motor neuron deficit in the limbs •Sometimes there is cognitive decline (fronto-temporal dementia) •Also associated with pseudobulbar affect or parkinsonism •Progressive - fatal within 3-5 years •Patients with bulbar involvement have poor prognosis
