Exam 1
______ is a CNS depressant. It acts on neurotransmitters in the brain and decreases neuronal excitability. It creates an addictive effect with GABA.
alcohol
How do you assess a client's remote memory?
ask the client to state a fact from their past that is verifiable (their birth date or their mother's maiden name)
A ______ ______ injury is suspected when intact skin has a localized purple discoloration and does not blanch when pressed. A thin blister or eschar can develop very quickly.
deep tissue
______ is a disorder characterized by sad or despondent mood or loss of interest in usual activities
depression
______ is the area of loss of the superficial layers of the skin, also known as the denuded area.
excoriation
Justice
fair and equal treatment for all
What are the effects alcohol has on the respiratory system?
increased risk for pneumonia, bronchitis, tuberculosis
Cravings may be heightened by ______ when abusing substances. This is a result of long-term changes in brain neurotransmission that occur after repeated detoxifications
kindling
______ drainage involves more than 75% of the dressing and may completely saturate the dressing prior to scheduled changes
large
What are the common symptoms of a girl with ADHD?
less aggression and impulsiveness but more anxiety, mood swings, social withdrawal, rejection, cognitive and language problems
The ______ metabolizes 95% of ingested alcohol. a. small intestine b. kidney c. liver d. stomach
liver
assault
making a threat to a client's person
Where is alcohol absorbed?
mouth, stomach, digestive tract
______ agonists attach to CNS receptors altering perception of and response to pain.
opioid
______ ______ disease is a disorder in which arteriosclerosis and atherosclerosis affect circulation to peripheral tissues particularly the lower extremities.
peripheral vascular disease
A ______ injury is an ischemic lesion of the skin and underlying tissue caused by external pressure that impairs the flow of blood and lymph.
pressure
Arterial or Venous Ulcer? Skin temp: normal
venous
The nurse is teaching a patient with atherosclerosis about their condition. Which patient statement indicates the teaching was successful? a. "I have plaque building up in my coronary arteries, which is restricting the blood flow to my heart." b. "Plaque is building up in my pulmonary artery, which is restricting blood flow to my heart." c. "Plaque is building up in my heart vessel valves, which is restricting the blood flow to my heart." d. "There is plaque building up in my femoral artery, which is restricting the blood flow to my heart."
"I have plaque building up in my coronary arteries, which is restricting the blood flow to my heart."
A patient diagnosed with peripheral vascular disease (PVD) asks the nurse, "What activities should I avoid doing with my legs and feet?" Which statement by the nurse is most helpful for this patient? a. "Take hot showers each morning to promote circulation." b. "You should only swim in cool water." c. "Wear knee-high stockings on each foot." d. "You should avoid sitting with your legs crossed."
"You should avoid sitting with your legs crossed."
What are examples of goals a patient will have in regards to alcohol abuse?
-Admit alcohol controlling his or her life -Agree to enter an alcohol treatment facility or outpatient program -Experience no (further) complications as a result of alcohol abuse or alcohol withdrawal -Obtain optimal nutritional status -Remain sober -Participate in a support group after discharge
In the planning phase, what are examples of short-term goals for a person suffering from substance abuse?
-Admit having substance abuse problem and having lost control of life as a result -Seek help to stop using substance -Experience no complications of drug withdrawal -Enter a drug rehabilitation program to change behavior
What are examples of short term goals for a patient with a substance abuse problem?
-Admit having substance abuse problem and having lost control of life as a result -Seek help to stop using substance -Experience no complications of drug withdrawal -Enter a drug rehabilitation program to change behavior
What are common manifestations of abrupt alcohol withdrawal?
-Anxiety -Tachycardia -Hypertension -Diaphoresis -Nausea, vomiting -Tremors -Sleeplessness -Irritability
How can a nurse promote safety for a client receiving treatment for a substance abuse problem?
-Assess level of disorientation -Consider higher level of care if patient cannot withdraw safely in home or community setting -Obtain drug history and urine, blood samples -Place patient in quiet, private room -Frequently orient patient to reality, environment -Ensure that patient has no access to potentially harmful objects -Monitor vital signs every 15 minutes until stable
How can a nurse promote patient safety in an outpatient or home setting?
-Assess patient's orientation, cognition -Have patient or others in setting monitor vital signs using reliable home equipment: signs frequently during first day of detox, several times/day after that -Teach patient/others signs and symptoms of severe withdrawal -Administer or teach patient/others to administer scheduled medications -Monitor for signs of alcohol intoxication -Suggest patient remain in quiet room to decrease excessive stimuli -Determine specific risks to patient safety Make sure patient is oriented to reality, environment
What diagnostics tests are used to diagnose secondary hypertension and would be ordered after the cholesterol panel?
-CT scan -renal function tests -intravenous pyelogram
What are examples of therapies for a patient who has a substance abuse problem?
-Detoxification -Aversion therapy -Group, individual, family counseling -Psychotropic medication -Cognitive-behavioral therapy -Self-help groups
What are expected outcomes for a patient suffering from substance abuse?
-Experiences no complications from withdrawal -Admits problem with substance abuse and seeks help -Enters substance abuse program -Can describe choices that contributed to substance abuse -Attends daily support group meetings -Remains substance free for appropriate period of time
What are expected outcomes of a patient with a substance abuse problem?
-Experiences no complications from withdrawal -Admits problem with substance abuse and seeks help -Enters substance abuse program -Can describe choices that contributed to substance abuse -Attends daily support group meetings -Remains substance free for appropriate period of time
In the planning phase, what are examples of long-term goals for a person suffering from substance abuse?
-Explore impact of addiction on family, job, friends -Describe, recognize use of denial -Change thinking, behavior -Regularly attend support group -Remain free of substance and maintain sobriety
What factors related to PVD would increase the risk for infection in wounds to the lower extremities?
-Impaired arterial circulation impairs body's ability to provide sufficient oxygen and nutrients to the cells in the lower extremities and the ability to remove metabolic waste products diminishes -Congested venous circulation also prevents the blood from mounting effective inflammatory and immune responses, significantly increasing the risk for infection in the ulcerated tissue
A female client is undergoing diagnostic testing for coronary heart disease. The nurse should assess for which symptoms that are indicative of heart disease? (Select all that apply.) A. Headache B. Indigestion C. Chronic fatigue D. Abdominal fullness E. Insomnia
-Indigestion -Chronic fatigue -Abdominal fullness
A client who exercises for 30 minutes every day and maintains a normal body weight develops primary hypertension. The client asks how this could have happened. Which finding in the client's health history should the nurse include in the response to the client? (Select all that apply.) A. Insulin resistance B. Working as an air traffic controller C. High magnesium intake D. Age: 62 years E. Family history of hypertension
-Insulin resistance -Working as an air traffic controller (stress) -Age: 62 years -Family history of hypertension
Manifestations of peripheral atherosclerosis include:
-Intermittent claudication -Rest pain -Paresthesia -Diminished or absent peripheral pulses -Pallor with extremity elevation (redness of skin or rubor when dependent) -Thin, hairless skin -Thickened toenails -Areas of discoloration or skin breakdown -May also induce rupture of abdominal aortic aneurysms and possible infection and sepsis
Manifestations of CVI include:
-Lower extremity edema that worsens with standing -Itching, dull leg discomfort or pain that increases with standing -Thin, shiny, atrophic skin -Cyanosis and brown skin pigmentation of lower leg and foot -Possible weeping dermatitis -Thick, fibrous (hard) subcutaneous tissue -Recurrent ulcerations of medial or anterior ankle -Necrosis and fibrosis of subcutaneous tissue cause the affected area of the leg to feel hard and somewhat leathery -Even the slightest trauma to the area can produce serious tissue breakdown
A client newly diagnosed with heart failure is prescribed digitalis, a positive inotropic drug. Which sign and symptom would the nurse instruct the client to report to the healthcare provider? (Select all that apply.) A. Nausea B. Weight loss C. Confusion D. Weight gain E. Vision changes
-Nausea -Weight loss -Confusion -Vision Changes
What are red flags that require immediate attention in a child suspected of having ASD?
-No babbling or communication gestures by 12 months -No single word by 16 months -No spontaneous two words by 24 months -Loss of language or social skills previously achieve
How can a nurse promote patient safety during withdrawal of a patient with a substance abuse problem?
-Observe for withdrawal symptoms, monitor vital signs -Provide adequate nutrition, hydration -Assess level of consciousness (LOC) frequently -Orient, reassure patient safety in presence of hallucinations -Explain all interventions before approaching patient -Administer medications per schedule -Provide positive reinforcement of appropriate thinking, behavior or recognition that delusions are not based in reality -Use simple step-by-step instructions, face-to-face interaction -Express reasonable doubt if patient relays suspicious or paranoid beliefs -Do not argue with patient experiencing hallucinations, delusions -Talk to patient about real events, real people -Respond to patient's feelings, reassure patient about safety from harm
How can a nurse promote patient safety during acute withdrawal?
-Observe patient for withdrawal symptoms -Assess BAL routinely and look for escalating signs of withdrawal -Administer scheduled medications according to protocol -Assess patient's level of orientation frequently -Explain all interventions before approaching patient -Provide positive reinforcement when patient's thinking, behavior are appropriate -Express reasonable doubt if patient relates suspicious or paranoid beliefs, reinforcing accurate perception of people, situations -Do not argue with patient experiencing delusions or hallucinations -Talk to patient about real events, real people Reassure patient about being safe from harm
What are expected outcomes for a patient receiving treatment for alcohol abuse?
-Patient undergoes withdrawal without physiologic complications -Patient controls anxiety to extent of refraining from drinking when anxiety rises -Patient displays new coping mechanisms -Patient does not start using alcohol again -Patient experiences no new complications as result of sobriety -Patient accepts responsibility of how behavior affects family unit
An interprofessional team for a patient receiving treatment for alcohol abuse would consist of:
-Physicians -Psychologists -Counselors -Nutritionists -Assistive personnel
A client has been diagnosed with secondary hypertension. Which condition should the nurse expect to find in the client's medical history? (Select all that apply.) A. Pregnancy B. Kidney disease C. Asthma D. Diabetes E. Lupus
-Pregnancy -Kidney disease -Diabetes
What are the 2 goals of the health promotion efforts in regards to substance abuse?
-Preventing drug use among children, adolescents -Reducing risks among adults
When dehiscence or evisceration occurs, the nurse should:
-Quickly support the wound with a large sterile dressing soaked in sterile normal saline -Place the patient in bed with knees bent to decrease pull on the incision -Notify the surgeon
How can a nurse promote healthy self-esteem with a patient undergoing alcohol abuse treatment?
-Spend time with patient, convey attitude of acceptance -Encourage patient to accept responsibility for own behaviors, feelings -Encourage patient to focus on strengths and accomplishments, not weaknesses and failures -Encourage participation in therapeutic group activities -Teach assertiveness techniques and effective communication techniques
The nurse is creating a plan of care for a client with hypertension. Which instruction should the nurse include? (Select all that apply.) A. Following a low-fat, no-sodium diet B. Using alcohol in moderation C. Ensuring that the diet includes at least 2 servings of milk products daily D. Beginning aerobic exercises E. Reducing smoking
-Using alcohol in moderation -Ensuring that the diet includes at least 2 servings of milk products daily -Beginning aerobic exercises
To treat a client with a suspected deep tissue injury, the nurse should apply:
-a moisturizing barrier cream -a nonadhesive protective dressing -consider support surfaces that will remove all pressure from the area
What are the most important lab values of a client with ADHD?
-abnormal patterns in two settings needed for diagnosis (home, school, or daycare) -screening test
Goals for clients with a healing wound center around:
-adequate nutrition -hydration -infection prevention -promotion of optimal wound healing
What are psychobiological interventions?
-administering prescribed medications -providing teaching to the client/family about medications -monitoring for adverse effects and effectiveness of pharmacological therapy
What are physiologic effects of chronic long-term use of marijuana?
-airway constriction, inflammation -increased incidence of acute, chronic bronchitis -decreased spermatogenesis and testosterone levels in men -suppresses follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin in women, which interferes with breastfeeding
What are the effects alcohol has on the liver?
-alcoholic hepatitis -cirrhosis -cancer -hepatomegaly -fatty liver
The client who experiences an infection in a wound would receive:
-antibiotics -debridement -dressing changes
A complication of left heart failure is cardiogenic pulmonary edema. Signs and symptoms include: anxiety, orthopnea, pink, frothy sputum, dyspnea, hoarseness, and cough
-anxiety -orthopnea -pink -frothy sputum -dyspnea -hoarseness -cough
What patient teaching will you provide the patient with PVD to reduce the risk of infection?
-apply lotion to dry areas -proper wound care -keeping the wound covered -use a bed cradle -keep wound covered
It is important for a nurse to identify illnesses that may trigger depression in their clients. What are examples of these illnesses?
-autoimmune -oncologic -metabolic -endocrine
What are 3 examples of a nonpharmacologic therapy used to help heal a large surgical wound?
-biosurgery -specialty bandages -hyperbaric oxygen therapy
Alcohol consumed in excess can lead to what?
-craving alcohol -diminished ability to function -life-threatening conditions
The first phase of heroin withdrawal usually lasts 10 days. What are common side effects in this phase?
-cravings -lacrimation (the flow of tears) -rhinorrhea (runny nose) -yawning -diaphoresis (sweating)
A nurse caring for a patient with depression should focus on safety ad meeting functional needs until the condition improves. What are 3 examples of these functional needs?
-daily hygiene -sleep -nutrition
Alcohol used in moderation can have positive effects. What are 2?
-decrease coronary artery disease -protects against stroke
What are 3 common problems related to ADHD?
-decreased attention span -impulsiveness -increased motor activity
What are common medications used to treat alcohol withdrawal?
-diazepam -carbamazepine -clonidine -chlordiazepoxide -phenobarbital -naltrexone
What are common symptoms of ADHD?
-difficulty completing tasks -constant fidgeting -frequently loud and interrupts -sleep disturbances -difficulty with social relationships in school, with parents, and siblings
What are common medications used to treat help with alcohol abstinence?
-disulfiram -naltrexone -acamprosate
What are protective factors of depression?
-eat healthy -regular exercise -avoid smoking -adequate sleep -stress management
Symptoms of chronic venous insufficiency include:
-edema of the lower extremities -hyperpigmentation
Nursing interventions for PVD include:
-elevate the legs when resting or asleep -avoid crossing the legs or putting pressure on the back of the knees -put on hose after the legs have been elevated
What are the symptoms of primary hypertension?
-elevated BP -headache -nocturia -visual disturbances
What are the stereotypical manifestations of someone with ASD that are indicative of rigid and obsessive behavior?
-head banging -twirling in circles -biting self -flapping hands or arms -may be self-stimulating or self-destructive
What are the two major processes that occur during the inflammatory phase of wound healing?
-hemostasis -phagocytosis
What are 3 common problematic physiologic effects of opiate use?
-hyperalgesia (increased sensitivity to pain) -hypogonadism (testosterone deficiency) -sexual dysfunction
Risk factors for pressure injuries include:
-immobility and inactivity -inadequate nutrition -fecal and urinary incontinence -decreased mental status -diminished sensation -advanced age -excessive body heat -diabetes -cardiovascular disease
What are two short term physiologic effects of marijuana use?
-increase in heart rate -bronchodilation
Risk factors associated with PVD and CVI include:
-increased cholesterol levels -excess body weight or obesity, and -physical inactivity -Clients age 50 and older
What are the phases of wound healing?
-inflammatory -proliferative -maturation or remodeling
The second phase of heroin withdrawal usually lasts months. What are common side effects in this phase?
-insomnia -irritability -fatigue -GI hyperactivity -premature ejaculation
What are conditions with high co-occurence with ASD?
-intellectual differences -mood or other mental health disorders -seizures -immune dysfunctions -GI issues
What are characteristics of a nurse-client relationship?
-it is goal directed -behavioral change is encouraged -a termination date is established
Why are mental health and development disorders in children and adolescents difficult to diagnose?
-lack of the ability or necessary skills to describe what is happening -a wide variation of "normal" behavior, especially in different developmental stages
What is the temporal lobe responsible for?
-language -sensory input
Why is an older adult client at risk for developing a pressure injury?
-loss of lean body mass -epidermal thinning -decreased skin elasticity -increased skin dryness
Manifestations of CVI include:
-lower extremity edema that worsens with standing -itching, dull leg discomfort or pain that increases with standing -thin, shiny, atrophic skin -cyanosis and brown skin pigmentation of lower leg and foot -possible weeping dermatitis -thick, fibrous (hard) subcutaneous tissue -recurrent ulcerations of medial or anterior ankles
Chronic alcohol use can damage other systems. What are the other complications?
-myocardial disease -erosive gastritis -acute and chronic pancreatitis -sexual dysfunction -increased risk of breast cancer
What are key assessments when taking care of a patient with substance abuse problems?
-observation and patient interview -•history of past substance use •medical and psychiatric history •psychosocial issues
What does the mini-mental state examination assess?
-orientation to time and place -attention span and ability to calculate by counting backward by 7 -registration and recalling of objects -language, including naming of objects, following commands, and ability to write
What are protective factors of ASD?
-prenatal care (folic acid and good health) -genetic counseling if familial tendency
What are the most important lab values of a client with ASD?
-presence of specific criteria in DSM-5 -screening test
Preventing a pressure injury involves:
-providing adequate nutrition -maintaining skin hygiene -avoiding skin trauma -providing support devices -providing mechanical devices for reducing pressure on body parts
Manifestations of a skin infection include:
-restlessness -purulent drainage -sweating and chills -foul smelling wound bed
What are severe manifestations of alcohol withdrawal?
-seizures -convulsions -delirium tremens
What are the effects alcohol has on the CNS system?
-seizures -neuropathies -sleep disturbances -alcoholic dementia
What are the risk factors of peripheral vascular disease?
-smoking -hypertension -High cholesterol -Diabetes -Family history of vascular disease -Obesity -Physical inactivity -Patients over the age of 50 -Occupations that require prolonged standing/sitting
What is the frontal lobe responsible for?
-social behaviors -motor function -problem solving -other higher functions
What are the 3 core characteristics of ASD?
-social deficits -language impairment -repetitive behaviors
What are common developmental abnormalities that indicate ASD in a child before the age of 3?
-social interaction -language used in social interactions -imaginative play
Clinical manifestations of a myocardial infarction (MI) include: tachypnea, anxiety, vomiting, and electrocardiogram (ECG) changes in the Q wave.
-tachypnea -anxiety -vomiting -electrocardiogram (ECG) changes in the Q wave -ST segment elevation
Independent nursing interventions for the client with an alteration in tissue integrity include:
-teaching the signs of wound infection -reviewing the process to discard soiled dressings -instructing on cleaning and dressing the foot wound
In reevaluating a plan of care for a patient receiving treatment for alcohol abuse, a nurse should consider:
-the patient's physiologic and mental health -coping responses -legal and occupational involvement -housing -peers social and spiritual support.
Wernicke Korsakoff syndrome is a combination of Wernicke's encephalopathy which consists of:
-the triad of ophthalmoplegia -ataxia -confusion
There is an increased occurrence of ASD in children with genetic abnormalities. What are some examples of them?
-tuberous sclerosis -fragile X syndrome -down syndrome -congenital rubella syndrome -neurofibromatosis
What are common medications given to treat nicotine abstinence?
-varenicline -rimonabant
A stage __ pressure injury has intact skin with localized redness that does not blanch when pressed.
1
Stage __ (mild) heart failure is when the client has no limitations of physical activity and no shortness of breath with normal physical activity. a. 1 b. 2 c. 3 d. 4
1
The first noticed symptom of ASD is delayed speech. Absence of babbling or other communication by __ year(s) of age is a red flag.
1
In Stage __ (moderate), a client has increased physical limitations with less than normal physical activity resulting in fatigue, shortness of breath, or palpitations; the client is comfortable at rest. a. 1 b. 2 c. 3 d. 4
3
The inflammatory phase of wound healing is initiated immediately after injury and lasts for how many days?
3-6 days
The albumin level determines nutritional status; a value below __ g/dL indicates poor nutrition.
3.5
For a patient who is bedridden, shearing force can be reduced by elevation of the head of the bed to no more than __ degrees. Patients with respiratory disorders may find it easier to breathe in Fowler position.
30
Stage __ (severe) is the most debilitating and the client experiences symptoms of cardiac insufficiency at rest. a. 1 b. 2 c. 3 d. 4
4
A client with stage __ (mild) heart failure has some physical limitations due to fatigue, shortness of breath, or palpitations; the client is comfortable at rest. a. 1 b. 2 c. 3 d. 4
2
A stage __ pressure injury has a shallow open wound or blister without sloughing.
2
The first noticed symptom of ASD is delayed speech. Absence of two-word phrases by __ year(s) of age is a red flag.
2
A client who has heart failure should not consume more than ______ mg of sodium per day.
2,000
A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? a. A client who has schizophrenia with delusions of grandeur. b. A client who has manifestations of depression and attempted suicide a year ago. c. A client who has borderline personality disorder and assaulted a homeless man with a metal rod. d. A client who has bipolar disorder and paces quickly around the room while talking to themselves.
A client who has borderline personality disorder and assaulted a homeless man with a metal rod. (A client who is a danger to himself or others is a candidate for a temporary emergency admission)
What assessment findings would cause you to believe a pressure injury is infected?
A pressure injury would appear infected if it were warm, red, odorous, swollen, or draining. The patient may have fever, chills, or an increased white blood cell count. There may be pain at the wound site.
An EF of less than __% is a maternal risk factor for major cardiac complications.
40
What is the relapse rate for substance abuse?
40-60%
Up until age __, men have a greater risk for hypertension than do women.
45
Heavy alcohol use is drinking ≥ __ drinks in one session on ≥ 5 days in past 30 days.
5
Between ages 45 and __, men and women have an equal risk for hypertension.
64
At age __ and older, women have a greater risk for hypertension than do men.
65
In the absence of hypoxemia, as indicated by a partial pressure of oxygen in arterial blood (PaO2) of __ to __ mm Hg, oxygen therapy is unlikely to help relieve dyspnea.
83-100
Normal SaO2
95-100%
Difficulty completing tasks that require focused attention, hyperactivity, hyperkinesis, and impulsivity are all characteristics of what disorder?
ADHD
Familial tendency, family stress, poverty, and poor nutrition may be contributing factors of ______.
ADHD
The pathophysiology of ______ is still unclear. However, studies suggest it may involve a deficit in dopamine and norepinephrine. A manifestation of the disorder is a delay in brain maturation in the area of self-regulation.
ADHD
While there is no way to prevent ______, it is recommended that women avoid smoking, drugs, and alcohol during pregnancy. Prenatal care strongly advised.
ADHD
______ is a disorder characterized by difficulty completing tasks that require focused attention, hyperactivity, hyperkinesis, and impulsivity.
ADHD
Imbalances in neurotransmitters contribute to the development of mental disorders. Norepinephrine imbalance is implicated in which of the following disorders?
ADHD, MDD, hypotension
An ABI (ankle-brachial blood pressure index) tests for peripheral vascular disease that may predict ______.
CAD (coronary artery disease)
______ results when venous blood collects and stagnates in the lower leg.
CVI
A patient recently diagnosed with peripheral vascular disease states to the nurse, "My legs burn when I am relaxing on the couch. I can't seem to find a comfortable position." How should the nurse respond to the patient's concern? a. "The pain you're referring to is called intermittent claudication. Does it improve with movement?" b. "The pain you're referring to is called intermittent claudication. Is it usually worse with activity?" c. "The pain you're referring to is called rest pain. Does it improve if you elevate your legs above your heart?" d. "The pain you're referring to is called rest pain. Does it improve when you hang your legs off the couch?"
"The pain you're referring to is called rest pain. Does it improve when you hang your legs off the couch?"
In adults, known risk factors for ADHD include:
-Antisocial behavior -Substance abuse -Involvement in serious accidents -Academic underachievement -Low occupational success
The maturation or remodeling phase of wound healing begins about day 21 and can extend for how long after the injury?
1-2 years
The nurse is evaluating a patient with chronic peripheral venous disease (PVD) and claudication following a change in treatment plan. The patient reports that for the past several nights burning pain is waking them from sleep. How should the nurse interpret these findings? a. The claudication is resolving. b. The new treatment plan is effective. c. A new problem is developing that requires further evaluation. d. The disease is progressing and tissue perfusion is altered.
The disease is progressing and tissue perfusion is altered.
Depression manifestations mnemonic
SIG E CAPS S- Sleep disturbance (too much or insomnia) and sad mood I- Interests diminished in pleasurable activities G- Guilt feeling; feelings of worthlessness E- Energy decreased or fatigue and (self)-Esteem loss C- Concentration diminished and indecisiveness A- Appetite changes (decreased or increased) with weight changes P- Psychomotor retardation (slowing) or agitation S- Suicidal thoughts and behaviors and thoughts of death
You are caring for a child who was involved in a bicycle accident resulting in below-the-waist paraplegia. How will you teach the parents to reduce the risk of pressure injuries?
The parents will be taught to help the child change position often; to make sure the child sits with equal pressure, especially on bony areas; and to instruct the child to shift position often in the wheelchair.
The nurse is caring for a patient with chronic venous insufficiency (CVI) who has a past medical history of thrombophlebitis. The nurse should recognize that this patient was at a high risk for developing CVI for which reason? a. Thrombophlebitis may create a toxin that damages veins. b. Thrombophlebitis may damage valves of deep veins. c. Thrombophlebitis may alter coagulation that damages deep veins. d. Thrombophlebitis may increase nitric oxide concentration, which damages veins.
Thrombophlebitis (inflammation of the vein caused by a thrombus) may damage valves of deep veins.
What nursing interventions can be implemented to reduce the risk of infection of a pressure injury?
To reduce possibility of infection, the nurse will keep the wound clean, administer treatment as ordered for wound care, and position the patient off the wound.
The nurse is assessing a patient and suspects peripheral vascular disease (PVD). Which test should the nurse anticipate being ordered to confirm this diagnosis? a. Arterial blood gas (ABG) b. Lung scan c. Segmental pressure measurement d. Electrocardiogram (ECG)
Segmental pressure measurement
A client recently diagnosed with hypertension has a family history of hyperaldosteronism. Which diagnostic test should the nurse expect to be ordered? A. Creatinine clearance B. Serum creatinine C. Serum potassium D. Renal function panel
Serum potassium
The nurse is caring for a client with a history of atherosclerosis. The client has chest pain that occurs with physical exertion or stress and is relieved with sublingual nitroglycerin. Which disorder should the nurse recognize the client is most likely experiencing? A. Prinzmetal angina B. Myocardial infarction C. Acute coronary syndrome D. Stable angina
Stable angina (Stable angina is a predictable form of angina, which usually occurs when the work of the heart is increased by physical exertion, exposure to cold, or stress)
Compare the pain experienced during exercise by a patient with PVD to that of a patient with angina.
With angina, pain occurs with activity that creates a great demand for oxygenation of diseased myocardial tissue and ischemia occurs. When oxygen demands are reduced at rest, chest pain goes away. Intermittent claudication is the characteristic pain associated peripheral atherosclerosis, activity increases the oxygen demand to diseased peripheral tissues. When this demand is unmet, ischemia occurs and results in pain.
What are 3 screening tools for substance abuse?
-Brief Drug Abuse Screening Test (B-DAST) -Objective Opiate Withdrawal Scale (OOWS) -Subjective Opiate Withdrawal Scale (SOWS)
What are common therapies for a person suffering from substance abuse?
-Detoxification -Aversion therapy -Group, individual, family counseling -Psychotropic medication -Cognitive-behavioral therapy -Self-help groups
What are long term goals for a patient with a substance abuse problem?
-Explore impact of addiction on family, job, friends -Describe, recognize use of denial -Change thinking, behavior -Regularly attend support group -Remain free of substance and maintain sobriety
What are 3 screening tools for alcohol abuse?
-MAST -CAGE questionnaire -CIWA-Ar
What are the common brand names of opiates?
-Vicodin -Percocet -OxyContin -Opana
What are common medications used to treat nicotine withdrawal from tobacco use?
-bupropion -nicotine replacement therapy -varenicline
What are the signs and symptoms of an infection?
-change in wound color -pain -drainage -positive culture of wound -fever -elevated WBC
During the health history portion of the nursing assessment for the client with PVD, the nurse will assess:
-client history of coronary artery disease (CAD) -current medications and diet -any complaints of pain
What are the most important lab values of a client with depression?
-complete blood count (CBC) and basic metabolic panel (BMP) -thyroid panel (T3, T4, TSH) -urine/blood drug screen
What are the effects alcohol has on the reproductive system?
-erectile problems -deceased testosterone -decreased sex drive -menstrual irregularities
An 86-year-old man visits the clinic and asks about risk factors for heart disease. Which modifiable risk factors would the nurse discuss with this client? (Select all that apply.) A. Exercise B. Smoking C. Ethnicity D. Sex E. Nutrition
-exercise -smoking -nutrition
What is the pertinent lab work for pressure injuries?
-hemoglobin -protein (especially albumin) -lymphocyte count
What are common medications used to treat opioid withdrawal?
-methadone substitution -clonidine -buprenorphine -naltrexone -levo-alpha-acetylmethadol
What are common examples of opiates?
-morphine -meperidine -codeine -hydrocodone -oxymorphone -oxycodone
What are the labs used to rule out other causes of a child's behavior for a client suspected of having ASD?
-neuroimaging -lead screening -DNA analysis -electroencephalography
What are factors that heighten a patient's risk of wound dehiscence?
-obesity -poor nutrition -multiple trauma -failure of suturing -excessive coughing -vomiting -dehydration -comorbidities such as diabetes
What are 6 questions that elicit a pattern of substance use behavior?
-past alcohol, substance abuse, polysubstance abuse -when patient first used alcohol -medical history of blackouts, delirium, or seizures -history of withdrawal syndrome, overdoses, or complications from alcohol use -arrests for driving under the influence or criminal acts while using alcohol -family history
Signs of digitalis (a positive inotropic drug) toxicity include:
-poor appetite -anorexia -nausea and vomiting -headache -altered vision -confusion
What are the 3 major types of exudate?
-serous -purulent -sanguineous
What are typical speech pattern abnormalities of a person with ASD?
-using "you" in place of "I" -echolalia (repetition of another person's spoken word) -repeating questions instead of answering them -fascination with rhythmic or repetitive songs and verses
affect
a client's affect is an objective expression of mood (a flat affect or a lack of facial expression)
mood
a client's mood provides info about the emotion that the client is feeling
Hippocampus
a neural center located in the limbic system; helps process explicit memories for storage
malpractice
a type of professional negligence
A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? Select all that apply. a. To assess cognitive ability, I should ask the client to count backward by sevens. b. To assess affect, I should observe the client's facial expression. c. To assess language ability, I should instruct the client to write a sentence. d. To assess the client's abstract thinking, I should ask the client to identify our most recent president's.
a, b, c
The nurse is performing an assessment on a 57-year-old client with newly diagnosed heart failure. The product of which factors determine a client's cardiac output? A. Stroke volume and urinary output B. Heart rate and urinary output C. Stroke volume and heart rate D. Heart rate and ejection fraction
Stroke volume and heart rate
Explain the relationship between physical exercise and pain in the patient with PVD.
Pain is the primary symptom of peripheral atherosclerosis. Intermittent claudication (a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity) is characteristic of PVD. The pain is often accompanied by weakness and is relieved by rest. Eventually rest pain may also occur during periods of inactivity. It is often described as a burning sensation in the lower legs. Rest pain increases when the legs are elevated and decreases when the legs are dependent (e.g., hanging over the side of the bed). The legs also may feel cold or numb along with the pain. Sensation is diminished, and the muscles may atrophy.
Which client reaction should the nurse expect during a coronary artery spasm? A. Gradual increase in systolic blood pressure B. Acute reduction in level of consciousness C. Sudden onset of acute chest pain D. Gradual increase in peripheral edema
Sudden onset of acute chest pain
Addiction mnemonic: dependence
TWO 6 PACK T - Tolerance W - Withdrawal O - Occupational, social, or recreational activities given up or reduced 6 -P - Persistent desire or unsuccessful efforts to cut down or control substance use A - Amount of use is excessive C - Continues substance use despite having persistent or recurrent physical or psychological problems K - Keeps spending a lot of time in search, use, or recovery from the substance.
The nurse is planning care for a patient with peripheral vascular disease (PVD) who is hospitalized due to increased pain associated with intermittent claudication. Which independent nursing intervention should the nurse implement? a. Assess patient pain every 12 hours using standard scale. b. Encourage the patient to walk the halls, regardless of pain. c. Teach the patient guided imagery. d. Administer pain medications as ordered.
Teach the patient guided imagery.
LOC: lethargic (somnolent)
The client is able to open their eyes and respond but is drowsy and falls asleep readily.
LOC: stuporous
The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. The client might not be able to respond verbally.
A client recently admitted to the coronary care unit (CCU) with left heart failure complains of sudden dyspnea, anxiety, and feelings of "drowning." What is the most likely cause of these changes? A. Hyperglycemia B. Pulmonary embolism C. Myocardial infarction D. Cardiogenic pulmonary edema
Cardiogenic pulmonary edema
ADHD (adults) manifestations mnemonic
DISTRACTED D - Distractibility I - Impulsivity S - School History R - Rating Scales A - Accidents C - Commitments T - Time Management E - Employment D - Decisions
Addiction mnemonic: abuse
DRiNK D- Dangerously driving a vehicle or machine when impaired by substances Ri- Role failure in home, school, or work because of recurrent substance use N- No respect for the law, leading to legal problems K- Keeps using a substance despite persistent or recurrent social or interpersonal problems
The nurse is teaching a group of adults about chronic venous insufficiency (CVI). Which should the nurse identify as the most common cause of CVI? a. Congestive heart failure (CHF) b. Deep vein thrombosis (DVT) c. Scleroderma d. Varicose veins
DVT
What is the most common cause of chronic venous insufficiency?
DVT
An OB/GYN nurse is counseling women with heart failure about pregnancy and risk factors. The nurse recommends that the women prevent pregnancy. Which is the most important risk factor that contributes to this recommendation? A. Cholesterol level of 220 mg/dL B. Ejection fraction (EF) of 38% C. Blood pressure of 126/80 mmHg D. Previous miscarriages
Ejection fraction (EF) of 38%
The nurse is planning care for a patient with peripheral vascular disease (PVD) who is scheduled to have revascularization surgery to improve circulation to the lower extremities. Which independent nursing intervention should the nurse include in the plan of care to promote patient tissue perfusion? a. Encourage regular exercise. b. Elevate lower extremities above the heart. c. Warm lower extremities using heating pad. d. Administer medication as ordered.
Encourage regular exercise.
African Americans are more at risk for heart failure. What are the most important risk factors in this population? (Select all that apply.) A. Hypotension B. Low levels of HDL C. Obesity D. Renal insufficiency E. Hypertension
Hypertension, Renal insufficiency, Obesity, and Low levels of HDL (which increases risk of atherosclerosis)
A nurse is evaluating lab results on a 70-year-old client. The nurse notices an increased level of brain natriuretic peptide (BNP). What does this indicate? A. Reduced cardiac workload B. Increased left ventricular pressure C. Decreased gas exchange in lungs D. Decreased vascular congestion
Increased left ventricular pressure
While Wernicke encephalopathy is reversible, it is considered a medical emergency and must be treated immediately to prevent ______ syndrome, since that is not reversible.
Korsakoff
If Wernicke's encephalopathy is left untreated, it can progress to what?
Korsakoff syndrome
What does the cerebellum control?
balance and movement
A ______ ______ suspends bed linens over the legs, preventing them from placing pressure on extremities and injured tissues. Minimizing pressure on the tissues promotes capillary blood flow.
bed cradle
During the early stages of hypoxia, what clinical indicator is usually elevated?
blood pressure
What does the brain stem control?
breathing, heart rate, blood pressure (involuntary actions)
Breakdown of RBCs in the congested tissues causes ______ (brown/rubor) skin pigmentation in peripheral vascular disease.
brown
Substance ______ disorder is a cluster of cognitive, behavioral, physiologic symptoms that indicate continued use of a substance despite significant negative consequences. It may involve permanent brain changes.
abuse
Care of a client who has MDD in the ______ (acute/continuation/maintenance) phase will show severe clinical findings of depression. Treatment is generally 6 to 12 weeks in duration.
acute
People with an ______ can have a genetic predisposition. There is often a stigma with this disorder that makes them discriminated against.
addiction
Various factors have been linked to ______. Biological, genetic, psychologic, and sociocultural factors are the main considerations. Even the dopamine reward system is hypothesized.
addiction
______ is defined as a psychologic or physical need for a substance or process to the extent that the individual will risk negative consequences to meet the need.
addiction
Why are obese patients at increased risk of wound infection and slower healing?
adipose tissue usually has a minimal blood supply
Negative outcomes of ______ use in those under legal drinking age include an interference with normal brain development, increased risk of developing an alcohol use disorder, and an increased risk of sexual assaults.
alcohol
______ is a term describing successful closure of a wound with little or no tissue loss.
approximated
Absent pulses, cool skin on the feet and toes, and gangrene are signs of ______ (arterial/venous) problems.
arterial
Arterial or Venous Ulcer? Edema: absent or mild
arterial
Arterial or Venous Ulcer? Location: toes, feet, shin
arterial
Arterial or Venous Ulcer? Skin appearance: normal to atrophic, pallor on elevation, rubor on dependency
arterial
Arterial or Venous Ulcer? Skin temp: cool
arterial
Arterial or Venous Ulcer? Ulcer appearance: deep, pale
arterial
Arterial or Venous Ulcer? gangrene: may occur
arterial
Arterial or Venous Ulcer? pain: usually severe, intermittent claudication, rest pain
arterial
Arterial or Venous Ulcer? pulses: decreased or absent
arterial
Wounds on the toes, absence of hair on the legs, cool extremities, and thick toenails are all features of ______ (venous/arterial) problems.
arterial
Where does plaque tend to form in the arteries?
arterial bifurcations
______ is an arterial disorder characterized by thickening, loss of elasticity, and calcification of arterial walls.
arteriosclerosis
How do you assess a client's recent memory?
ask the client to recall recent events (visitors from the current day) or the purpose of the current mental health appointment or admission
How do you assess a client's immediate memory?
ask the client to repeat a series of numbers or a list of objects
PVD arises primarily from _____ and other disorders that impair cardiovascular function.
atherosclerosis
______ is a condition in which fatty deposits build up and block coronary arteries. These buildups are made of cholesterol, fatty substances, cellular waste products, calcium, and fibrin.
atherosclerosis
______ is a form of arteriosclerosis in which deposits of fat and fibrin obstruct and harden arteries.
atherosclerosis
______ disorder is characterized by impaired communication and social interaction patterns and repetitive, restrictive, and stereotyped behaviors.
autism spectrum disorder
______ is a disorder characterized by impaired communication and social interaction patterns, as well as, repetitive, restrictive, and stereotyped behaviors.
autism spectrum disorder
A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion. Select all that apply. a. The DSM-5 includes client education handouts for mental health disorders. b. The DSM-5 establishes diagnostic criteria for individual mental health disorders. c. The DSM-5 indicates recommended pharmacological treatment for mental health disorders d. The DSM-5 assists nurses in planning care for client's who have mental health disorders. e. The DSM-5 indicates expected assessment findings of mental health disorders.
b, d, e
Normal respiration rate
12-20 breaths per minute
Temporary emergency admission to mental health care is not to exceed __ days.
15
The proliferative phase of wound healing extends from day 3 or 4 to about day __ post injury.
21
Children as young as __ can be diagnosed with ADHD.
3
Rapid loss of blood and the onset of shock indicate ______ (internal/external) hemorrhage.
external
What are common abnormal responses to sensory stimuli that a person with ASD may experience?
extreme aversion to touch, loud noises, or bright lights
______ is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces
exudate
negligence
failing to provide adequate care in a personal or professional situation when one has an obligation to do so
T or F. ASD is more common in females.
false
A client in ______ position has pressure on the heels, pelvis, sacrum, and vertebrae.
fowler
______ supplements have been shown to slow the progression of PVD and a very low-fat or vegetarian diet, not a high-protein diet, decreases cholesterol and atherosclerosis.
garlic
Treatment of Wernicke's encephalopathy incolves the prompt administration of thiamine, followed by ______.
glucose
______ tissue forms in the proliferative phase of wound healing.
granulation
What does the medulla control?
heart rate and breathing
A ______ is a localized collection of blood underneath the skin that may appear as a bruise. It can place pressure on blood vessels and obstruct blood flow.
hematoma
______ level is used to measure oxygen delivery to the skin.
hemoglobin
______ is a term used to describe rapid or excessive bleeding.
hemorrhage
______ is the cessation of bleeding due to the formation of blood clots and a scab.
hemostasis
Severe liver damage from chronic alcohol use can progress from fatty liver to ______ or cirrhosis.
hepatitis
Alcohol disrupts activity in the ______, which is responsible for memory. Therefore, large amounts of alcohol consumed rapidly will cause blackouts. a. cerebellum b. hippocampus c. amygdala d. prefrontal cortex
hippocampus
veracity
honesty when dealing with a client
Women are often misdiagnosed throughout the lifespan because ADHD in women presents with inattentiveness, depression, and stress rather than ______.
hyperactivity
Salt substitutes should be avoided with potassium-sparing diuretics because they often contain potassium and can result in ______.
hyperkalemia
In the late stages of hypoxia, patients are likely to develop ______.
hypotension
Intermittent ______ is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity.
caludication
The Frank-Starling mechanism occurs as the result of the heart muscle being stretched; active tension is created by altering the overlap of thick and thin filaments. This increase in contractile force leads to increased _____ ______.
cardiac output
Statins such as atorvastatin (Lipitor) are used to decrease ______. Generalized muscular tenderness and pain is a concerning side effect.
cholesterol
Modeling, operant conditioning, and systematic desensitization are all examples of ______ and ______ therapies.
cognitive and behavioral
Why is a client with type I diabetes mellitus at risk for developing a pressure injury?
compromised oxygen delivery to the tissues
Korsakoff syndrome manifests as aphasia and ______, which is when a person creates stories to fill in the gaps in their memory which they believe to be true.
confabulation
false imprisonment
confining a client to a specific area physically, verbally, or using a chemical restraint when it is not part of the client's treatment
Care of a client who has MDD in the ______ (acute/continuation/maintenance) phase will show an increased ability to function. Treatment is generally 4 to 9 months.
continuation
______ occurs when a health care team members displaces characteristics of people in their past onto a client.
countertransference
Oxygen, especially when delivered long-term and/or without sufficient humidification, is extremely drying and can cause ______ in the nasal and oral mucosa.
cracks
What 4 things should a nurse emphasize when providing patient education to a patient receiving treatment for alcohol abuse?
importance of balanced diet, adequate sleep, healthy recreational activities, and caring support system
A patient is admitted with impaired tissue healing of the lower extremities due to peripheral vascular disease (PVD). The nurse applies a bed cradle. Which effect should the nurse expect from this intervention? a. Decreased shearing force b. Improved capillary blood flow c. Lowered risk of infection d. Diminished risk of deep vein thrombosis (DVT)
improved capillary blood flow
Why is a client with a history of anorexia nervosa at risk for developing a pressure injury?
inadequate nutrition, which leads to weight loss, muscle atrophy, and loss of subcutaneous tissue
Diuretics ______ (increase/decrease) urine output and ______ (increase/decrease) blood volume.
increase; decrease
What is the cause of swelling at the site of injury?
increased vascular permeability and leakage of fluid out of the vessel
Swelling, wound distention, sanguineous drainage, and hematoma indicate ______ (internal/external) hemorrhage.
internal
______ causes tissue necrosis and eventual ulceration.
ischemia
Abnormal amounts of collagen may appear resulting in a hypertrophic scar or ______.
keloid
A client in the ______ position has pressure on the knee and ilium.
lateral
______ are used to determine if an infection is present.
leukocytes
substance overdose
life threatening condition requiring emergency hospitalization
Alcohol interferes with the ability to form new ______-term (long/short) memories.
long
Men who drink ≤4 drinks on any one day and ≤14 drinks per week are considered ______ (low/high) risk for alcohol dependence.
low
Women who drink ≤3 drinks on any one day and ≤7 drinks per week are considered ______ (low/high) risk for alcohol dependence.
low
fidelity
loyalty and faithfulness to the client and to one's duty
______ is when tissues become softened by prolonged wetting or soaking.
maceration
Care of a client who has MDD in the ______ (acute/continuation/maintenance) will experience a remission of manifestations. This phase can last for years.
maintenance
______ is a synthetic opiate use to treat chronic pain and opiate addiction.
methadone
______ drainage covers less than 25% of the dressing.
minimal
______ anxiety decreases problem-solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious. a. mild b. moderater c. severe d. panic
moderate
______ drainage involves 25-75% of the dressing without leakage prior to scheduled dressing changes.
moderate
Weakness of the upper arms is an atypical symptom indicative of ______ ______ in women
myocardial infarction
A ______ ______ mask delivers oxygen concentrations of 24-40%.
nasal canula
decerebrate rigidity
neck and elbow extension, wrist and finger flexion
A ______ mask delivers oxygen concentrations of 60% to 80%.
nonrebreather
A ______ (neurotransmitter) deficiency affects attention and behavior.
norepinephrine
Administering oxygen therapy with a nonrebreather mask has which of the following advantages?
offers the highest oxygen concentration of the low-flow systems
Risk factors for CAD include non-modifiable factors such as:
older age (over age 45 years in men and over age 55 years in women), family history of early heart disease, and race
Increased heart rate is a manifestation of ______.
pain
The conditions that can cause secondary hypertension include:
pregnancy after 20 weeks of gestation, diabetes, and kidney disease
What are two types of abnormal posturing in a client who is comatose?
decorticate rigidity and decerebrate rigidity
Individuals with depression often have ______ (increased/decreased) gray matter volume and lower metabolic activity in the medial prefrontal cortex.
decreased
Individuals with depression often have ______ (increased/decreased) limbic system activity.
decreased
The serum potassium level will be ______ (increased/decreased) with hyperaldosteronism.
decreased
______ is an unintended separation of wound margins due to incomplete healing. It usually involves an abdominal wound in which the layers below the skin also separate.
dehiscence
Alcohol, sedatives, hypnotics, anxiolytics, and cannabis are all examples of CNS ______.(depressants/stimulants)
depressants
A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? a. chlordiazepoxide b. bupropion c. disulfiram d. carbamazepine
disulfiram
The pathophysiology of ADHD is unclear, however, studies suggest it may result from a deficit in what two neurotransmitters?
dopamine and norepinephrine
A client with heart failure is prescribed an angiotensin-converting enzyme (ACE) inhibitor. What is the most important side effect that may interfere with compliance? A. Diarrhea B. Dry cough C. Rash D. Visual disturbances
dry cough
Rest pain increases when the legs are ______ (elevated/dependent) and decreases when the legs are ______ (elevated/dependent). The legs may also feel cold or numb along with the pain.
elevated, dependent
The description by the client that something "gave way" indicates a dehiscence with possible ______.
evisceration
______ is a protrusion of internal viscera through a surgical wound.
evisceration
The type of hypertension most often found in the older child and adolescent is ______ (primary/secondary) and is associated with family history, obesity, and diabetes.
primary
______ (primary/secondary/tertiary) intention healing is healing that occurs where the tissue surfaces have been closed and there is minimal or no tissue loss. It is characterized by the formation of minimal granulation tissue and scarring.
primary
A client in the ______ position has pressure on the zygomatic bone.
prone
______ exudate is a large quantity of cells and necrotic debris that form an opaque milky discharge that is thicker than serous exudate (aka pus or suppuration) a. serous b. purulent c. sanguineous d. serosanguineous
purulent
______ exudate is produced by pyogenic bacteria. It can be a tinge of blue, green, or yellow.
purulent
______ is the replacement or renewal of destroyed tissue cells by cells that are identical or similar in structure and function.
regeneration
Pain, in the form of intermittent claudication, is the primary symptom of PVD and is often relieved by ______.
rest
During the implementation phase of caring for a client suffering from substance abuse, a nurse should promote patient ______ and provide patient education.
safety
To increase the client's blood flow, one goal is to prevent the aggregation of platelets in the arteries. ______ ______ (aspirin) is a pharmacologic measure to control the aggregation.
salicylic acid
______ exudate is a large amount of red blood cells that form a bright or dark red discharge indicating new or old damage to capillaries (aka hemorrhagic exudate) a. serous b. purulent c. sanguineous d. serosanguineous
sanguineous
Wound tissues that are moist, with no measurable exudate, are said to have ______ drainage
scant
______ (primary/secondary) hypertension is more often found in younger children and is associated with kidney, heart, or endocrine abnormalities.
secondary
______ (primary/secondary/tertiary) intention healing is healing that occurs when a wound's edges cannot or should not close. An example would be a pressure ulcer.
secondary
A client diagnosed with primary aldosteronism has polyuria, weakness, paresthesia, and an elevated blood pressure. Which condition should the nurse expect as the most likely cause for the elevated blood pressure? A. Hypertensive crisis B. Stroke C. Primary hypertension D. Secondary hypertension
secondary hypertension
______ exudate is a clear or blood-tinged discharge commonly seen in surgical incisions. a. serous b. purulent c. sanguineous d. serosanguineous
serosanguineous
A ______ (neurotransmitter) deficiency affects mood, sexual behavior, sleep cycles, hunger, and pain perception.
serotonin
______ exudate is a watery, clear or straw-colored discharge that accompanies mild inflammation a. serous b. purulent c. sanguineous d. serosanguineous
serous
A ______ mask delivers oxygen concentrations of 40-60%.
simple
Instructions on skin hygiene and the use of moisturizers are independent nursing interventions to promote ______ ______.
skin integrity
The highest modifiable risk factor for CAD is:
smoking
Many individuals work with a ______. They are a recovering alcoholic with several years of sobriety and provide peer support.
sponsor
The nurse reviews alginate dressings with a new nurse. For which type of pressure injury should the nurse identify this dressing is used? (Select all that apply.) A. Stage 4 without eschar B. Stage 4 with eschar C. Stage 1 D. Stage 2 E. Stage 3
stage 2, 3, and 4 without eschar
Cocaine, amphetamines, inhalants, hallucinogens, and caffeine are all examples of CNS ______. (depressants/stimulants)
stimulants
Medical history and ______ level are important assessment information.
stress
______ ______ is the amount of blood exerted from the left ventricle per beat and can be altered by factors of preload, contractility, and afterload
stroke volume
______ abuse is the use of any chemical in a manner inconsistent with medical or culturally defined social norms.
substance
______ (primary/secondary/tertiary) intention healing is healing that occurs after closing a wound that has been left open for 3-5 days to allow edema or infection to resolve. It is also known as delayed primary intention.
tertiary
autonomy
the client's right to make their own decisions. However, the client must accept the consequences of those decisions. The client must also respect the decisions of others.
beneficence
the quality of doing good; can be described as charity
Wernicke Korsakoff syndrome is caused by ______ deficiency and is commonly seen in chronic alcoholism.
thiamine
What are narcotic analgesics (derived from natural or synthetic opiates) used for?
to relieve pain
battery
touching a client in a harmful or offensive way is considered battery (giving an injection against the client's will)
A ______ relationship occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client's personal life.
transference
When the healthcare provider believes that a client has experienced a myocardial infarction (MI), diagnostic tests will include cardiac markers, including a ______ test, which measures the levels of troponin T or troponin I proteins in the blood. These proteins are released when the heart muscle has been damaged.
troponin
T or F. A patient with PVD should not elevate their lower extremities because this decreases circulation to them.
true
T or F. African Americans with hypertension more often have low renin levels and altered ability to excrete sodium at normal blood pressure levels.
true
T or F. Alcohol withdrawal delirium can progress to death.
true
T or F. Application of a moisture-retaining protective dressing is appropriate for a pressure injury without eschar or after the eschar has been surgically removed.
true
T or F. As heart failure worsens, BNP levels rise, and as the heart stabilizes, BNP levels decrease
true
T or F. A side-lying position or keeping the head of bed elevated more than 30 degrees can put pressure on specific body areas.
true
T or F. Beta-adrenergic blocking agents are contraindicated in patients with asthma, chronic lung disease, bradycardia, or heart block.
true
T or F. Biofeedback is used to improve peripheral circulation
true
T or F. Chronic use of alcohol leads to a cross-tolerance to general anesthetics, barbiturates, benzodiazepines, and other CNS depressants.
true
T or F. ECG changes such as ST segment elevation are associated with a myocardial infarction (MI), indicating that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately.
true
T or F. Edema increases the distance between the capillaries and the cells. It slows the diffusion of oxygen to the tissue cells and of metabolites away from the cells.
true
T or F. Hypertension often has no observable signs or symptoms. The nurse should ask about morning headaches or cervical pain.
true
T or F. In the early stages of hypoxia, heart rate rises and arterial oxygen saturation falls below 94%.
true
T or F. Men are more likely to have drug problems, but progression of addiction is faster among women
true
T or F. Mental health and development disorders are not always easily diagnosed, potentially resulting in delayed or inadequate treatment interventions.
true
T or F. Mentally healthy children and adolescents trust others, view the world as safe, accurately interpret their environments, master developmental tasks, and use appropriate coping skills.
true
T or F. Moist dressings are used for venous stasis ulcers, not dry dressings.
true
T or F. Prinzmetal (variant) angina occurs unpredictably and often at night
true
T or F. Substance use is a frequent comorbid condition with other mental disorders.
true
T or F. There is a strong association with preterm birth and ADHD.
true
T or F. Use of elastic compression stockings is essential to healing of venous stasis ulcers.
true
T or F. When eschar has formed, surgical debridement and removal of necrotic material is necessary.
true
T or F. When used in moderation. Alcohol can have positive effects.
true
T of F. Substance addiction should be treated like any other chronic illness.
true (relapse serves as a trigger for renewed intervention)
A person with ______ (stable/unstable) angina is not getting enough blood flow and oxygen to the heart muscle and this is a direct risk factor for a myocardial infarction.
unstable
The stress response leads to ______ (vasoconstriction/vasodilation), increasing pain. Stress reduction techniques, when combined with other measures to promote blood flow, can help reduce pain.
vasoconstriction
What causes redness at a site of injury?
vasodilation which brings an increase of RBCs to the site
Arterial or Venous Ulcer? Edema: may be significant
venous
Arterial or Venous Ulcer? Location: over medial or anterior ankle
venous
Arterial or Venous Ulcer? Skin appearance: brown discoloration, stasis dermatitis, cyanosis on dependency
venous
Arterial or Venous Ulcer? Ulcer appearance: superficial, pink
venous
Arterial or Venous Ulcer? gangrene: does not occur
venous
Arterial or Venous Ulcer? pain: usually mild, aching pain
venous
Arterial or Venous Ulcer? pulses: normal
venous
Brown pigmentation of the skin of the lower extremity and edema are features of ______ (venous/arterial) problems.
venous
Elevation promotes ______ (arterial/venous) return from the extremity, increasing circulation and relieving pain.
venous
Chronic ______ ______ is a disorder of inadequate venous return over a prolonged period of time making it difficult for blood to return to the heart.
venous insufficiency
Intentional Torts Against Persons
willful actions that damage a client's property or violate client rights
Why is it important to normalize thiamine first before giving glucose when treating a patient with Wernicke's encephalopathy?
without thiamine pyrophosphate, most of the glucose will become lactic acid and that can lead to metabolic acidosis
A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? a. Assist the client with systemic desensitization therapy. b. Teach the client appropriate coping mechanisms. c. Assess the client for comorbid health conditions. d. Monitor the client for adverse effects of medications.
Monitor the client for adverse effects of medications.
A patient started a new treatment plan for chronic peripheral venous disease (PVD) and claudication a week prior to the nurse's visit. The patient states, "For about a week or so, I've been waking up in the middle of the night and my legs have felt like they were on fire." Which intervention by the nurse is most appropriate? a. Explain that this is an expected clinical manifestation of the condition. b. Notify the healthcare provider. c. Encourage the patient to increase daily walking. d. Instruct the patient to elevate the legs while sleeping.
Notify the healthcare provider (Pain at rest is a sign that the disease is progressing and that perfusion is altered.)
Contrast appropriate nursing interventions to prevent pressure injuries in patients age 6, 30, and 80 with limited mobility.
Nursing interventions for all age groups are similar and should include a systematic skin inspection at least daily; prompt cleaning after toileting; minimizing skin exposure to moisture; and use of proper positioning, transferring, and turning techniques. Care for all patients depends on nutrition, injury, or surgery and the patient's ability to care for self.
Normal PaCO2
35-45 mmHg
normal cardiac output
4-8 L/min
People with ______ often have impairments in language, cognition, and social skills that make them seem different from other people.
ASD
______ has a possible genetic component. Children with certain genetic abnormalities have an increased occurrence and familial tendency. Advanced age of both parents is another risk factor.
ASD
______ results from defects in genes and gene expression in all areas of the cell-cycle expression. There is an atypical brain construction. An MRI will also show abnormalities of neurons of the cerebral cortex
ASD
ADHD (children) manifestations mnemonic
ATENTION A = Annoying T = Temperamental E = Energetic N = Noisy T = Task incomplete I = Inattentive O = Oppositional N = Negativism
ASD manifestations mnemonic
AUTISTIC PEOPLE A- Affect isolation U- Unrelated to others T- Twiddle I -I/You confusion in speech S - Self-mutilation T - Temper tantrums I - Inconsistent development C - Concrete thinking P - Perceptual difficulties E - Echolalia O - Orderly P - Physical motor disorder L - Lack language skills E - Excessive activity
The nurse is preparing a bulletin featuring peripheral vascular disease (PVD). Which should the nurse include as a risk factor for developing PVD? a. Female sex b. Age 50 or older c. Being underweight d. Drinking alcohol
Age 50 or older
While assessing an 82-year-old patient the nurse finds that the patient's systolic pressure is consistently high, while the diastolic pressure is within normal limits. Which statement correctly explains this phenomenon?
Aging decreases arterial compliance, resulting in increased pressure within the vessels.
milieu therapy
An inpatient treatment approach involving professionals and staff members encouraging a person with a severe mental disorder to engage in prosocial and therapeutic activities.
The nurse is reviewing the pharmacologic profile of a client with a non-healing wound. Which class of medications should the nurse question as it can delay wound healing? A. Proton pump inhibitor B. Cardiac glycoside C. Opioid D. Anti-inflammatory
Anti-inflammatory
What type of drugs interfere with healing?
Anti-inflammatory drugs (e.g., steroids, aspirin) and antineoplastic agents interfere with healing
The nurse is admitting a client to the coronary care unit (CCU) and is assessing risk factors for heart failure. What is the most concerning risk factor? A. Body mass index (BMI) of 18.0 B. Blood pressure of 188/122 mm/Hg C. Influenza D. Total cholesterol of 184 mg/dL
Blood pressure of 188/122 mm/Hg (hypertension is a major risk factor because the heart must work harder for effective blood circulation)
Which nursing intervention should the nurse recommend to promote tissue perfusion in a patient with peripheral vascular disease (PVD)? a. Tell patient to elevate their lower extremities above their heart. b. Advise patient to cross their legs when they sit. c. Encourage patient to exercise. d. Direct patient to ice lower extremities.
Encourage patient to exercise
A nurse should teach the HALT acronym to assist their patient in recognizing behaviors that lead to relapse. What is the HALT acronym?
H-hungry A-angry L-lonely T-tired
A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? a. Coordinate holistic care with social services. b. Identify the client's perception of their mental health status. c. Include the client's family in the interview. d. Teach the client about the current mental health disorder.
Identify the client's perception of their mental health status. (Assessment is the priority action when using the nursing process approach to client care. Identifying the client's perception of their mental health status provides important info about their psychosocial history.)
A nurse is assessing a client and notices pitting edema in the lower legs. The client has a history of mild congestive heart failure (CHF), which is controlled with medication, and reports that the swelling has become worse lately. Which could the increased edema indicate? A. The client has not been compliant with medications. B. The client has a possible progression of CHF. C. The client has increased physical activity. D. The client has been under stress.
The client has a possible progression of CHF.
LOC: alert
The client is responsive and able to fully respond by opening their eyes and responding to a normal tone of voice and speech. The client answers questions spontaneously and appropriately.
LOC: comatose
The client is unconscious and does not respond to painful stimuli
What is the HEADSSS standardized testing tool?
Home environment Education/employment Activities Drug and substance use Sexuality Suicide/depression Safety
decorticate rigidity
flexion and internal rotation of upper-extremity joints and legs
To avoid progressing to hypertension, clients with prehypertension should:
follow their treatment regimen, maintain a healthy weight and diet, reduce salt intake, reduce saturated and total fat intake, engage in regular physical activity, use stress-management techniques, and avoid baths that are too hot
