exam E 3.4

The nurse is assessing the stoma of a patient with a healthy, well-healed colostomy. The nurse expects the stoma to appear: 1 portuding into the ostomy bag 2 Red and moist 3 Budding 4 concave to the abdomen 5 Pale, pink and moist

2 3

A nurse is getting a new admit with a history of Parkinson's. What symptoms will the nurse anticipate? 1 impulsive behaviors 2 impaired gait 3 drooling 4 frequent urination 5 flat affect

2 3 5

When planning care for a patient with amyotrophic lateral sclerosis (ALS), a priority nursing intervention would include: Clear airway maintenance Means of adjusting to diagnosis Increased periods of exercise Alternative means of communication

Clear airway maintenance

The nurse explains that multiple sclerosis (MS) is most likely caused by: Environmental factors and genetic predisposition. Bacterial infection of the myelin Allergic response to antiviral medications Allergic response to antibiotics

Environmental factors and genetic predisposition. While cause is unknown, environmental factors and genetics have been connected

What sign would a patient with amyotrophic lateral sclerosis (ALS) probably report first? Slurred speech Frequent falls Weakened hands Difficulty swallowing

Frequent falls losing strength and coordination would lead to falls, trouble moving where they hadn't had issues before.

An appropriate intervention for patients who have impaired physical mobilities is: monitor for fever gait training strict asceptic technique isolation precautions

gait training

If the ALS patient has difficulty removing secretions, what might be indicated? assistive devices plasmaphersis gentle suctioning administration of Tensilon (edsophonium)

gentle suctioning

A ventilator is alarming "high pressure" and the patient is restless. The nurse has ensured the tubing has no kinks, what is the nurse's priority action? call respiratory therapy silence the ventilator turn the pateint to their side and strike their back to stimulate a cough remove the patient from the ventilator and start bagging them

remove the patient from the ventilator and start bagging them

A patient has been admitted to the medical unit after several days of watery diarrhea related to Crohn's disease. The healthcare provider recognizes which of the following symptoms as most concerning? Elevated hematocrit Palpitations and twitching Elevated leukocytes Right upper quadrant pain

Palpitations and twitching Twitching and Palpitations are signs that electrolytes are not within normal ranges, the other symptoms are expected.

A patient with Parkinson's disease experiences posture and gait changes. Which of the following statements best reflects how gait is affected in this disease? Patient displays limp, fidgeting movement of legs when walking Patient displays muscle rigidity and brief, jerky motor movements Tremors cause the patient's ambulation to appear spastic Patient is bedridden, ambulation is not possible

Patient displays muscle rigidity and brief, jerky motor movements

The nurse encourages the patient with multiple sclerosis (MS) that his disease appears to be the most common type, which is: Primary progressive Relapsing-progressive Secondary progressive Relapsing-remitting

Relapsing-remitting

The nurse is aware that the person with ulcerative colitis is at risk for: cancer of the colon chronic urinary infections intussusception volvulus

cancer of the colon (chronic irritation.)

Early signs and symptoms of ineffective breathing and hypoxia in the patient include: fever and rapid respirations bradycardia and lethargy dyspnea and cough tachycardia and restlessness

tachycardia and restlessness

Which statement regarding Crohn's disease would be considered true? "There is a cure with colostomy" "Pseudopolyps are found on the affected segments" "It affects the full thickness of the small intestine" "It manifests as bloody diarrhea with abdominal cramping"

"It affects the full thickness of the small intestine" UC is known more for bloody stools, crohns can affect anywhere in the intestinal tract and is full thickness through all the layers of tissue.

A nurse is reinforcing teaching with a patient who has a prescription for Infiliximab,an intravenous immunosuppressant medication . Which of the following should the nurse include in the teaching? "Notify the provider if you have an active infection or fever." "This medication may cause yellowing of the sclera" "This medication may cause your stools to turn black" "Take this medication on an empty stomach & sit upright for 30 minutes after taking"

"Notify the provider if you have an active infection or fever." Immunosuppressants put patients at greater risk of infections as they weaken the immune system.

The nurse is explaining Parkinson's disease to the student nurse. Which statement by the nurse is correct regarding the pathophysiology of the disease? "The pathophysiology of the disease is caused by the deterioration of the myelin sheath of the basal ganglia." "Excess dopamine and deficient acetylcholine are the cause of Parkinson's disease." "When the immune system attacks the dopamine receptors and prevents dopamine uptake." "Parkinson's is caused by depletion of dopamine uptake and excess of acetylcholine."

"Parkinson's is caused by depletion of dopamine uptake and excess of acetylcholine." Parkinson's is not an immune system disease, it is a decrease in dopamine uptake at the receptor sites.

The healthcare provider is teaching a patient diagnosed with Crohn's disease who is recovering from a bowel resection. Which of the following statements made by the patient indicates the teaching has been effective? "Now I can discontinue taking my multivitamin supplements." "Now that the bowel has been removed, the disease is cured." "The disease might reappear in another part of the bowel." "I might develop ulcerative colitis because some of my bowel is missing."

"The disease might reappear in another part of the bowel." bowel resection is a treatment but there is no cure to crohn's. Patient should continue to supplements as done before, ulcerative colitis is not caused by resections.

The nurse gave morphine per doctor order, what assessment data would the nurse want to collect post medication? Select all that apply 1 patient reports pain reducation 2 patient needs to urinate 3 patient complains of being hungry 4 respiratory rate of 18

1 4

Which of the following would the nurse include as a priority when planning teaching for the patient diagnosed with ALS? Advanced Directives Bowel and bladder diversions Vision protection Treatment for dyskinesia

Advanced Directives

A client diagnosed with ALS is dealing with muscle spasticity. Which of the following is most likely to be prescribed? Hydralazine Lidocaine Methylprednisolone (Solu-Medrol) Baclofen (Lioresal)

Baclofen (Lioresal)

The nurse is assessing a patient with Parkinson's disease. What does the nurse anticipate to assess in regard to tremors? Decreasing when there is voluntary movement Being absent when the body is at rest Occurring 100% of the time Characterized by a tonic and clonic muscle activity

Decreasing when there is voluntary movement when the patient is moving the tremors are not noticed. They are noticed when at rest.

A patient with Parkinson's is considering taking St. John's wort, an herbal remedy for depression, in addition to Sinemet and L-dopa. What information would be the best for the nurse to give the patient? Doses of St. John's wort and Parkinson's drugs should be taken on alternate days Depression is reduced by the use of herbal remedies such as St. John's wort Herbal remedies can interfere with the effectiveness of the Parkinson's drugs St. John's wort must be taken in large doses to reduce depression

Herbal remedies can interfere with the effectiveness of the Parkinson's drugs We always need to be aware that herbal remedies can interfere with medications.

The nurse anticipates that drug therapy for an acute severe attack of multiple sclerosis (MS) will be: Oral Muscles relaxants and opioids Massive dose of IV antibiotics IV methylprednisolone IM injections of interferon beta-1b

IV methylprednisolone Acute flareups of MS need fast decrease of inflammation and antibodies. Steroids through the IV will be the fastest and most effective

To assess the therapeutic effectiveness of an antiparkinson's drug, the nurse will observe the patient's: Decreased emotional stability Decreased caloric and nutritional intake Increased sleep patterns Increased ability to ambulate and speak

Increased ability to ambulate and speak

Why would a patient with amyotrophic lateral sclerosis (ALS) be prone to depression? Communication is altered Mobility is limited Nutritional intake is poor Intellectual capacity is not affected

Intellectual capacity is not affected

During an acute exacerbation of inflammatory bowel disease, a patient is to receive total parenteral nutrition (TPN) and lipids. Which of these interventions is the priority when caring for this patient? Change the administration set every 78 hours Monitor urine specific gravity every shift Monitor the patient's blood glucose per protocol Infuse the solution in a large peripheral vein

Monitor the patient's blood glucose per protocol Specific gravity is not checked every shift, the IV tubing set is changed every 24 hours, TPN requires a central line to infuse, Blood glucose is checked due to the high dextrose content in TPN.

In planning care for a patient with ulcerative colitis. Which intervention is most appropriate? Help the patient to list effective coping mechanisms to deal with weight loss Encourage large amounts of favorite and culturally acceptable foods Offer small frequent amounts of high protein, high-calorie food Advise the patient to exercise less and adopt a more sedentary lifestyle

Offer small frequent amounts of high protein, high-calorie food Nutrition is a priority concern with these patients, frequent high protein, high calories meals and snacks will help them maintain adequate nutrition.

A Parkinson's patient is depressed because his drug protocol of L-dopa and Sinemet are no longer controlling his symptoms. Which would be the most helpful information? A craniotomy is effective in controlling Parkinson's disease symptoms The effect of these drugs has an uneven course; symptoms will begin to subside again soon The L-dopa should be increased and Sinemet decreased Other drugs can be combined with L-dopa to increase its effectiveness

Other drugs can be combined with L-dopa to increase its effectiveness

A patient is experiencing an acute episode of ulcerative colitis. Which is priority for this patient? Replace lost fluid and sodium Restrict the dietary intake of foods high in potassium Note any change in the color and consistency of stools Monitor for increased serum glucose level from steroid therapy

Replace lost fluid and sodium during acute episodes the patient is losing large amounts of fluid and sodium. Maintaining F&E balance becomes the priority.

A patient with multiple sclerosis is seen by the home health nurse and complains of severe fatigue. What is the best suggestion by the nurse to help diminish the effects of fatigue? Scheduling rest periods during the day Including daily-dose multivitamins Relaxing in a warm bath Performing deep-breathing exercises

Scheduling rest periods during the day

The nurse is caring for a patient with a new diagnosis of Parkinson's disease. Which of the following assessment data would best describe the symptom of an individual with Parkinson's disease? Tinnitus Diplopia Headache Shuffling gait

Shuffling gait

The home health nurse caring for a patient with multiple sclerosis (MS) is planning an exercises program with the patient. Which is the best type of exercise for this patient? Weight training Progressive walking Swimming Isometric exercises

Swimming

A nursing assistant did an exceptionally good job by encouraging a resident to get out of their room and go to an activity. Select the response by the LPN charge nurse that would best encourage the NA to continue this effort. Tell the NA they are a great nursing assistant and you wish all assistants were like her. Report the NAs good efforts to the nursing home's administrator and board of directors. Write a note for the NAs file explaining the NA did not leave the resident in his room. Tell the NA you know how hard they worked to get the resident out of his room and how pleased you are that they are concerned with the resident's need for socialization.

Tell the NA you know how hard they worked to get the resident out of his room and how pleased you are that they are concerned with the resident's need for socialization.

The nurse is educating the family of a patient in the late stages of amyotrophic lateral sclerosis (ALS). What teaching point is most important for the nurse to include? The patient's cognitive and mental capacity will most likely remain intact throughout the disease progression The patient's ability to swallow will remain intact The patient's breathing should not be affected by the disease The patient's ability to move the upper limbs may be affected.

The patient's cognitive and mental capacity will most likely remain intact throughout the disease progression

The nurse is planning care for a patient with multiple sclerosis. What symptom is important for the nurse to know about that affects mobility status? Painful joints and dizziness Rigidity and spasticity Visual and perceptual problems Malnutrition and shortness of breath

Visual and perceptual problems

Which exam utilizes a radiopaque substance instilled into the colon by enema in order to detect ulceration of the intestine? barium enema esophagogastroduodenoscopy colonoscopy upper GI series

barium enema

A vent is alarming "high pressure" and the patient is restless. What is the nurses first priority? elevate the head of the bed call the doctor reconnect the ventilator tubing check the ventilator tubing for a kink

check the ventilator tubing for a kink high pressure alarms go off if there is a block in the air system either through a kink in the tubing or a blockage inside the patients airway.

Which may be prevented by frequent position changes and range of motion exercises? necrosis infection contracture hemorrhage

contracture