Health Deviations Final Exam

administering kayexelate enema

must be done by RN. LPN can do cleansing enema before and after. If given PO,

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations?

oliguria tachypnea tachycardia hypotension

empyema

pus in the pleural cavity tx - 4 to 6wks of strong antibiotics

parietal lobe functions

sensation, body position

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

stroke and cardiac arrest

Dysphagia indicates damage to which lobe of the brain?

temporal

potassium IV infusion rate

cant exceed 10-20mEq/hr

normal magnesium level

1.5-2.5

normal urine output

1.5L/day or 60mL/hr

Normal serum osmolality

275-300

normal hematocrit

35-50%

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated.

5% DW

DASH diet

high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein.

frontal lobe functions

high level cognition, voluntary muscle movement, personality, Broca's area (speech)

COPD complications

ARDS atelectasis hypercapnia cor pulmonale (R ventricle enlargement - distended neck veins, BLE edema, enlarged liver, ascites, pleural effusion, heart murmur)

r sided stroke s/s

Altered perception of deficits (poor insight) Unilateral neglect (ignore the L side of body; can't see it or feel it, so it's "not there" Loss of depth perception Poor impulse control and judgement L-sided hemiplegia or hemiparesis L-side visual deficits; hemianopsia (loss of visual field) impaired short term memory distractability

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

Assessing the client's respiratory status, orientation, and skin color

A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid?

hypertonic fluids

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees (minimize risk of aspiration)

A client with a magnesium concentration of 2.6 mEq/L (1.3 mmol/L) is being treated on a medical-surgical unit. Which treatment should the nurse anticipate will be used?

IV furosemide to enhance excretion of magnesium

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke?

Intracerebral hemorrhage

considerations when giving IV potassium

NEVER given IV push Check renal function watch for arrhythmias watch for infiltration

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.

National Institutes of Health Stroke Scale (NIHSS) score LOC at time of admission Age

A patient diagnosed with multiple sclerosis (MS) has ataxia. Which medications could be used to treat this clinical manifestation?

Neurontin beta blockers antiepileptics benzos

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Offer a prescribed antiemetic medication.

cognitive deficits caused by stroke

Poor abstract reasoning Decreased attention span Short- and long-term memory loss

A nursing student understands that emphysema is directly related to which of the following

Respiratory acidosis from airway obstruction

Purpose of having a pneumonia pt cough sputum into a cup?

To see which antibiotics will be effective (not to assess characteristics of sputum!)

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way?

Weakness starting in the muscles supplied by the cranial nerves

antidote for magnesium overdose

calcium gluconate

administering albumin

blood product must be administered by RN (LPN can monitor after started) Monitor BP and for s/s of FVE

earliest signs of deterioration in neuro status

change in behavior and LOC

diseases related to etiology of COPD

chronic bronchitis and emphysema

drug that can increase risk of stroke

cocaine (vasoconstricting effect)

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

confusion

which cranial nerve is tested for PERRLA?

cranial nerve 3, 4, and 6

Ischemia compensatory mechanism for someone w/ occlusion/stroke

high BP. Want to bring it down slowly so that it doesnt stop blood flow to brain

Early sign of third spacing

decreased output despite adequate intake

A client with a history of mitral stenosis is admitted to the intensive care unit (ICU) with the abrupt onset of atrial fibrillation. The client's heart rate ranges from 120 to 140 bpm. The nurse recognizes that interventions are implemented to prevent the development of

embolic stroke

left sided stroke s/s

expressive/receptive aphasia Agnosia (unable to recognize objects) Alexia (difficulty reading) Agraphia (difficulty writing) R-side hemiplegia (paralysis) or hemiparesis (weakness) R-side visual deficits; hemianopsia (visual field loss) Depression, anger, frustration

Which of the cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear?

facial

Which is often the most disabling clinical manifestation of multiple sclerosis?

fatigue

A nurse is assessing a client with heart failure. What breath sound is commonly auscultated in clients with heart failure?

fine crackles

A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. Which electrolyte imbalance is consistent with these findings?

hypomagnesemia

oxygen toxicity s/s

hypoventilation substernal chest pain N/V, fatigue, HA sore throat, nasal stuffiness dyspnea

temporal lobe functions

memory of sound and language, hearing

why would a COPD pt be given narcotics?

vasodilatory effect, decreases workload of breathing (not getting it for pain)

occipital lobe function

vision, memory

vitamin supplements for COPD pt

vit C, magnesium, calcium

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

wheezes with wet lung sounds