Hurst quiz 3/23
arthroscopy
visual examination of a joint to diagnose joint problems. perform RICE post-op Notify the primary healthcare provider of tingling in the right leg. Gradually start an exercise program to prevent scarring. Place a plastic bag over wound when showering.
systemic lupus erythmematosus (SLE) signs of a flare up
autoimmune disease where the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs. there are periods of them being ok, then they have flare ups. Warning Signs of a Flare: • Increased fatigue • Pain • Rash- butterfly rash across nose & cheecks • FEVER!! • Abdominal discomfort • Headache • Dizziness
What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia?
vitamin b12 deficiency 2. Smooth, red beefy tongue 3. Burning feeling in feet
Halo traction
Halo type bar that encircles the head screws are inserted into the outer table of the skull. The halo is attached to bed or rods that is secured to a rest Never pull on any part of the halo traction. It can damage or loosen the traction. Pin care is done to prevent infection. Clean around pins at least twice daily with sterile q-tip applicator. Use a new sterile q-tip for each pin site to decrease contamination from one pin site to another. Do not use ointments or antiseptics unless prescribed. no showers, take a sponge baths or sit in bath of 2-3 inches of water
Sjogren's (SHOW-grins) syndrome
disorder of the immune system identified by its two most common symptoms — dry eyes and a dry mouth
cystitis symptoms
inflammation of the bladder symp: 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia
Metronidazole
an antibiotic that treats vaginal infections. no alcohol while taking thus bc can interact with each other, causing severe nausea and vomiting as well as cramping and flushed appearance.
what is bruising in the left up quadrant indicative of?
a ruptured spleen and internal bleeding. This adolescent will require a CT scan, and possibly emergency surgery.
A client diagnosed with human immunodeficiency virus (HIV) is to be sent home today. The nurse has initiated discharge instructions on the proper handling of blood and body fluid at home. The nurse knows the teaching is successful when the client makes what statement?
"I should clean area with a 10% mixture of bleach and water." The proper method to clean spills of blood or body fluids at home is to use a 10% solution of household bleach, which means 9 parts of water to 1 part bleach. It is recommended to leave the bleach solution on the contaminated area for 10 to 20 minutes, and then rinse with hot water. Any towels or cloths used to clean the area should be double bagged and discarded.
A client diagnosed Alzheimer's disease has been prescribed memantine. What should the nurse teach the caregiver about this medication?
1. When beginning this medication provide ambulatory assistance. 5. If the client cannot swallow the capsule you sprinkle on applesauce.
nausea and heartburn in an elderly person is indicative of what?
M.I, nurse needs to assess for this.
why does a nurse take a blood sample from both arms of a patient with sepsis? why not just take a blood sample from 1 arm?
Sepsis/septicemia, is a serious infection in the bloodstream which can be caused by bacteria, parasites, fungi or even a virus. Blood cultures provide vital information regarding what organisms are present in the blood so the proper medication can be ordered. Standard procedure is to obtain two separate blood samples from two separate veins approximately 30 minutes apart to be certain of obtaining samples of all organisms present.
A first time mother-to-be shares with the nurse a sense of indifference towards the impending birth of the infant. The client is concerned about "being a good mother" because of current lack of interest. What response by the nurse would be most appropriate at this time?
Such feelings are not unusual for first time mothers."
Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy?
sudden weakness or paralysis on one side of the face that causes it to droop (main symptom), drooling, eye problems (such as excessive tearing or a dry eye), loss of ability to taste, pain in or behind ear, numbness in the affected side of face, increased sensitivity to sound. 1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 5. Inability to taste. 6. Numbness of affected side of face.
The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take?
.1.Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. -The nurse has the right to do this as well, but may have to accept any disciplinary action. Again documentation is critical. Why was the assignment refused?
A client with diabetes mellitus has a newly prescribed insulin pump. Which statements made by the client indicate understanding of an insulin pump?
1. "I will attach the pump to my waistband or wear it in the pocket of my pants." 3. "I may take my insulin pump off when I exercise." 4. "I need to check my blood glucose level several times a day." the catheter needs changed q3 days
The nurse is conducting a developmental screening by first gathering history information from the parent of a toddler. What information obtained by the parent would the nurse consider a risk factor for developmental problems?
1. Birthweight less than 3 pounds, 4 ounces (1.5 kg). -preterm birth <37 weeks -baby <2.3 lbs 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.
The nurse is assessing the injection site of a healthy client who received a Mantoux skin test 48 hours ago. Which finding at the injection site indicates a need for further evaluation?
16 mm induration An induration of 15 mm or greater is usually considered positive in people who have normal or mildly impaired immunity. A client with a positive reaction of 15mm or greater will need further evaluation by a primary healthcare provider.
3-month old client receiving potassium IV therapy. Which actions indicate to the charge nurse that the staff nurse understands IV management?
2. Applies elbow restraints to prevent dislodgment of the IV catheter. 3. Checks the IV site for blood return hourly bc K+ irritates the vein. 5. Attaches a volume-controlled IV administration set to IV bag prior to beginning IV therapy. -Always use a volume-controlled IV administration set with an infant or small child. These sets hold no more than 100-150 mL of fluid, so the maximum amount that could accidentally be infused is limited. Always use microdrip tubing which is a 60 gtt chamber. Microdrip chambers are used for children and for clients who can not tolerate a fast infusion rate or large volumes
A nurse is teaching a group of expectant parents about epidural anesthesia. What information should the nurse include?
2. Post procedure position should be side lying. 4. The major complication is hypotension. 5. Usually administered at 3-4 cm dilation. -there is no headache bc the needle doesn't go into spinal column, but rather the epidural space -mom can have epidural even if she's had c-sections before
A client is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The priority action by the nurse is to prepare for which procedure?
Painless, bright red vaginal bleeding is a sign of a placenta previa. Ultrasound can confirm this diagnosis with minimal risk to the mother and her fetus.
rheumatoid arthritis
a system inflammatory response that affects joint, cardiovasc, and respiratory system. symptoms: painful joint stiff for 30 min after waking up severe fatigue fever also affects eyes, skin, mouth blood vessels
The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment?
preschoolers need 11-13 hrs of sleep. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?
what should an LPN do if the nurse asks her to do a intervention out of their scope of practice?
refuse the intervention, no questions asked
