Hurst quiz /answers

An elderly client diagnosed with Alzheimer's disease has become combative, restless and wanders at night. What medication is best?

Haloperidol -mild antipsychotic used to treat either mental or mood disorders, including uncontrollable movements and emotional outbursts. This drug is relatively safe for elderly clients and can be used at bedtime to enhance rest.

denture care

Hot water can make denture material sticky. Cool water should be used. Standard precautions are to don gloves anytime coming into contact with body fluids. The gauze helps to grip the dentures. Moistening dry dentures help with insertion. do not Wrap dentures in tissue may cause them to be accidently thrown away. A towel needs to be placed in the sink prior cleaning to prevent damage to the dentures if they are dropped.

what lab should be checked often when dealing with HTN, why?

Hypertension is one of the leading causes of end stage renal disease. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications.

at what level does vital lung capacity have to be before warranting mechanical ventilation?

If the vital lung capacity drops below 800 mL, mechanical ventilation is warranted. respiratory distress: HR >120 or <70, RR>30

how do we know if an appendix has ruptured?

Increasing pain and rigid, board-like abdomen are signs that the appendix may have ruptured, with resulting peritonitis developing.

The client is noted to have a blood glucose level of 390 mg/dL, what insulin should you give?

Insulin Aspart (rapid acting insulin) in order to get the blood sugar down fast. it kicks in within 15 minutes

NPH insulin

Intermediate-acting insulin Onset: 2-4hr, peak: 6-12 hr, 16-20 hr

A client on a surgical unit frequently quarrels with the staff. Which nursing intervention should the charge nurse implement?

Involve

A child diagnosed with acute lymphocytic leukemia (ALL) is receiving vincristine sulfate during the induction phase of chemotherapy. What client side effect should the nurse report immediately to the primary healthcare provider?

Paresthesia This is an uncommon but serious reaction to chemotherapy. The abnormal tingling or pins and needles sensation is caused by pressure or damage to peripheral nerves. Immediately notify the primary healthcare provider of this critical side effect of vincristine therapy.

What interventions should the nurse initiate while caring for a client who has a cooling blanket in place?

Perform comparison check with another thermometer periodically. Assess client skin condition hourly. Observe for signs of chilling. Perform comparison check with another thermometer periodically to ensure there is no problem associated with equipment failure. For cooling treatments, extended periods of cooling can cause areas of decreased perfusion, skin burns, and tissue injury. Chilling can increase metabolism and body needs.

how should one walk with a cane?

Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time.

A client has arrived at the emergency room reporting tingling to both lower legs over the past 24 hours. The only significant health history is a cold for the past week. During the nursing assessment, the client indicates that both thighs are feeling numb. What priority action should the nurse initiate immediately?

Prepare for intubation. The symptoms reported by this client indicate the onset of Guillian-Barre syndrome, an acute inflammatory disease that may occur following a respiratory illness and is characterized by progressive, ascending paralysis. The extent of paralysis varies by client, but airway is always the greatest concern. Because the client's lack of sensation is progressing, the nurse should anticipate the health care provider may need to immediately intubate to protect the airway.

Hoe to you treat/prevent foot fungi/athletes foot?

Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. Wash feet daily with soap and water. Wear shower sandals when showering in public places. Wear shoes that allow the feet to breathe. NO CORNSTARCH on feet bc it is carb that the fungus can feed on

Following a thyroidectomy, a client reports shortness of breath and neck pressure. Which nursing action is the best response?

Remove the dressing and elevate the head of bed. stay with the client.

A right-handed client's intravenous (IV) infusion has infiltrated at the client's left dorsal metacarpal vein. The nurse would initially assess which vein to start another intravenous infusion?

The cephalic vein is located on the dorsal aspect of the hand and forearm. Since the infiltrated IV was located in the dorsal metacarpal vein, the next vein proximal to the metacarpal vein is the cephalic vein. The cephalic vein is located on the forearm, which is easily accessed and a stable location for an IV.

A client arrives by ambulance after being thrown from a horse. The client is pale, clammy and tachycardic with bruising over left upper abdominal quadrant. The nurse is aware what prescription by the primary healthcare provider takes priority?

The signs and symptoms displayed by the client suggest a ruptured spleen and shock. The greatest concern in this situation is internal bleeding and possible emergency surgery. The client will need blood; therefore, the nurse should immediately obtain blood for type and cross match.

One hour after administering pyridostigmine, the nurse notes increased salivation, lacrimation, and urination in the client. What initial action should the nurse take?

These are signs and symptoms of cholinergic crisis. The client can get increasingly worse. The primary healthcare provider can prescribe atropine as treatment of overdose.

The parents of a 4 year old child have recently had a new baby and the parents report that the 4 year old had been dry all night for 8 months and is now wetting the bed again. What should the nurse assess first?

Urinalysis Always assess the physiologic problem first to rule out a urinary tract infection (UTI). Once a physiologic cause is removed as the cause other assessment should be performed. If a UTI is present, treatment should start immediately. Adjustment to the new baby (regression) could be the cause but address physiological symptoms first.

myasthenia gravis

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles they must take their medication ON TIME, not early (leads to weak muscles), not late (leads to aspiration)

petussis what vaccine is used to prevent it?

acute infectious disease (whoop) Whooping cough) DPaT should be given at 2, 4, and 6 months of age

Who needs to eat a low-residue diet? why? what are some low-residue foods?

anyone with Crohn's Disease, diverticulitis or Ulcerative Colitis. goal of diet: decrease fiber in order to limit bowel peristalsis while still including nutritional elements for clients. Cooked oatmeal or pasta are both good choices bc both hav soluble fiber which absorbs water and passes through GI tract more slowly Cantaloupe- good choice, since it is a great source of nutrients but has little pulp.

new admit

are priority and considered unstable UNTIL the nurse assesses them.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider?

breathlessness

Negligence

careless neglect, often resulting in injury

what canned food should ppl with celiac stay away from

cream based canned soups bc they hide wheat in it.

what can longterm steroid use lead to?

decreases serum calcium, so the body takes calcium from the bone and puts it in the blood in order to bring the serum calcium back to a normal level. Every time a steroid is given, calcium is removed from the bone, thus leading to a greater risk for osteoporosis and fractures.

symptoms of anorexia

depression amenorhhea brittle, dry nails low BP they wear baggy clothes

signs of major depression

difficult focusing short tempered hand wringing- fidgeting with your hands

what should a nurse do for a 5 year old client with moderate pain ?

distract them with a book or turning on the TV. Heat pack/cold compress also works -kids 5-8yrs old can rate their pain but their unable to describe it

who is at highest risk for suicide?

elderly men (ex. 80 man with suicidal thoughts)

what does nurse do if client is manic and causing a distraction?

give them something purposeful to do. Purposeful activities help the client use energy and focus on something. Distractibility is the nurse's most effective tool.

Which signs/symptoms should the nurse monitor for in a client admitted with a diagnosis of pheochromocytoma?

hyperglycemia hypermetabolism HTN headache profuse sweating palpitation tachycardia caused by increased boluses of epi/norepinephrine

A client becomes progressively cyanotic and unresponsive post central line insertion. Which action should the nurse take?

immediately place the client in the left side-lying position with the client's head down. This position will trap a bubble in the right ventricle preventing it from passing into the pulmonary circulation.

Cholecystitis

inflammation of the gallbladder; usually associated with gallstones gallstones block the cystic duct or common bile duct--> bilde backing into the gallbladder causing inflammation.

Bacterial Meningitis s/s

inflammation of the protective membranes covering the brain and spinal cord caused by various types of bacteria 1. Positive Kernig's sign 2. Positive Brudzinski's sign 4. Photophobia 5. Severe headache 6. Nuchal rigidity Brudzinski's sign is the involuntary lifting of the legs when the neck is passively flexed (head is lifted off the examining surface). Kernig's sign is positive when the thigh is bent at the hip and knee at 90 degree angles and attempts to extend the knee are painful, resulting in resistance. Both of these signs are thought to indicate meningeal irritation. These seem to be caused when the motor roots become irritated as they pass through inflamed meninges, and the roots are brought under tension. Photophobia (sensitivity to bright light), severe, unrelenting headache, and nuchal rigidity (stiff neck) are all believed to be due to irritation of the meninges.

What situation would require social service to be involved?

ingestion of toxic substances (bleach), fractures, suspected neglect or abuse, burns.

Insulin Aspart

is a rapid-acting insulin and starts to work within 15 minutes after given subcutaneously.

What does increased ammonia in the body do? What is one medication that can rid the body of ammonia?

leads to Neurologic deterioration in clients with cirrhosis. The ammonia goes to the brain, causes brain deterioration. lactulose, helps rid the body of ammonia, by causing you to poop more.

Insulin Glargine or Detemir

long-acting insulin no peak time

Cholecystitis teaching

low fat diet avoid gas causing foods lose weight if needed

Assault

physical attack

The nurse is assessing a client admitted with acute gastritis. Which client information is most significant?

pt takes Ibuprofen for arthritic pain. This is bad bc Ibuprofen is an (NSAID). NSAIDs are highly associated with GI irritation. **don't choose Spicy foods. They may not be tolerated by clients with gastritis, but spicy foods have not been linked to causing gastritis.

Cholecystitis symptoms

right upper quadrant pain that can radiate to the R. shoulder pain, n/v when consuming high fat foods Jaundice clay-colored stools Steatorrhea purritis - itchy skin dyspepsia- indigestion + gas increased WBC Increased Bilirubin (>1)

The nurse is caring for a client taking digoxin. Which electrolyte imbalance should be of most concern?

serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity could occur.

Cholinergic Crisis

stems from Too much medication N&V, diarrhea, cramps hypotension Tensilon to distinguish from Myasthenia Crisis Atropine to reverse Respiratory support may be needed Anticholinesterase drugs are aimed at enhancing function of the neuromuscular junction. Acetylcholinesterase is the enzyme that breaks down acetylcholine. Thus inhibition of this enzyme by an anticholinesterase inhibitor will prolong the action of acetylcholine and facilitate transmission of impulses at the neuromuscular junction. Pyridostigmine is the most successful drug of this group in long-term treatment of myasthenia gravis. Cholinergic crisis happens when too much cholinergic medications are taken and, if not treated accordingly, respiratory failure and hypotension might happen. When cholinergic crisis takes place, the muscles cannot react to the inflow of acetylcholine so symptoms usually follow. Symptoms may include salivation, lacrimation, urination, and defecation. Failure of the respiratory system occurs due to the insufficient gas exchange. Flaccid paralysis, too much sweating, bronchial secretions, and miosis develop.

The charge nurse overhears the nurse giving her number to her pt right before discharge what should the charge nurse do?

the charge nurse should interrupt the process and continue with the discharge procedure. Then the nurse should be counseled immediately so that further inappropriate behavior does not occur.

Insulin Regular

this is a short acting insulin takes 30 minutes - 1 hour to work

The nurse is caring for a client who receives hemodialysis three times a week. What dietary education should the nurse provide for this client?

. Increase protein intake - Protein can help maintain blood protein levels and improve health.2. Restrict fluids Decrease sodium - helps control bP and reduce weight Increase phosphorus Decrease potassium

how long does it take for SSRI's to take effect?

1-3 weeks

The nurse manager is developing a new yearly evaluation form for the staff. What statement(s) by the nurse manager would most likely improve staff outcomes?

1. "How often do you need help to finish assignments?" NO, this is talking down on them 2. "Are there any new skills you feel capable to learn?" NO- this is negatively worded 3. "Describe how you organize your daily assignments." YES 4. "Which tasks are most difficult for you to complete?" NO, this is not positive "Explain any new goals you would like to achieve." YES

The nurse is examining a client in the emergency department who is suspected of having acute cholecystitis? What data obtained by the nurse would help to validate this problem?

1. Abdominal guarding 2. Anorexia 3. Positive murphy's sign 5. Steady epigastric pain

A pediatric nurse is teaching a group of new parents about what to expect regarding their infants eyes and vision. What points should the nurse include?

1. At 4 weeks of age, the infant should be able to gaze at objects. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age.

What food should the nurse include when teaching an older adult about increasing vitamin B12 intake?

1. Calf liver 2. Feta cheese 4. Shrimp 5. Tuna

What vaccination is recommended for children to receive at 6 months

1. Diphtheria 2. Hib 3. Influenza MMR is given at 12-18 months and ask if baby is allergic to gelatin

What medications should the nurse anticipate the primary healthcare provider prescribing for the client with portal hypertension and bleeding esophageal varices associated with advanced cirrhosis?

1. Oxygen 3. Propranolol 4. Vitamin K 5. Lactulose We know that they need oxygen because they may have been bleeding. Propranolol acts to reduce portal venous pressure and reduce esophageal varices bleeding. Vitamin K is a clotting factor and helps to correct clotting abnormalities because of the damaged liver. Lactulose decreases what? Ammonia, which is elevated with cirrhosis.

What tasks can be delegated to LPN? what cant an LPN do?

1. Take initial vital signs. 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia. LPN cant do: 2. Measure cervical dilation bc its an invasive procedure 3. Check fundal height and fetal heart rate (FHR) bc this is an assessment of fetal well being. nurse must do this.

Which health promotion instructions should the nurse provide to a client diagnosed with cirrhosis?

1. Use a shower chair when performing hygiene. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene. NO ALCOHOL for this person bc cirrhosis is causes by chronic alcoholism

How many hours should a 2-5 yr old sleep? How many oz of juice should a 2-5 yr old have?

11-12 hrs of sleep 4-6 oz

Parkinson's disease

A disorder of the central nervous system that affects movement, often including tremors.

A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client?

A private room on the gynocological unit. **don't choose private room on postpartum floor bc it can be too difficult for mother to be on a unit with other babies.

Libel

A written defamation of a person's character, reputation, business, or property rights.

A client was admitted to the medical unit after an acute stroke. Which nursing activity can the registered nurse delegate to the LPN/VN? You answered this question Incorrectly 1. Screen client for contraindications for tissue plasminogen activator (tPA) therapy. 2. Place seizure precaution equipment in client's room. 3. Perform passive range of motion (ROM) exercises. 4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours.

Administer enoxaparin 1 mg/kg subcutaneously every 12 hours. 1. RNs job 2 &3 can be done by UAP

valvular heart disease s/s

Any disease process involving the heart valves Orthopnea- breathlessness in the recumbent position, relieved by sitting or standing. So if my valves are messed up, this can put a strain on the heart. There may be an increase in pressure behind the affected valve. This back pressure can cause blood and fluid to build up in the lungs or lower part of the body (depending on which valve is affected). If it backs up to the lungs we see respiratory problems like orthopnea. paroxysmal nocturnal dyspnea - attacks of severe shortness of breath and coughing that generally occur at night. Fluid is backing up into the lungs again.

Which tasks can the RN delegate to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke and is being rehabilitated?

Assist the client using a walker. Calculating the intake and output. Encourage and assist the client with the use of a hairbrush on the affected side.

"I wanted to take the car to work, but the train station took all the tracks. Driving is the ticket when you want to go to the movies. No one needs money in heaven. We have money in our foods." How should the nurse document this conversation?

Associative looseness-speech in which ideas shift from one unrelated subject to another in an unrelated manner

Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority?

Avoid dropping the medication directly on the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems if meds were dropped onto the cornea.

Which medication does the nurse expect will help decrease tremors in a client diagnosed with hyperthyroidism?

Beta blockers help anxiety and tremors. Beta blockers reduce the effects of adrenaline in the body and help decrease anxiety. Beta blockers block these receptors. They stop various organs in the body from accepting adrenaline.

A nurse has received morning report on multiple clients. What client should the nurse assess first?

Client on heparin drip reporting bleeding gums when brushing teeth. Bleeding gums sometimes occurs in those who brush teeth too vigorously; however, bleeding in a client on a heparin drip could indicate a serious side effect. This client should be seen immediately.

Which victim would the nurse decontaminate first in a biological terrorist event?

Exposed victims with no symptoms are first priority

Which assessment finding by the nurse is most indicative of fluid volume overload?

FIRST:Client has pitting edema in lower extremities. 2ND: weight gain of 2 lbs