Mrs. Harrington portion of final
What is the preoperative ostomy care?
(Wound ostomy continence nurse will Mark the site and provide Emotional, physical support) Teaching, Bowel prep, and Antibiotics
What is ammonia?
A by-product of protein catabolism. Normal range: 15-60 mcg/dL abnormal findings: ↑ in cirrhosis and hepatitis
What is the Rosenbaum card?**
A handheld visual acuity chart measures near acuity. (to smell a rose you have to hold it to your nose) The handheld visual acuity chart is held by the patient 14 inches from the eyes to read the letters.
What is the brachialis?
A muscle in the upper arm deep to biceps brachii that originates on the humerus and inserts into the proximal end of the ulna
What are the normal results of the Romberg test?
Able to maintain standing position without loss of balance
What is decorticate posturing?
Abnormal flexion: Hands pulled to chest and hyper-extended. Internal rotation and adduction of the arms with flexion of the elbows, wrists & fingers. "flexor - toward the cord" (cord up and hands to defend)
A patient is admitted with chronic gastritis type B. Which of the following signs and symptoms would the nurse anticipate finding? 1. Anorexia 2. Dysphagia 3. Diarrhea 4. Feeling of fullness
Anorexia
What are the therapeutic interventions and nursing care for eye trauma?
Antibiotic ointment, Surgery, and Enucleation (Entire eyeball removal)
What is an x-ray?
Bones appear as white areas
Which type of gastritis is Difficulty in absorbing vitamin B12 associated with?
Chronic gastritis type A
Which type of gastritis can be treated with antibiotics associated with?
Chronic gastritis type B
Which type of gastritis is Bacteria Helicobacter pylori associated with?
Chronic gastritis type B
What is mastoiditis?
Complication of otitis media
What is Hyperopia?
Farsightedness
What are the diagnostic tests for Guillain-Barre syndrome?
Lumbar puncture with CSF analysis, EMG, Nerve conduction velocity, and Pulmonary function testing
What symptoms of stroke did Amanda's grandpa exhibit? What are other signs of stroke to be aware of?
Max exhibited right-sided weakness and difficulty speaking; additional symptoms might include dizziness, head pain, confusion, and vision changes. In women, nausea, face or limb pain, chest pain, shortness of breath, hiccups, or palpitations can occur.
The nurse is caring for a patient with suspected appendicitis. Mark the area where the pain (a classic symptom of appendicitis) localizes.
McBurney's point (between the right ileac crest and the belly button)
How was placement of the feeding tube verified?
Measured the length of the tube and compared it to insertion measurement that was verified with x-ray.
What are some causes of constipation?
Medications, Hemorrhoids or fissures, and Low intake of fiber and fluids
What is the etiology of IBS?
More common in women, HEREDITARY**, and Bowel nerves more sensitive
Symptoms of multiple sclerosis are caused by damage to which structure(s)? 1.Hypothalamus 2.Cerebral cortex 3.Cholinergic receptors 4.Myelin sheath
Myelin sheath
What is Diverticulosis?
Outpouchings in colon
The nurse is caring for a patient after an appendectomy. Which of the following interventions should the nurse include in the patient's plan of care to prevent respiratory complications? Select all that apply. 1. Pain control 2. Early ambulation 3. Bedrest 4. Coughing and deep breathing 5. Incentive spirometer
Pain control, Early ambulation, Coughing and deep breathing, and Incentive spirometer
What are the s/s of a herniated disk?
Pain, Muscle spasm, Numbness or tingling of extremity, Weakness, and Atrophy
What is the nursing care for bone cancer?
Postoperative care (Ex. wound care and dressing care) and Supportive care
What is barotrauma?
Pressure in the middle ear caused by atmospheric changes
What is the pathophysiology of an abdominal hernia?**
Protrusion of organ or structure through weakness or tear in wall of abdomen
What are warning signs of stroke? Select all that apply. 1.Sudden severe headache 2.Sudden dizziness 3.Sudden dyspnea 4.Sudden muscle spasticity 5.Sudden numbness on one side
Sudden severe headache and Sudden numbness on one side
What are the general s/s of absorption disorders?
Weight loss, Weakness, and General malaise
What is indicative of a bowel obstruction?
a high-pitched tinkling sound that is proximal to the obstruction and absent distal to the obstruction may be heard.
Is Serum glucose more than 150 mg normal or abnormal for the pancreas?
abnormal
How long is the ileum?
about 11 feet in length.
What is the nursing diagnosis for GERD?
acute pain
Which bones are effected with osteoporosis?**
all bones (systemic)
What is synarthrosis?
an immovable joint (most facial bones have this)
What is the central canal?
carries cerebrospinal fluid through the spinal cord
What is acute/chronic pain a nursing diagnosis for?
central nervous system infections and traumatic brain injury
What is the second largest region of the brain?
cerebellum
What is the largest portion of the brain?
cerebrum
Is diminished triceps reflex a symptom of lumbar or cervical spine dysfunction?
cervical
Difficulty swallowing is called ________________.
dysphagia
What are the phalanges?
fingers, toes
What are secondary headaches?
head and/or neck trauma, infection, and other
What is the best way to get build up off after removal of a cast?
lotions, warm soaks (if the doctor has allowed them to bath), or showers (do not scrub the skin)
What is the postprocedure care for a lumbar puncture/spinal tap?
maintain flat bedrest for 6-8 hours as ordered by HCP, encourage fluids, monitor the puncture site (Ex. for leaks), and monitor movement, sensation, and presence of headache
What does decreased postural stability as we age result in?
more accidents and falls
How do the thoracic vertebrae curve?
outward
Excessive fat in the stools. _____
steatorrhea
What is the synovial membrane?
this moist, slippery membrane lines the inside of the joint capsule, where it secretes synovial fluid
What is otomy?
to open
The nurse is explaining ear care to a patient. Which patient statement would indicate the need for further teaching of ear care? Select all that apply. 1."The ear must be manually cleaned." 2."Cotton swabs can be inserted into ear." 3."Earplugs can be used for swimming." 4."With a cold blow nose with one nare closed." 5."Use an ear dryer after frequent swimming." 6."Avoid swimming in contaminated water."
"The ear must be manually cleaned.", "Cotton swabs can be inserted into ear.", and "With a cold blow nose with one nare closed.",
What is done if an external fixation is draining a lot?
(you probably have an infection) a C&S will be done)
What is the brachioradialis?
A muscle that originates on the lateral supracondylar ridge of the humerus and inserts into the distal styloid process of radius
What is an avulsion fracture?
A piece of bone is torn away from the main bone while still attached to a ligament or tendon.
Which of the following settings is most therapeutic for an agitated patient with a head injury? 1. A day room with family visitors and a variety of caregivers 2. A semiprivate room with one or two consistent caregivers 3. A ward with other patients who have head injuries and volunteers to assist with needs 4. A hallway near the nurse's station with adequate sensory stimulation
A semiprivate room with one or two consistent caregivers
What is a T-tube?
A surgical drain ensuring bile drains freely from the gallbladder after surgery
What is alanine aminotransferase (ALT)?
ALT is an enzyme made in the liver. Normal findings 13 months to 60 years: Male 19-36 units/L; Female 24-36 units/L 61 to 90 years: Male 13-40 units/L; Female 10-28 units/L Older than 90: Male 6-38 units/L; Female 5-24 units/L abnormal findings: ↑ with chronic liver damage and hepatitis
What are some medications that can exacerbate myasthenia gravis (aka do not take)?**
ANTIBIOTICS (some), alpha interferon, ANTICHOLINERGIC AGENTS, BETA BLOCKERS, Botulism toxin, CALCIUM CHANNEL BLOCKERS, chloroquine, LITHIUM, MAGNESIUM, NEUROMUSCULAR BLOCKING AGENTS (such as those used during surgery), penicillamine, PREDNISONE, procainamide, quinidine
What are the nursing diagnoses for rheumatoid arthritis?
Acute Pain, Disturbed Body Image, Fatigue, Self-Care Deficit (Bathing, Dressing, Feeding, Toileting), and Impaired Physical Mobility
What are the nursing diagnoses for acute and chronic pancreatitis?
Acute Pain, Imbalanced Nutrition, Ineffective Breathing Pattern, and Risk for Injury
What are the nursing diagnoses for intestinal obstruction?
Acute Pain, Risk for Deficient Fluid Volume, Risk for Electrolyte Imbalance, and Risk for Dysfunctional Gastrointestinal Motility
What are the nursing diagnoses for infection and/or inflammation of the eye?
Acute Pain, Risk for Injury, and Deficient Knowledge
What is presbycusis?**
Aging process causes Degeneration of organ of Corti and Inability to decipher high-frequency sounds
What are the synovial joints?
All freely movable joints (diarthroses) are this Many of these joints also have bursae (small sacs of synovial fluid between the joint and structures that cross over the joint). Bursae lessen wear in areas of friction.
What serum lab value is elevated, which contributes to HE?
Ammonia level.
WHat is involved in daily screening for macular degeneration?
Amsler grid
________________ is the term that describes unequal pupils.
Anisocoria
What are the s/s of chronic gastritis type B?
Anorexia, heartburn, belching, sour taste, and nausea/vomiting
What are the therapeutic interventions for hiatal hernia?
Antacids, Small meals, No reclining 1 hour after eating, Raise head of bed 6 to 12 inches, and Avoid Eating 3 hours before bedtime, Spicy foods, Alcohol, caffeine, and Smoking
What is the treatment for chronic gastritis type B?
Antibiotics
What are the therapeutic interventions for otitis media?
Antibiotics and Myringotomy (During this procedure, an incision is made in the tympanic membrane, and fluid drains out or is suctioned out of the middle ear.)
What are the therapeutic interventions for meningitis?
Antibiotics, Antipyretics, Cooling blanket as needed, Dark, quiet environment, Analgesics (Ex. Codeine products, Corticosteroids, and Antiemetics (*Droplet isolation if bacterial*)
What are the therapeutic interventions for peptic ulcer disease?
Antibiotics, PPI's, H2-receptor antagonists, Bismuth subsalicylate, Sucralfate (Carafate), and Antacids (temporary solution)
The nurse would include which of these medications in the teaching plan for peptic ulcer management? Select all that apply. 1.Antibiotics 2.Proton pump inhibitors 3.Histamine-2 receptor antagonists 4.Calcium channel blockers 5.Bismuth subsalicylate
Antibiotics, Proton pump inhibitors, Histamine-2 receptor antagonists and Bismuth subsalicylate
What is gingivitis?
As people get older, the gingivae have a greater tendency to bleed, a condition known as gingivitis. If the supporting tissues in the sockets of the teeth become inflamed, bone loss occurs, resulting in a condition known as periodontitis (pyorrhea). Periodontitis can lead to tooth mobility or loss. Good oral hygiene habits cannot be overemphasized in the prevention of gum disease. Flossing every day is very important. If the patient is unable to floss because of arthritis or other conditions, an electric toothbrush or a Waterpik device is helpful in providing oral hygiene.
A patient who is newly diagnosed with amyotrophic lateral sclerosis says to the nurse, "I do not want to be kept alive on machines." Which nursing action is best in response? 1. Ask the patient whether advance directives have been prepared and provide information if indicated. 2. Reassure the patient that decisions about machines will not have to be made for a long time. 3. Inform the patient that individuals with amyotrophic lateral sclerosis are not candidates for artificial ventilation. 4. Explain to the patient that a ventilator will be necessary to maintain respiratory function as the disease progresses.
Ask the patient whether advance directives have been prepared and provide information if indicated.
What effect of Ménière disease did Jan experience that can be a safety concern?
Balance
The nurse is collecting data for a patient who develops jaundice and dark-colored urine. The nurse recognizes that which of the following is most likely the cause of these clinical manifestations? 1. Encephalopathy 2. Pancreatitis 3. Bile duct obstruction 4. Cholecystitis
Bile duct obstruction
What is the mode of transmission for Hepatitis C?
Blood transfusions, IV drug use. Rarer: unprotected sex.
What is the nursing care for a fracture?
Cast, traction, pin care (Palming wet cast), Pain management, Neurovascular checks (VERY IMPROTANT), Skin care, Nutrition, Self-care deficits, and Psychosocial (Ex. might be destressed bc they can't work)
What is a Pathological (also called neoplastic) fracture?
Caused when bone is weakened either by pressure from a tumor or an actual tumor within the bone.
Which type of gastritis is Autoimmune gastritis associated with?
Chronic gastritis type A
In planning care for a 75-year-old patient, the nurse recognizes that which of these can affect safety? Select all that apply. 1.Decreased elasticity of lens: Presbyopia 2.Decreased depth perception 3.Decreased pupil size 4.Difficult night vision 5.Sensitivity to glare 6.Sees yellow, orange, red hues clearly
Decreased depth perception, Difficult night vision, and Sensitivity to glare
When collecting data on a patient's external ear, the nurse palpates a small protrusion of the helix called the Darwin tubercle. What action would the nurse take for this finding? 1. Document it, as it is a normal finding. 2. Report it to the registered nurse, as it is an abnormal finding. 3. Report it to the health care provider immediately, as it is a serious finding. 4. Inform the patient that further testing for this finding will need to be ordered.
Document it, as it is a normal finding.
To protect from aspiration, what intervention should be carried out first following a stroke? 1.Sit patient upright for meals. 2.Have a swallowing evaluation done. 3.Avoid use of straws. 4.Use a thickener for liquids.
Have a swallowing evaluation done.
What are the therapeutic interventions for otosclerosis?
Hearing aids, Ossiculoplasty, and Stapedectomy
What subjective data is collected about the musculoskeletal system?
History (including Injury, Occupation, Family history, and Nutritional history) and Psychosocial (aka Deformities affect body image)
What are the diagnostic tests for trigeminal neuralgia?
History and physical, Computed tomography (CT) scan, and MRI
What are the diagnostic tests for Bell Palsy?
History and physical, EMG, and Rule out stroke
What are the diagnostic tests for IBS?
History, Physical examination, Stool specimen, Colonoscopy, and IBSchek: Antibody test (IBSchek is a new antibody test that identifies IBS cases that have developed two antibodies in response to exposure to a bacterial toxin found in food poisoning that results in watery diarrhea)
What are the diagnostic tests for Parkinson disease?
History, Physical examination, and M R I
Why is it important for Jack to direct his own care?
Jack has very little control over his environment or care;allowing him to direct his care not only allows some autonomy and self-esteem but is also helpful to a newstudent!
What complications is Jack at risk for due to his quadriplegia?
Jack is at risk for skin breakdown (which he already has), infection (respiratory, urinary, wound), deep veinthrombosis (DVT), orthostatic hypotension, renal complications, depression, substance abuse, and autonomic dysreflexia.
Which of the following actions should the nurse take to help prevent increased intracranial pressure in a patient following a traumatic brain injury? 1. Cluster care so the patient can have long periods of rest. 2. Keep the head of the bed elevated at 30 degrees. 3. Suction frequently to keep the airway clear. 4. Do not give anything by mouth.
Keep the head of the bed elevated at 30 degrees.
What are the therapeutic interventions for GERD?
Lifestyle changes, Medications (Antacids Histamine-2/H 2 receptor antagonists, Proton pump inhibitors (P P I's)) Transoral incisionless fundoplication (T I F) (Esophy X), Endoscopic procedures (Radiofrequency waves), and Fundoplication
What symptoms did Mrs. Kirk have during GI bleeding?
Light-headed and seeing spots.
What is Asterixis?
Liver flap
Which meal would be the best choice for a patient with myasthenia gravis? 1. Baked chicken sandwich, fresh carrots, apple 2. Meatloaf, mashed potatoes, canned green beans 3. Steak, baked potato, green salad 4. Tacos, fresh vegetables, sliced peaches
Meatloaf, mashed potatoes, canned green beans
What should be done for a pt with incontinence?
Monitor for incontinence, Determine usual elimination patterns, Provide assistance with toileting schedule, and Respond quickly to requests for help.
What is the postoperative care to prevent bleeding after a total hip replacement?
Monitor incision and Drainage from drain if present•
A home health care nurse is developing a plan of care designed to prevent complications in a patient with impaired respiratory function secondary to a neurological disorder. Which of the following would the nurse include in the plan? Select all that apply. 1. Monitor oxygen saturation and respiratory rate and depth. 2. Elevate the head of the bed. 3. Maintain patient on bedrest. 4. Suction every 4 hours. 5. Encourage patient to deep breathe and cough every 2 hours.
Monitor oxygen saturation and respiratory rate and depth, Elevate the head of the bed, and Encourage patient to deep breathe and cough every 2 hours.
What is the hinge?
Movement in one plane
What is optical coherence tomography?
Optical coherence tomography takes a picture of the retina. Light beams are shone into the eye at various angles.
What is used to treat Herpes simplex type 1 (cold sores)?
Oral acyclovir reduces occurrences*** (prophylactic measure)
What is the nursing care for osteoporosis?
Pain relief, Symptom management, Education (such as Prevention, Diet of Increase calcium and vitamin D, Exercise, and Medication) and Fall prevention
What is Bilirubin?
Pigment from the breakdown of hemoglobin in red blood cells
What is a stoma?
Portion of bowel sutured onto abdomen
What are the nursing diagnoses for ear trauma?
Risk for Infection, Acute Pain, and Deficient Knowledge
What is the nursing care for colorectal cancer?
Support and education and Postoperative care
What was the cause of Mrs. Kirk's gastrointestinal (GI) bleeding?
Use of aspirin, two tablets four times a day.
What is diabetic retinopathy?***
Vascular changes in retinal blood vessels such as Microaneurysms and Preproliferative retinopathy
What is the preprocedure care for an angiogram?
Verify informed consent, Give clear liquid diet if ordered, Insert I V catheter, and Administer sedation as ordered.
WHat is the purpose of a Snellen test?
Visual acuity
What is the mode of transmission for Hepatitis E?
Water contaminated with human feces or raw or undercooked pork or venison.
What does blood mixed with gastric contents resemble?
a dark, granular material resembling coffee grounds is produced. This material can be vomited or passed through the GI system and mixed with stools.
What is synovial fluid?
a slippery, viscous fluid that has the consistency of an egg white and lubricates the joint, nourishes the cartilage, and contains phagocytes to remove debris
What is ischemic?
deficient blood flow to organ or tissue
What is the etiology of an ischemic stroke?
deficient blood supply
What are the preoperative nursing diagnoses for amputation?
deficient knowledge and disturbed body image
The nurse is caring for a patient who has an emesis with a coffee ground appearance. Mark the area that is producing the coffee ground appearance.
epigastric
What function does the cerebellum control?
equilibrium and coordination
The nurse is assisting with discharge instructions for a patient. Which of these medications would the nurse teach the patient can cause hearing loss? Select all that apply. 1. acetaminophen (Tylenol) 2. erythromycin (E-Mycin) 3. furosemide (Lasix) 4. gentamicin (Garamycin) 5. aspirin (Bayer) 6. tobramycin (Tobrex)
erythromycin (E-Mycin), furosemide (Lasix), gentamicin (Garamycin), aspirin (Bayer), and tobramycin (Tobrex)
What is gastric plication?
folds the stomach inwardly, and then sutures hold the folds in place. This reduces the stomach's volume and limits the food that can be ingested at one time. It can be reversed. It is investigational.
What are the metatarsal bones?
foot bones
What is the occipital bone?
forms the rear of the skull and much of its base
What are people with osteoporosis prone to?
fractures
What happens as a result of bone calcium loss as we age?
fractures
What is the surgical management for hiatal hernia?
fundoplication (the top part of your stomach — called the fundus — is folded and sewn around the lower esophageal sphincter, a muscular valve at the bottom of your esophagus. This reinforces the lower esophageal sphincter, making it less likely that acid will back up into the esophagus.)
What happens to the gallbladder as we age?
gallstones
What is cholelithiasis?
gallstones
What are neurofibril nodes?
gaps in the myelin sheath (that occur at evenly spaced intervals)
Surgical removal of the stomach. _____
gastrectomy
What is Herniorrhaphy?
involves making an incision in the abdominal wall, replacing the contents of the hernial sac, sewing the weakened tissue, and closing the opening.
How do the lumbar vertebrae curve?
inward
What is the etiology of multiple sclerosis?
it is unknown but could be due to possible auto immune response or possible viral infection and has a hereditary link
What is anorexia?
lack of appetite (a common symptom of many diseases)
What are the therapeutic interventions for diabetic retinopathy?
laser photocoagulation and Vitrectomy (removal of vitreous humor)
What is the radius?
lateral bone of the forearm
What is the auditory canal?
leads through the temporal bone to the ear drum. The glands lining this canal produce secretions that mix with dead skin cells to form cerumen
What is the gastric acid stimulation test?
measures the amount of gastric acid for 1 hour after subcutaneous injection of a histamine drug.
What is open reduction with internal fixation management of a fracture?****
metal plates/screws and prosthesis (artificial joint not necessarily whole limb) (The fractured bone ends are reduced (aligned) by direct visualization through a surgical incision (open reduction). The bone ends are held in place by internal fixation devices such as metal plates and screws or by a prosthesis with a femoral component similar to that used for total joint replacement) (you can't see it bc it is inward)
Nerve pain is also called ____________.
neuralgia
20% to 30% over average weight for age, sex, and height. _____
obesity
What is an oblique fracture line?
oblique
Blood not visible in feces _______
occult
What is an open fracture?
one that breaks the skin
What is the function of the accessory organs of digestion (liver, gallbladder, and pancreas)?
produce or store digestive secretions
What is risk for impaired skin integrity a nursing diagnosis for?
spinal cord injury
What is risk for sexual dysfunction a nursing diagnosis for?
spinal cord injury
What is self-care deficit (dressing/feeding/toileting/bathing) a nursing diagnosis for?
spinal cord injury and Parkinson's disease
What is a fracture that twists around the shaft of the bone?
spiral
What is background retinopathy?
the earliest stage. Microaneurysms form on the retinal capillary walls. These microaneurysms may leak blood into the central retina or macula. The leakage may cause edema. If it does, the patient may notice a decrease in color discrimination and visual acuity.
What are the synaptic knobs?
the end of the axon branches that have axon terminal endings each containing a neurotransmitter
How long is the duodenum?
the first 10 inches and contains the hepatopancreatic ampulla (ampulla of Vater), the entrance of the common bile duct and the pancreatic duct. `
What is the ulna?
the forearm bone located on the "pinky" side of the upper appendage
A patient is scheduled to have magnetic resonance imaging of the abdomen. Patient data collected includes no known drug allergies, history of hypertension, surgical history of appendectomy, and left cardiac permanent pacemaker implantation. Mark the area in which the contraindication to the magnetic resonance imaging is located that the nurse will report to the health care provider
the heart
What is ineffective breathing pattern a nursing diagnosis for?
traumatic brain injury
What is ineffective cerebral tissue perfusion a nursing diagnosis for?
traumatic brain injury
What is esophageal cancer?
usually detected in advanced stages because of its location near many lymph nodes that allows it to metastasize.
What tests are done for auditory acuity?
whisper voice test, Rinne test, and Weber test
The nurse is counseling a patient with frequent anal fissures and a history of constipation. Which of the following patient statements indicates that further teaching is required? Select all that apply. 1. "There isn't much I can do except seek pain relief whenever I have a fissure." 2. "It is important that I not ignore the urge to have a bowel movement." 3. "Decreasing the amount of fluid I drink each day will reduce stool frequency and subsequent irritation." 4. "Opioid analgesics medications are probably needed to help with this condition." 5. "Sitz baths may provide healing and comfort." 6. "I should eat a high-fiber diet."
"There isn't much I can do except seek pain relief whenever I have a fissure.", "Decreasing the amount of fluid I drink each day will reduce stool frequency and subsequent irritation.", and "Opioid analgesics medications are probably needed to help with this condition."
The nurse is collecting data during a patient's clinic visit. Which question will best collect data about a patient's preventive ear health? 1. "What symptoms are you having?" 2. "Tell me about your ear pain." 3. "When was your last hearing evaluation?" 4 "What medications do you take?"
"When was your last hearing evaluation?"
What are three things that should be taught to all patients with myasthenia gravis?
(1) DO NOT take any new drugs, over the counter or prescription, without consulting your neurologist. (2) The importance of around-the-clock anticholinesterasemedication in preventing muscle weakness. (3) Energyconservation techniques and timing of medication withactivities.
What are seizures?**
**ABNORMAL ELECTRICAL DISCHARGES** in the brain related to instability of neuronal cell membranes
What are the s/s of dementia?***
**Recent memory affected first, ** Remote memory affected later, Forget how to perform simple tasks, Wandering, Aphasia, Behavioral problems, and Total dependence
The nurse is caring for a patient who is diagnosed with otosclerosis and asks what the disease is. Which is the most appropriate response by the nurse? 1. "Infection of the external ear commonly caused by moisture." 2. "It is a tumor of the eighth cranial nerve." 3. "Hardening of the stapes due to new bone growth." 4. "Inflammation of the inner ear caused by pathogens."
"Hardening of the stapes due to new bone growth."
What is the Glasgow Coma Scale score?
0-4 (4 being ideal)
What is the low vision for a LogMAR chart?
0.5-1.3
What are the fracture healing phases?
1. clot formation at the fracture site 2. fibroblasts and osteoblasts arrive 3. fibrocartilage callus forms 4. new born forms 5. bone remodeling continues until bone is intact and repair and healing are completed
What is the reflex arc?
1. somatic receptors (located in the skin, a muscle, or a tendon) detect a sensation (Ex. the stretching of the thigh muscle when the patellar tendon is tapped) 2. then the afferent/sensory nerve fibers send a signal directly to the spinal cord 3. the impulse immediately passes to a motor neuron 4 and the motor neuron initiates an impulse back to the muscle, causing it to contract, producing a slight kick in the lower leg
What is the normal range for intraocular pressure?**
10 to 21 millimeters of mercury
What percentage of strokes are preceded by a transient ischemic attack (TIA)?
15%
What are the therapeutic interventions and nursing care for eye trauma involving chemicals?
15- to 20-minute irrigation
What is the therapeutic level for phenobarbital (Luminal)?
15-40 mcg/mL
What is the legal blindness for a Snellen chart/E chart/Rosenbaum card?
20/200 or worse with correction
How many bones are in the human skeleton?
206
What is an overweight BMI?
25 to 29.9 kilogram per square meter
How many people had chronic liver disease and cirrhosis in 2015?
3.9 million
How many coccyx vertebrae are there?
4 fused
Following ischemic stroke, thrombolytic therapy must be given within how many hours? 1. 1.5 2. 2 3. 4.5 4. 6
4.5
How soon after symptom onset must a person who has had a stroke receive thrombolytic treatment? 1. 30 minutes 2. 1 hour 3. 2 hours 4. 4.5 hours
4.5 hours
How many sacrum vertebrae are there?
5 fused
How many cervical vertebrae are there?
7
HOw long does it take for a C&S to process?
72 hours (first 24 is preliminary)
What is legal blindness for a LogMAR chart?
>1.3
What is the biceps brachii?
A "2-headed" muscle whose heads originate on shoulder girdle, fuse, and insert into the radial tuberosity of the radius
What is the vastus medialis?
A muscle toward the midline of the leg. Part of the quadriceps that flex/extend the leg at the knee.
What is accommodation?
Adjustment of the eye for distance to focus the image on the retina by changing lens curvature.
What is the preprocedure care for a computed tomography (CT) scan?
Administer contrast dye if ordered, Check allergies, and Request order for sedation if indicated (check renal function prior to test)
The nurse would evaluate the patient as requiring further teaching if the patient stated which of these serum blood tests is elevated in gout? Select all that apply. 1. Alkaline phosphatase 2. Calcium 3. Creatine kinase 4. Myoglobin 5. Phosphorus 6. Uric acid
Alkaline phosphatase, Calcium, Creatine kinase, Myoglobin, and Phosphorus
What health care team members were involved in Max's care?
Amanda and her grandfather were at the center of the team. In the hospital, a stroke team was involved as well as physicians, nurses, a nursing assistant, and speech, occupational, and physical therapists.
What are the therapeutic measures for the ears and hearing?
Anti-infectives, Anti-inflammatories, Antihistamines, Decongestants, Ceruminolytics, Diuretics, Ear health maintenance, Assistive devices (ex. Hearing aids), Hearing service dogs (they are trained to respond to sounds such asCrying baby, smoke alarm, or oven timer)
What are the therapeutic interventions for labyrinthitis?
Antibiotics, Sedation, and Bedrest (Antibiotics are used to treat bacterial inner ear infections. Viral infections usually run their course in about 1 week. Mild sedation may help the patient relax. Although there is no specific medicine to relieve dizziness, antihistamines can be used if they prove helpful on an individual basis. Patients may be placed on bedrest.)
What is the pathophysiology of myasthenia gravis?**
Antibodies destroy acetylcholine (ACh) receptors causing ACh is unable to stimulate muscle contraction resulting in Loss of voluntary muscle strength
Which medication class is used to reduce symptoms of muscle weakness from myasthenia gravis? 1. Anticholinesterase 2. Anticholinergic 3. Adrenergic 4. Beta blocker
Anticholinesterase
What medications are used for Ménière disease?
Antiemetic for nausea and meclizine (Antivert) for vertigo.
What will a pt with a liver transplant be on?
Antirejection medications
What are the therapeutic interventions for restless legs syndrome?
Application of heat or cold, Leg massage, Warm baths, Medications to control symptoms, and Lifestyle modifications such as Smoking cessation, Regular sleep schedule, Alcohol avoidance, and Exercise routine
The nurse would educate the nurse's aide on the use of which of these techniques for safe patient movement? Select all that apply. 1.Apply non-skid footwear. 2.Lift up under patient's arms to reposition. 3.Use lifting device. 4.Use lift sheet. 5.Sit on bedside before standing. 6.Use walking belt.
Apply non-skid footwear, Use lifting device, Use lift sheet, Sit on bedside before standing, and Use walking belt.
A patient is having an acute episode of gastric bleeding. The health care provider orders 1,000 mL of 0.9% normal saline via intravenous route, a complete blood count, a nasogastric tube to low-wall suction, and oxygen by nasal cannula. Which order should the nurse perform first? 1. Administer 1,000 mL of 0.9% normal saline. 2. Draw blood for a complete blood count. 3. Insert a nasogastric tube. 4. Apply oxygen by nasal cannula.
Apply oxygen by nasal cannula.
What are the later s/s of acute liver failure?
As the condition worsens, symptoms become more severe; these include jaundice, hepatic encephalopathy (HE) (resulting in confusion and coma), bleeding, and abdominal distention.
What are some examples of mydriatics?
Atropine (Isopto Atropine), Diphenhydramine (Benadryl), and Hydroxyzine (Vistaril)
A patient is admitted to a medical unit with a diagnosis of Guillain-Barré syndrome. The patient's legs are weak, causing difficulty walking without assistance. Which of the following is most likely responsible for this syndrome? 1. Bacterial infection 2. Heredity 3. High-fat diet 4. Autoimmune reaction
Autoimmune reaction
What is the treatment for peptic ulcer disease?
Avoid irritants such as Spicy foods, Smoking, Caffeine, and Alcohol
Which of the following instructions should the nurse include in the teaching plan for the patient with portal hypertension? Select all that apply. 1. Cough and deep breathe every 2 hours. 2. Avoid straining to have a bowel movement. 3. Avoid heavy lifting 4. Increase fluid intake. 5. Take vitamin K supplement. 6. Consult health care provider before use of aspirin.
Avoid straining to have a bowel movement, Avoid heavy lifting, and Consult health care provider before use of aspirin.
What is an morbid obesity BMI?
B M I >40
What is the basal cell secretion test?
BEfore this test, the patient should avoid taking any drugs that could interfere with gastric acid secretion, such as anticholinergics and antacids. The patient is NPO after midnight the night before the test. For the procedure, a nasogastric (NG) tube is inserted, and the contents of the stomach are suctioned out through the tube using a syringe.
Which stoma color indicates an inadequate blood supply and is a priority for the nurse to report? 1.Black 2.Bluish 3.Pink 4.Red
Bluish
What are the s/s of Mallory-Weiss tear?
Bright red, bloody emesis and Bloody or tarry stools
What are the diagnostic tests for chronic pancreatitis?
C T scan, M R I, Endoscopic ultrasound (goes in like you are doing endo but also does ultrasound), Pancreas function tests, Pancreatic enzymes normal or low, and High fecal fat level
What are the diagnostic tests for a traumatic brain injury?
C T scan, M R I, and Neuropsychological testing
What are the diagnostic tests for Cerebral Aneurysm/ Subarachnoid Hemorrhage?
CT scan and cerebral angiogram
What are visible veins around umbilicus?
Caput medusae
What are the therapeutic interventions for absorption disorders?
Celiac disease (High-calorie, high-protein, gluten-free diet****) and Lactose intolerance (Avoid lactose foods; use Lactaid; Lactase enzyme drops or tablets (e.g., Lactaid or Dairy Ease) digest about 70% of lactose in foods.)
What are the risk factors for liver cancer?
Chronic H B V or H C V, Nutritional deficiencies, and Exposure to hepatotoxins
What is the purpose of the ciliary body?
Circular muscle changes shape of lens
The nurse is providing care for a patient with a hemorrhagic stroke. Which of the following medication orders would the nurse question? Select all that apply. 1. Simvastatin (Zocor) 2. Clopidogrel (Plavix) 3. Carbamazepine (Tegretol) 4. Tissue plasminogen activator (tPA) 5. Metoprolol (Toprol) 6. Warfarin (Coumadin)
Clopidogrel (Plavix), Tissue plasminogen activator (tPA), and Warfarin (Coumadin)
Which of these is a complication of cirrhosis? Select all that apply. 1.Clotting defects 2.Varices 3.Ascites 4.Perforation of gallbladder 5.Encephalopathy 6.Hepatorenal syndrome
Clotting defects, Varices, Ascites, and Hepatorenal syndrome
What is nystagmus?
Constant involuntary cyclical eyeball movement.
What is the patient teaching for a computed tomography (CT) scan?
Contrast dye may cause feeling of warmth, sudden urge to urinate may occur, and Signs and symptoms of allergic reaction to report
What is true of aging and the eye?
Decreased elasticity of lens (aka Presbyopia), Difficult peripheral vision, Decreased pupil size, Difficult night vision, Sensitivity to glare, Clearer: Yellow, orange, red hues, Distorted depth perception, and Decreased lacrimal secretions
What happens to the musculoskeletal system as we age?
Decreased muscle mass/strength, Decreased elasticity of ligaments, tendons, cartilage, Decrease in intervertebral space, and Changes in posture and gait changes
What is malabsorption bariatric surgery?
Decreases calorie/nutrient absorption
When performing a neurologic assessment, which of the following is a symptom of increasing intracranial pressure that the nurse should immediately to the primary care provider? 1. Constricted pupils 2. Decreasing level of consciousness 3. Narrowing pulse pressure 4. Bradypnea
Decreasing level of consciousness
What is the nursing diagnosis for gastric bleeding?
Deficient Fluid Volume
What are the effects of osteoporosis?
Deformities, Functional effects, Emotional effects, and Socialize less
What is primary open-angle glaucoma (POAG)?****
Degeneration of drainage system blocks aqueous fluid ***
What is the pathophysiology of multiple sclerosis?**
Degeneration of myelin sheath that causes inflamed nerves which results in slowed or blocked nerve impulses
What are the s/s of Huntington's disease?
Dementia (including Personality changes, Inappropriate behavior, PARANOIA, and Violence), Choreiform movements (involuntary, irregular, jerky, dance-like movements), Dysphagia, Depression, and Death
What is the purpose of the circular iris?
Dilates and constricts pupil
What are the therapeutic interventions for ascites caused by cirrhosis/chronic liver disease?
Diuretics, Sodium restriction, Albumin infusion, Paracentesis, and Transjugular intrahepatic portosystemic shunt (shown in illustration)
What is a Colostomy?
Diversion of large bowel through abdominal wall
What is an Ileostomy?
Diversion of small bowel through abdominal wall
A patient has been diagnosed with a hiatal hernia. The patient has heartburn and occasional regurgitation. Which intervention should the nurse teach the patient to reduce the symptoms? 1. Eat small, frequent meals. 2. Recline for 1 hour after meals. 3. Sleep flat without a pillow. 4. Eat a bedtime snack.
Eat small, frequent meals.
What is a colostomy?
Effluent becomes less liquid and more solid as location of ostomy becomes more distal in colon.
What are confusion and coma symptoms of?
Encephalopathy
What is arthroscopy?
Endoscopy of joints with local or general anesthesia
What is serum alkaline phosphatase?
Enzyme made by osteoblasts to mineralize bone
What should be done for the nutrition status of a pt with neurological disorder?
Evaluate swallowing
What are the therapeutic interventions for osteoarthritis?
Exercise, Weight control, Medication (such as N S A I D's and Synvisc-One (Synvisc-One (one injection) or SYNVISC (three injections) is injected directly into osteoarthritic knees to replace the cushioning synovial fluid ( Pain can be relieved and flexibility restored for up to 6 months.), Heat or cold therapy, Complementary therapies (such as Imagery, music therapy, acupressure, acupuncture), and Surgery (ex. Total joint replacement) (No cure)
What is vomiting?
Expelling stomach contents through esophagus and mouth
What should be done for a pt with deficient knowledge?
Explain what happened to patient, Explain tests and procedures, Orient patient and family to setting, Provide instruction for care at home, and Evaluate need for home nursing.
What is decerebrate posturing?
Extensor response: Hands pushed to sides and body hyper-extended. Arms are stiffly extended, adducted & hyperpronated. Hyperextension of the legs with plantar flexion of the feet. (May indicate more serious damage.) "extensor = All E's"
How can a patient with increased intracranial pressure be monitored?
External ventricular drain (aka placement of a catheter into one of the lateral ventricles of the brain), Subarachnoid bolt (aka a subarachnoid bolt tightly screwed into the burr hole after the dura has been punctured), and Intraparenchymal monitor
What are the accessory structures of the eyes?
Eyelids, Eyelashes, Conjunctiva, Lacrimal gland, and Tears
What are the normal results of an assessment of accommodation?
Eyes turn inward and pupils constrict when focusing on a near object
After a knee replacement, dislocation is a possible complication. 1.True 2.False
False, dislocation is not a concern.
True or false: Clean the prosthesis socket with alcohol and water, and dry it completely.
False. Clean with mild soap and water.
What is constipation?
Fecal mass held in rectum which causes Feces to become dry, hard
What is Ascites?
Fluid in abdominal cavity from decreased albumin level
What types of eye trauma are considered an emergency?
Foreign bodies, Burns, Abrasions, Lacerations, and Penetrating wounds
What is a risk factor for gastric cancer?
H. Pylori infection
What are the normal results of the Weber test?
Heard equally
What is the purpose of the Weber test?
Hearing acuity
The nurse would administer lactulose to the patient with which of these conditions?***** 1.Pancreatitis 2.Hepatic encephalopathy 3.Diabetes 4.Ascites
Hepatic encephalopathy
What is liver inflammation?
Hepatitis
What are gastric ulcers?
High left epigastric that cause upper abdominal burning/gnawing pain that is*** increased 1 to 2 hours after meals or with food **
What are the risk factors for oral cancer?
Highest risk from alcohol or tobacco use
In which of these stages of hepatitis does jaundice occur? 1.Prodromal 2.Icteric 3.Convalescent 4.Recovery
Icteric
What are the therapeutic interventions for diarrhea?
Identify cause, Replace fluids/electrolytes, Increase fiber/bulk, Diphenoxylate (Lomotil**), loperamide (Imodium**), Probiotic (Lactinex) restores normal flora, and Antimicrobial agents for infection
What is the nursing diagnosis for hearing loss?
Impaired Verbal Communication
What are absorption disorders?
Inability to absorb one or more major nutrients
The nurse is contributing to the plan of care for a 78-year-old patient's elimination needs. Which of the following interventions should the nurse recommend to reduce complications due to the aging change of slowed motility? Select all that apply. 1. Decrease ambulation. 2. Decrease fluid intake. 3. Increase dairy products. 4. Increase dietary fiber. 5. Increase activity level.
Increase dietary fiber and Increase activity level.
What is Appendicitis?
Inflamed appendix
What is Hepatitis?
Inflammation of liver cells
What is the etiology of a herniated disk?
Injury or May be unknown
What are the s/s of trigeminal neuralgia?
Intense pain on one side of face including Forehead, cheek, nose, jaw, and triggered by touch, talking, other stimulation
What are the s/s of hepatitis in the icteric stage?
Jaundice and worsening symptoms (Lasts 2 to 6 weeks)
What is the etiology of restless leg syndrome?
Kidney failure, Iron deficiency, Diabetes, Parkinson disease, Peripheral neuropathy, and Family history
What are the basic parts of a neurological assessment that Betty performed?
Level of consciousness and orientation, vital signs, pupil responses, bilateral strength in extremities, and sensation.
What is restrictive bariatric surgery?
Limits how much stomach can hold
The nurse is caring for a patient with macular degeneration. During data collection, which symptom would the nurse anticipate the patient to report? 1. Loss of peripheral vision 2. Sudden darkness 3. Dull ache in the eyes 4. Loss of central vision
Loss of central vision
What is Presbyopia?
Loss of lens elasticity
The nurse is caring for a patient with cataracts. During data collection, which findings would the nurse expect? Select all that apply. 1.Loss of visual acuity 2.Halos around lights 3.Pain 4.Sensitivity to glare 5.Decreased color vision
Loss of visual acuity, Halos around lights, Sensitivity to glare, and Decreased color vision
What is an Optician?
Makes prescribed corrective lenses.
What is gastric cancer?
Malignant lesion in stomach
What are some other issues of the external ear?
Masses and Trauma
What are some s/s of tonic clonic seizures**?
May have aura, USUALLY LOSE CONSCIOUSNESS, RIGIDITY FOLLOWED BY MUSCLE CONTRACTION AND RELAXATION, INCONTINENCE, and POSTICTAL PERIOD (usually sleep during this period)
What is the nursing care for absorption disorders?
Monitor Fluids, electrolytes, nutritional status, Daily weight, and Intake and output and Education
What should be done for a pt with acute or chronic confusion?
Monitor changes in thought processes, Place calendars, clocks in environment, Reduce stressors, Maintain patient's usual routines, Communicate slowly and clearly, and Involve family.
What is the nursing care for lower gastrointestinal bleeding?
Monitor stools/bleeding, Vital signs (they could go into hypovolemic shock), Shock signs, and Diagnostic prep
What is a Gastrojejunostomy (Billroth Two)?
More distal stomach removed remaining is Anastomosed to jejunum. this surgery Treats duodenal problems
What is the purpose of the Fovea centralis?
Most acute color vision
What is Cholesterol?
Most common substance found in gallstones
Where does absorption of nutrients occur?
Most takes place in the small intestine. (The large intestine is where the majority of water is reabsorbed. Indigestible material, mainly cellulose, is then eliminated from the large intestine.)
What are diverticulosis?
Multiple diverticula
What are the nursing diagnoses for nausea and vomiting?
Nausea and Risk for Aspiration
What are the s/s of hiatal hernia?
None, Pain, Heartburn, Fullness, and Reflux
Which neurotransmitter mediates the sympathetic response? 1. Acetylcholine 2. Prostaglandin 3. Norepinephrine 4. Serotonin
Norepinephrine
What is the nursing care for labyrinthitis?
Nursing management includes helping the patient manage symptoms and self-care. Educate the patient about safety issues while on bedrest and sedatives to prevent falls and injury. The patient should avoid turning the head quickly to help alleviate vertigo. The patient is assisted to cope with anxiety that may be present because of the frustration surrounding hearing loss or loss of work.
What is Arcus senilis?
Opaque white ring around the periphery of thecornea in aged persons from deposits of fat.
What is a complication of an open fracture?
Osteomyelitis
What is the purpose of an assessment of the visual fields?
Peripheral vision
When testing visual fields, the nurse examines which part of vision? 1. Peripheral vision 2. Near vision 3. Distance vision 4. Central vision
Peripheral vision
What complications could develop in Evan from hitting the steering wheel in the accident?
Pneumothorax from a rib fracture or a cardiac contusion from a blow to the chest.
What is abdominal circulation?
Portal
What is included in a physical inspection of the musculoskeletal system?
Posture, Gait, Mobility aids, Deformities, and Crepitation (aka rice krispies)
What is the postoperative care to prevent pain after a total hip replacement?
Provide pain relief.
What is an end stoma?
Proximal bowel end brought to abdominal wall
What are the signs of rejection of a liver transplant?
Pulse >100 beats per minute, Temperature >101 degrees Fahrenheit, R U Q pain, Increase in jaundice, Decrease in bile from T-tube, and Elevated liver enzymes
What is the purpose of an assessment of accommodation?
Pupillary response to near and far distance
The nurse asks the patient to perform which of these to check muscle strength? Select all that apply. 1.Blink. 2.Cough. 3.Push feet against nurse's hands. 4.Squeeze nurse's hands. 5.Swallow. 6.Wiggle toes.
Push feet against nurse's hands and Squeeze nurse's hands.
What is the treatment for stress-induced gastritis?
Quick trauma care, Early feeding, Prophylactic antacids, and histamine blockers, and Sucralfate that Binds to ulcer base
What is the abbreviation for location of liver?
RUQ
What are the therapeutic interventions for esophageal cancer?
Radiation, Chemotherapy, and Surgery (Ex. Esophagectomy, Esophagogastrostomy, Dacron esophageal replacement, and Esophagoenterostomy)
What are the therapeutic interventions for oral cancer?
Radiation, Chemotherapy, and Surgery (Ex. Radical or modified neck dissection: will likely have permanent tract with radical and JP drain after surgery)
What is an MRI?
Radio waves and magnetic field view of soft tissue
What are the therapeutic goals for a fracture?
Realignment of bone ends and Immobilization
What is a risk factor for C. diff?
Recent hospitalizations and antibiotic use
Which speech and language deficit is a patient experiencing who is unable to comprehend all language? 1.Receptive dyphasia 2.Expressive dyphasia 3.Receptive aphasia 4.Expressive aphasia
Receptive aphasia
Which term is used to describe difficulty understanding speech following a stroke? 1.Receptive aphasia 2.Expressive aphasia 3.Dysphagia 4.Dysarthria
Receptive aphasia
The nurse identifies which of the following as normal effects of aging on the central nervous system? Select all that apply. 1. Increased postural stability 2. Reduced blood flow to the brain 3. Impaired short-term memory 4. Sleep disturbances 5. Loss of deep tendon reflexes 6. Decrease in acetylcholine
Reduced blood flow to the brain, Impaired short-term memory, Sleep disturbances, and Decrease in acetylcholine
What is the nursing care for oral cancer?
Referral for Alcohol/tobacco cessation, Preoperative teaching (Ex. Tracheostomy and Communication), and Postoperative (Airway and Nutrition)
What is the articular?
Relating to a joint
What are some additional manifestations of multiple sclerosis?
Remissions, Exacerbations (Due to stress or illness), Immobility, and Death usually from infection
What is Pancreatectomy?
Removal of all or part of the pancreas
What is Colectomy?
Removal of large bowel
What is lavage?
Removal of material from the stomach (aka flushing the stomach)
What is the nursing care for Mallory-Weiss tear?
Report bleeding and Teaching (ex.Avoid alcohol and how to take their Medications)
The nurse is caring for a 1-day postoperative patient who has a new end colostomy that is a dusky color. Which action is the priority for the nurse to take? 1. Check the stoma drainage in 1 hour. 2. Monitor the stoma color in 4 hours. 3. Place a new ostomy appliance over the stoma. 4. Report this finding to the health care provider now.
Report this finding to the health care provider now.
What are the complications of Gastroesophageal reflux disease (GERD)?
Respiratory (such as Asthma, Aspiration pneumonia, Bronchospasm, and Laryngospasm) and Barrett's esophagus (precancerous)
What are the complications of Guillain-Barre syndrome?
Respiratory failure (BIG ONE**), Infection, Depression, Pneumonia, Urinary tract infection, and Complications of immobility
Which assessment takes priority in the patient with Guillain-Barre Syndrome? 1.Respiratory rate and depth 2.Blood pressure and pulse 3.Bowel sounds 4.Muscle strength
Respiratory rate and depth
What is combination bariatric surgery?
Restrictive and malabsorption
What are the types of bariatric surgery?
Restrictive, Malabsorption, and Combination
What is a stress fracture?
Results in the bone being fractured across one cortex. This is an incomplete fracture.
What are the normal results of the Snellen test?
Right eye (OD) 20/20, left eye (OS) 20/20
The nurse is caring for a patient who has had repair of a right inguinal hernia. Mark the area where the nurse would view the surgical site.
Right groin area
What are the nursing diagnoses for pancreatic cancer?
Risk for Deficient Fluid Volume and Risk for Impaired Tissue Integrity
Which of the following nursing diagnoses is most appropriate for the nurse to contribute to the plan of care for a patient with symptoms of a bowel obstruction? 1. Self-Care Deficit: Feeding related to nil per os (NPO) status 2. Acute Urinary Retention related to fluid volume depletion 3. Risk for Deficient Fluid Volume related to nausea and vomiting 4. Ineffective Coping related to prolonged hospitalization
Risk for Deficient Fluid Volume related to nausea and vomiting
What test are done for balance testing?
Romberg test
What is pivot?
Rotation
What is the preoperative care for surgery on a herniated disk?
Routine teaching and Teach log-rolling technique
What are the causes of peritonitis?
Ruptured appendix, Peptic ulcer, Pancreatitis, and Diverticulitis
What are the s/s of acute angle-closure glaucoma (AACG)?***
SEVERE eye pain, Blurred vision, Rainbows around lights, Eye redness, steamy cornea, Photophobia, and tearing
What are the s/s of Cerebral Aneurysm/ Subarachnoid Hemorrhage?
SEVERE headache, photophobia, Vomiting, Disorientation, Increased intracranial pressure, Changes in level of consciousness, Seizures, Nuchal rigidity, Pupil changes, and Motor dysfunction
What is the pathophysiology of gout?
SYSTEMIC connective tissue disorder that causes Uric acid build-up and Urate crystals deposited in joints/connective tissues which results in Severe inflammation (flare ups may be localized but uric acid build-up is systemic)
What is sludge?
Salivation Lacrimation Urination Diarrhea Gastrointestinal cramping (a severe crisis has been described as "liquid pouring out of every body orifice)
What is the prophylactic treatment for Ménière Disease?***
Salt-restricted diet, Diuretics, Antihistamines, Vasodilators, and Avoid alcohol, caffeine, tobacco (b/c they are vasoconstrictors)
What is bicarbonate juice?
Secretin stimulates the production of bicarbonate pancreatic juice. Cholecystokinin stimulates secretion of the pancreatic enzyme juice.
What are the complications of a brain tumor?
Seizures, Headaches, Memory impairment, Cognitive changes, Ataxia, Hemiparesis, Aphasia, Lethargy, Coma, and Death
What are the s/s of a brain tumor?
Seizures, Motor and sensory deficits, Headaches, Speech and vision disturbances, Personality changes, and Hormone disturbances
What are the diagnostic tests for constipation?
Self diagnosis and History and physical with rectal examination
What is retinal detachment?
Separation of retina from choroid layer of eye
What are the diagnostic tests for pancreatic cancer?
Serum amylase/lipase (elevated caused by secondary pancreatitis), A L P (elevated) Bilirubin (elevated) Coagulation studies, Carcinoembryonic antigen, X-ray, C T, M R I, ultrasound, E R C P (aka retrograde), and Biopsy
What are the diagnostic tests for hepatitis?
Serum tests (including Liver enzymes (elevated), Serum bilirubin (elevated), Prothrombin, and Serological tests) and Liver biopsy
What is a carbuncle?
Several hair follicles forming an abscess
What is gliding?
Side-to-side movement
what is dementia?
Significantly impaired intellectual functioning that involves impaired normal activities and relationships, impaired problem solving and emotional control, personality changes, and behavioral problems
The nurse is teaching the patient about contracture prevention after an above-the-knee amputation. The nurse evaluates the patient as requiring further teaching if the patient states which of these interventions should be used? Select all that apply. 1. Lie prone for 30 minutes. 2. Sit in chair for 2 hours. 3. Elevate stump on pillow daily. 4. Ensure stump lies flat on bed. 5. Elevate head of bed during the day. 6. Elevate foot of bed daily.
Sit in chair for 2 hours, Elevate stump on pillow daily, Elevate head of bed during the day, and Elevate foot of bed daily.
What are the s/s of bone cancer?
Site pain and swelling and Tender, palpable mass
What provides a rest period from the pain of trigeminal neuralgia?
Sleep provides a period of relief from the pain. Therefore, persons with TN may sleep most of the time to avoid painful attacks. They also may refrain from activities such as talking, face washing, teeth brushing, shaving, and eating to prevent pain. Frequent blinking and tearing of the eye on the affected side also occur.
What are the s/s of mild gastric bleeding?
Slight weakness or diaphoresis
What is the lower gastrointestinal system comprised of?
Small intestines, Large intestines, Rectum, and Anus
What are bursae?**
Small sacs of synovial fluid between joint and other structures that lessen wear in areas of friction (Can become inflamed)**
What is the bursa?
Small sacs of synovial fluid between joints and tendons
What is the fibula?
Smaller lower leg bone
Mechanical digestion in the stomach is accomplished by which of the following structures? 1. Mucosa 2. Smooth muscle layers 3. Striated muscle layers 4. Gastric glands
Smooth muscle layers
What is dual energy x-ray absorptiometry?
Special x-ray evaluating bone density
What is the emergency treatment for a fracture?
Splint it as it lies! (DO NOT TRY TO STRAIGTEN IT UP if it is bent backwards do NOT move it) and Seek medical treatment.
The nurse is assisting with a Romberg test. What action should the nurse take for patient safety? 1.Ask patient to sit during test. 2.Stand near patient. 3.Dim the room lights. 4.Close curtains to reduce glare.
Stand near patient.
What are the therapeutic interventions for colorectal cancer?
Surgery (Ex. Resection, Abdominoperineal resection, or Colostomy), Radiation, Chemotherapy, Monoclonal antibody therapy (boosts immune system and helps it to fight), Analgesics, and Parenteral nutrition as necessary (anastomosis has to heal)
What are the therapeutic interventions for a brain tumor?
Surgical removal, Radiation therapy, Chemotherapy, and Symptom control (via Anticonvulsants and Steroids)
What is an ostomy?
Surgically created opening diverts stool or urine to outside of body
What is synovitis?
Swollen synovial tissue within the joint
What is delirium?
TEMPORARY mental disturbance
Which of the following responses indicates sympathetic nervous system activation? 1. Tachycardia, dilated pupils 2. Increased peristalsis, abdominal cramping 3. Hypoglycemia, headache 4. Pupil constriction, bronchoconstriction
Tachycardia, dilated pupils
A patient is diagnosed with aphthous stomatitis (canker sore). Which nursing action should the nurse implement? 1. Explain not to brush teeth until the sore has healed. 2. Encourage patient to use a mouthwash four times a day. 3. Apply acyclovir ointment to sore for pain relief. 4. Teach patient to apply topical tetracycline several times a day to the sore.
Teach patient to apply topical tetracycline several times a day to the sore.
What is the nursing care for gout?*******
Teach pt to: Drink plenty of fluids, especially water. Consider eating cherries or drinking cherry juice. Avoid high-purine (protein) foods, such as organ meats, shellfish, and oily fish (e.g., sardines). Avoid alcohol. Avoid all forms of aspirin and medications containing aspirin. Avoid diuretics. Avoid excessive physical or emotional stress.
what is the nursing care for hiatal hernia?
Teaching, Preoperative care, and Postoperative (Monitor for dysphagia with eating, Report dysphagia, and Repair may be too tight)
What is Intussusception?
Telescoping of the bowel
What is a double-barrel stoma?
Temporary ostomy in which both ends of colon outside abdominal wall, form two stomas. Proximal stoma is functioning stoma and Distal stoma is mucous fistula (almost like a back-up)
Muscles are attached to bones by which of the following? 1. Tendons 2. Ligaments 3. Fascia 4. Other muscles
Tendons
What is an ileostomy?
Terminal ileum to abdominal wall after total colectomy
What was discovered in 1982 that is the cause of most peptic ulcers?
The bacteria called Helicobacter pylori, commonly referred to as "H. pylori."
What is hepatic portal circulation?
The blood supply of the liver differs from that of other organs. The liver receives oxygenated blood by way of the hepatic artery. By way of the hepatic portal vein, blood from the abdominal digestive organs and the spleen is brought to the liver before being returned to the heart.
What is albumin?
The body protein in the greatest concentration. Evaluates liver, kidney, and nutritional status. Normal range: 20 to 40 years: 3.7-5.1 g/dL 41 to 60 years: 3.4-4.8 g/dL 61 to 90 years: 3.2-4.6 g/dL Older than 90: 2.9-4.5 g/dL abnormal findings: ↑ in acute and chronic liver disease, kidney disease, and malnutrition
What is the sarcolemma?
The cell membrane of the muscle fiber and Electrical impulse is sent over this.
Why are the eyes often affected first in myasthenia gravis?
The eyes are controlled by very small muscles. Largermuscles have many more fibers, and if some are weak,others can take over.
How does the liver function in phagocytosis by Kupffer cells?
The fixed macrophages of the liver (named Kupffer cells or stellate reticuloendothelial cells) phagocytize worn formed elements and pathogens.
What is perilymph?
The fluid between bone and membrane
How does the liver function in storage?
The liver stores the minerals iron and copper; the fat-soluble vitamins A, D, E, and K; and the water-soluble vitamin B12.
What is treatment for Helicobacter pylori?
The most effective treatment for H. pyloriis triple therapy: two antibiotics to decrease bacterial resistance and a proton pump inhibitor (PPI) or H2-receptor antagonist.
Why couldn't Max receive tissue plasminogen activator (tPA)?
The onset of his symptoms was unknown, so it could not be confirmed that he was within the 4.5-hour window. After 4.5 hours, the risks of tPA outweigh the potential benefits.
A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful? 1. The patient rates the pain at 3 to 4 on a 0 to 10 scale. 2. The patient has full range of motion of the upper extremities. 3. The patient verbalizes the need for daily strengthening exercises. 4. The patient is able to ambulate 25 feet safely.
The patient is able to ambulate 25 feet safely.
A 67-year-old gentleman being evaluated and treated in the emergency department for a stroke has clopidogrel (Plavix) ordered per os (PO) now. Which of the following would cause the nurse to hold the medication? Select all that apply. 1. The patient has weak grip strength in the right hand and strong in the left. 2. The patient's smile is crooked. 3. The patient's gag reflex is positive. 4. The patient's voice sounds gurgly after taking a sip of water. 5. The patient's blood pressure is 168/90 mm Hg. 6. The patient has an allergy to aspirin.
The patient's smile is crooked, The patient's voice sounds gurgly after taking a sip of water,
What is gavage?
The process of giving a tube feeding
The nurse turns a 2-day postoperative patient with a right total hip replacement using three pillows between the legs. The nurse later returns and finds the patient lying supine with legs crossed. Which of the following should the nurse immediately observe to determine whether a complication has developed? 1. The right knee for crepitation 2. The left leg for internal rotation 3. The left leg for loss of function 4. The right leg for shortening
The right leg for shortening
How does the liver function in activation of vitamin D?
The skin, kidneys, and liver each perform a role in providing the body with activated vitamin D.
What is the synaptic cleft?
The space between the muscle fiber and the motor neuron and Acetylcholine is released into this area.
What are the therapeutic interventions for stroke?
Thrombolytic therapy, Airway management, Control of hypertension, fever, glucose, and Seizure prevention** (big one**)
What are the therapeutic interventions for myasthenia gravis?
Thymectomy, Anticholinesterase agents, Steroids, and Plasmapheresis
What are the therapeutic interventions for the external ear?
Topical antibiotics, Irrigations, Analgesics, and Incision & drainage
What is the acute treatment of Ménière Disease?
Tranquilizers, Vagal blockers, and Bedrest
How can hepatitis be prevented?
Transmission precautions, Standard precautions, Hand hygiene, Vaccines (for HAV and HBV), Immunoglobulin (IGs are plasma donor antibodies that circulate in the recipient's blood for up to 3 months.), and Public health measures
What is the purpose of the optic nerve?
Transmit images
What needs to be treated with gastric bleeding?
Treat hypovolemic shock if present.
What are the symptoms of Ménière Disease?
Triad of symptoms: Vertigo, Hearing loss, and Tinnitus
The patient with which disorder would benefit from avoiding cold windy weather? 1.Amyotrophic lateral sclerosis 2.Bell palsy 3.Trigeminal neuralgia 4.Multiple sclerosis
Trigeminal neuralgia
What are the Cranial Nerve Disorders?
Trigeminal neuropathy/neuralgia and Bell palsy
What is a Fistula?
Tunnel connection between bowel and another organ
What are the s/s of chronic gout?***
Urate deposits under skin (tophi) and Renal stones
Which of these laboratory values should the nurse monitor for a patient with gout? 1. Blood urea nitrogen 2. Creatinine 3. Uric acid 4. Cholesterol
Uric acid
Which cranial nerve contributes to control of heart rate and blood pressure? 1.Trochlear 2.Abducens 3.Vagus 4.Accessory
Vagus
What is the significance of abnormal findings of prothrombin time (PT)?
Value prolonged. Liver can no longer make prothrombin; patient bleeds more easily.
What are dilated esophageal veins?
Varices
Why must you verify tube placment?
Verifying tube placement is essential to prevent complications or death from incorrect tube placement. NG tube placement must be verified after insertion and then intermittently to ensure the tube is in the correct position and not in the lungs, esophagus, pleural space, or brain.
What is Varices?
Weakened, swollen veins
What is the etiology of an abdominal hernia?
Weakness in abdominal wall with increased intra-abdominal pressure
What is obesity?
Weight >20% than ideal body weight
What is an example of a virus that causes meningitis?
West Nile
What are the s/s of lower gastrointestinal bleeding?
When blood has been in the GI tract for more than 8 hours and has come in contact with hydrochloric acid, it causes melena, or black and tarry stools. The presence of melena indicates bleeding above or in the small bowel. Bleeding from the colon or rectum is usually bright red (hematochezia). (Occult blood, melena, bright-red stools)
What are the diagnostic tests for fractures?
X-ray and Computed tomography (C T) scan
What is a dislocation?
a common injury in which the ends of the bones (joints) are moved out of their normal position
What is Paget's disease?***
a rare, noncurable metabolic bone disease that results in abnormal weak bones and is painful
What is jaundice a sign of?
a red blood cell disorder
What is it called when you wire a pts jaw shut?
a reduction (you reduce it back into place)
What is audiometric testing?
a screening tool to determine the type and degree of hearing loss
Is Foul-smelling, fatty stools normal or abnormal for the pancreas?
abnormal
Is Jaundice normal or abnormal for the pancreas? 7. _____
abnormal
Is Pleural effusion normal or abnormal for the pancreas?
abnormal
Is Positive Chvostek sign normal or abnormal for the pancreas?
abnormal
Is Presence of Cullen sign normal or abnormal for the pancreas?
abnormal
What nerve is being assessed when using the hands to check neck/shoulder strength?
accessory
What is the Achilles tendon (calcaneal tendon)?
ankle area
Loss of appetite. _____
anorexia
Where is the synovial joint?
between the articular cartilage and ligaments
How is abdominal girth measured?
by placing a tape measure around the patient's abdomen at the iliac crest. A mark is made at the measurement site so measurements are made at the same location for comparison.
What is thrombotic?
caused by a clot
What is hyperthermia a nursing diagnosis for?
central nervous system infections
Liver disease may cause _____ disorders.
clotting
What is dexamethasone (Decadron)?
corticosteroid
What are the types of intracranial surgery?**
craniotomy (to open), craniectomy (to remove), and cranioplasty (to repair)
What is sequestrum?*****************
dead bone resulting from ischemia
What are sensory (afferent) neurons?
detect stimuli (such as touch, pressure, heat, cold, or chemicals) and then transmit information about the stimuli to the CNS
What is diplopia?
double vision
Which type of neuron transmits impulses from the central nervous system to the muscles and glands? 1. Afferent 2. Efferent
efferent
An ________________ is a test that uses scalp electrodes to evaluate brain activity.
electroencephalogram
What is pancreatic lipase?
emulsified fats to fatty acids/monoglycerides
What are pts receiving a proctosigmoidoscopy and a colonoscopy at risk for?
falls
What happens as a result of muscle strength declination as we age?
falls
Muscle twitching, or ____________, occurs in amyotrophic lateral sclerosis.
fasciculation
What is a continent ostomy?
formed by taking a portion of the terminal ileum to construct an internal reservoir with a nipple valve. A stoma is created, and the patient is taught to insert a catheter into the stoma three or four times a day to empty the reservoir. A continent ileostomy surgical procedure takes longer and requires additional instruction for the patient to be able to do self-care. It is important for the patient to empty the pouch routinely to prevent pouch rupture.
What is the temporal bone?
forms lower sides of cranium and part of cranial floor contains middle and inner ear structures
What is the etiology of Huntington's disease?
genetic (autosomal dominant)
What is the os coxae?
hip bone
What is a nursing implication for phenytoin (Dilantin)?
hold tube feeding 1 hour before med admin and 2 hours after (b/c it binds to tube feedings)
What is the etiology of seizures?
idiopathic (no cause identified) or acquired (underlying neurological disorder (such as brain injury))
What is ataxia?
imbalanced, staggering gait
What is cushing triad a symptom of?
increased intracranial pressure
What is osteomyelitis?***
infection of the bone
What is the patella?
kneecap
What is the epidural space?
lies between the outer covering of the spinal cord and the vertebrae; it contains a cushioning layer of fat as well as blood vessels and connective tissue
What is the mandible?
lower jaw bone
Is foot drop a symptom of lumbar or cervical spine dysfunction?
lumbar
Is inability to walk on the toes a symptom of lumbar or cervical spine dysfunction?
lumbar
What is a gastric analysis?
measures the secretions in the stomach. (The two tests performed are the basal cell secretion test and the gastric acid stimulation test.)
What is nuchal rigidity a symptom of?
meningitis
What is some subjective data collected during a neurological assessment?
mental status, intellectual function, thought content, perception, language ability, memory, and pain (pain is a priority)
What is the brainstem made of?
midbrain, pons, and medulla oblongata
What is cerebral vasoconstriction followed by vasodilation a symptom of?
migraine
What is the myelin sheath made of?
mostly lipids
What is the frontal lobe responsible for?
motor function, speech motor function (Broca's area), and personality aspects including imitativeness, emotion, judgement, reasoning, and conscience
What controls the six cardinal fields of gaze?
motor nerves
Which procedure does the nurse understand is used to drain fluid from the inner ear? 1. Myringotomy 2. Myringoplasty 3. Mastoidectomy 4. Stapedectomy
none of the above
Is Blood pressure and pulse 15% from patient's baseline normal or abnormal for the pancreas?
normal
Is Serum lipase = 15 unit/L normal or abnormal for the pancreas?
normal
What is a closed fracture?
one that does not break the skin
Which fracture has an increased risk for infection?
open fracture
What nerve is being assessed when using a snellen chart?
optic
What is important for a pt with reduction/fixation?
oral care (can't brush their teeth but can use mouthwash)
What is important to your overall health?
oral health care
What is the biceps femoris?
part of the muscles of hte hamstring
What is the semimembranosus?
part of the muscles of hte hamstring
How are seizures classified?
partial or generalized
What is a spontaneous fracture from bone disease?
pathilogical
What is indicative of fatty embolism?
petechia of the chest
What is external fixation management of a fracture?
pins or metal frame that allows for care of wounds (used when bone damage is severe, as in crushed or splintered fractures, or if the bone has numerous breaks. After the fracture is reduced, the surgeon inserts pins into the bone. The pins are held in place by an external metal frame to prevent bone movement) (you can see it)
Myasthenia gravis is sometimes treated with _____, which separates blood cells from plasma to remove antibodies.
plasmapheresis
What is the postoperative care to prevent hip dislocation after a total hip replacement?
prevent adduction or hyperflexion (usually with an abductor pillow which immobilizes the legs)
What are the types of gout?
primary and secondary
What do osteoblasts do?
produce bone growth and repair bone
What is the only digestive function of the liver?
production of bile
Avoid high _________ foods, such as organ meats, shellfish, and oily fish, such as ____________.
purine; sardines
The _______ sphincter prevents backup of duodenal contents into the stomach.
pyloric
What are motor (efferent) neurons?
relay messages from the brain (which the brain emits in response to stimuli) to the muscle or gland cells
What is Crohn's disease marked by?
remissions and exacerbations
What are the nine abdominal regions?
right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right iliac, hypogastric, left iliac
What are the symptoms of a left-sided infarct?
right-sided weakness or paralysis, aphasia (in left-brain-dominant clients), and depression related to disability is common
What is the scapula?
shoulder blade
What is the parietal bone?
sides of cranium
What is the postoperative care for a total knee replacement?
similar to total hip replacement (Ex. infection prevention, NEUROVASCULAR CHECK, wound care, ambulation, ect.)
What function does the temporal lobe control?
speech
What is anxiety a nursing diagnosis for?
spinal cord injury
What is constipation a nursing diagnosis for?
spinal cord injury
What is impaired gas exchange a nursing diagnosis for?
spinal cord injury
What is the nursing care for metastatic bone disease?
supportive care (as with other cancers)
What is a sign of a broken clavicle?
the arm/shoulder will hang/droop forward (they will often pick it up and put it in place with a figure eight bandage that goes around both shoulders)
The nurse is collecting data on a patient who is experiencing an acute attack of gout. Which area will the nurse expect the patient to have most commonly occurring symptom of gout.
the big toes
What is the clavicle?
the bone of the shoulder girdle/ collar bone
What is Broca's area?
the motor speech area that controls the movements involved in speaking
What are the quadriceps femoris?
the muscle group that extends the leg, located in the anterior thigh (comprised of rectus femoris, vastus lateralis, and vastus medialis)
What is true of farsightedness/distant objects?
the nearly parallel light rays require little light refraction thus the ciliary muscle relaxes
How do people with macular degeneration see?*****************
they cannot see through the center of the eye and only see the periphery (WHICH CAN CAUSE SAFTEY CONCERNS)
What is true of fused bones?
they do not move
What is the femur?
thigh bone
What is the preoperative care for a total hip replacement?
total joint education program and autologous blood donation (The patient donates blood before surgery per guidelines (e.g., time frames specified, hemoglobin levels normal). This blood is then available for reinfusion postoperatively if needed.)
Which is done more often a total knee replacement or a total hip replacement?
total knee replacement
What is the etiology of Bell Palsy?
unknown
What is the cause of Crohn's disease?
unknown but (AUTOIMMUNE and hereditary link)
What is prodromal?
warning sign
What is contralateral hemiparesis?
weak on opposite side
What is an aneurysm?
weakness in artery wall
What is at the bedside of a pt with a jaw fixation?
wire cutters in case they begin to vomit profusely (pt will eat through a straw this pt will be on antiemitics)
What are the carpals?
wrist bones
What is the diagnostic test for Paget's disease?
x-ray
What is the rational for interventions for the nursing diagnosis impaired physical mobility r/t hip precautions and surgical pain?
• Activity is restricted due to hip precautions and weight-bearing limitations. • Immobility complication scan occur in multiple body systems if preventive measures are not used.
How can you evaluate the interventions for the nursing diagnosis impaired physical mobility r/t hip precautions and surgical pain?
• Does the patient transfer and ambulate as instructed by physical therapy? • Is the patient free from complications of immobility?
The nurse knows the patient understands teaching about an angiogram when the patient makes which of the following statements? 1. "A small needle will be inserted into my spinal column to withdraw fluid for examination." 2. "I will be in a large machine that uses magnetic energy to create images; it has a noisy knocking sound." 3. "Electrodes will be placed on my head to monitor electrical activity in my brain." 4. "A catheter will be placed in an artery in my groin, and dye will be injected that will make my vessels show up on x-ray."
"A catheter will be placed in an artery in my groin, and dye will be injected that will make my vessels show up on x-ray."
A patient with amyotrophic lateral sclerosis expresses concern about not having enough breath to sing anymore. Which explanation by the nurse is best? 1. "Amyotrophic lateral sclerosis can damage the nerves to your bronchi and bronchioles, causing constriction and reduced airflow." 2. "The demyelination of your nerves caused by amyotrophic lateral sclerosis causes confusion in the impulses to your lungs." 3. "Amyotrophic lateral sclerosis can affect your vocal cords, making it difficult to form sounds as you speak or sing." 4. "Amyotrophic lateral sclerosis may be affecting the nerves that go to your respiratory muscles, making them weak."
"Amyotrophic lateral sclerosis may be affecting the nerves that go to your respiratory muscles, making them weak."
The nurse is teaching the patient ear care after ear surgery. The nurse would evaluate the patient as understanding the teaching if the patient stated which of these ways to care for the ear after surgery? 1. "I will blow my nose very gently for the first week after surgery." 2. "I should blow both sides of my nose at the same time." 3. "I will avoid sneezing for 2 weeks." 4. "I will cough with my mouth open for 1 week after surgery." 5. "I will not fly for 1 week after surgery." 6. "I will change the cotton plug daily."
"I will blow my nose very gently for the first week after surgery.", "I will cough with my mouth open for 1 week after surgery.", "I will not fly for 1 week after surgery.", and "I will change the cotton plug daily."
The nurse is caring for a patient with bacterial conjunctivitis. The patient would require further teaching if the patient stated which of the following? Select all that apply. 1."It is not a contagious infection." 2."It is also called 'pinkeye'." 3."Antiviral eyedrops are used to treat it." 4."Conjunctival redness, itching, and pain may occur." 5."Frequent hand hygiene is essential."
"It is not a contagious infection." and "Antiviral eyedrops are used to treat it."
A patient makes an appointment to see a health care provider for recurrent severe headaches. Which instruction by the nurse will help gather the best additional data before the appointment? 1. "Try relaxation and warm moist compresses for your headaches and document your response." 2. "Call and come in the next time you have a headache so you can be examined." 3. "Keep track of how many headaches you have before you come in." 4. "Keep a diary of your headaches, recording symptoms, timing, and headache triggers."
"Keep a diary of your headaches, recording symptoms, timing, and headache triggers."
A patient sees the health care provider after falling twice for seemingly no reason. Diagnostic tests are done, and the patient is diagnosed with multiple sclerosis. Which of the following explanations will help the patient understand the disease? 1. "You have a buildup of myelin in your nervous system, causing congestion and muscle weakness." 2. "You are missing a neurotransmitter that is important to muscle contraction." 3. "The receptor sites on your muscles are damaged, so they can't contract correctly." 4. "The insulation on your nerve cells is damaged, which slows the impulses to the muscles."
"The insulation on your nerve cells is damaged, which slows the impulses to the muscles."
A patient is wondering about ileostomy odor and is provided information by the nurse. Which of the following responses by the patient would indicate that teaching has been effective? Select all that apply. 1. "A teaspoon of baking soda in your pouch will absorb all the odor." 2. "The plastic in the pouch is odor-proof, so there is no odor as long as there is no leak." 3. "Effluent from an ileostomy can have an odor." 4. "Changing your pouch and face plate daily will help prevent odor." 5. "Colostomies are the only ostomy that can smell bad from time to time."
"The plastic in the pouch is odor-proof, so there is no odor as long as there is no leak." and "Effluent from an ileostomy can have an odor."
The nurse evaluates the patient as understanding teaching on the purpose of a test dose of gold therapy if the patient states which of these? 1."To avoid waste of expensive gold." 2."To determine the necessary dose." 3."To determine the therapeutic response." 4."To assess for an allergic reaction."
"To assess for an allergic reaction."
The nurse evaluates the patient as understanding the primary reason that food and fluids are held until the gag reflex returns after an esophagogastroduodenoscopy procedure if the patient states which of these? 1. "To rest the vocal cords." 2. "To prevent aspiration." 3. "To keep the throat dry." 4. "To prevent vomiting."
"To prevent aspiration."
A patient has been prepped for an internal eye examination. Anesthetic drops and a mydriatic drug have been administered. Which instruction should the patient be taught for eye safety following the examination? 1. "Wear sunglasses after the exam." 2. "Rub your eye hourly to increase blood circulation." 3. "You may reapply contact lenses when the eye exam is completed." 4. "Flush your eye with water to remove the eye drops."
"Wear sunglasses after the exam."
The nurse is assigned to care for a patient who has been diagnosed with a musculoskeletal disease that causes decreased bone density. Which data collection questions are most appropriate by the nurse? Select all that apply. 1. "Do you have any broken bones?" 2. "Has your doctor informed you not to exercise so you will not break a bone?" 3. "What forms of physical activity are you able to participate in?" 4. "Does your spouse have bone problems?" 5. "Do you exercise regularly?" 6. "What is typically included in your daily diet?"
"What forms of physical activity are you able to participate in?", "Do you exercise regularly?", and "What is typically included in your daily diet?"
Which explanation would the nurse give to the patient who had a Snellen chart finding of 20/80? 1. "You can see at 80 feet what those with normal vision can see at 20 feet." 2. "You can see at 20 feet what those with normal vision can see at 80 feet." 3. "You can see four times farther than those with normal vision can see." 4. "Your vision is normal."
"You can see at 20 feet what those with normal vision can see at 80 feet."
What are the interventions for the nursing diagnosis impaired physical mobility r/t hip precautions and surgical pain?
*Reinforce transfer and ambulation techniques. • Monitor the patient for and take measures to prevent complications of immobility. • Turn patient every 2 hours to the side ordered and check skin .• Keep heels off bed .• Teach patient to deep breathe and cough every 2 hours while awake. • Teach use of incentive spirometer every hour while awake. • Apply thigh-high elastic stockings as ordered. • Give anticoagulants as ordered. • Encourage the patient to practice leg exercises. • Mobilize the patient as soon as possible as prescribed.
The nurse needs to administer aspirin 62 mg to a post-stroke patient. It is supplied in 1-grain tablets. How many tablets should the nurse prepare? __________
1 tablet
What is the therapeutic level for phenytoin (Dilantin)?
10-20 mcg/mL
How many thoracic vertebrae are there?
12
What are the ribs?
12 thin, flat, curved bones that form a protective cage around the organs in the upper body
What is the normal vision for a Snellen chart/E chart/Rosenbaum card?
20/20 (this means the patient can see at 20 feet what the normal eye clearly sees at 20 feet.****)
What is the normal vision for a LogMAR chart?
20/20=0.00
What is the window to administer thrombolytic therapy?************
3- 4.5 hours
The nurse cares for patients after eye surgery. Which of these patients would the nurse provide specific positioning instructions to after eye surgery to prevent complications? 1. 19-year-old after removal of congenital cataract 2. 30-year-old woman after pneumatic retinopexy 3. 52-year-old man after trabeculectomy 4. 82-year-old man after corneal transplant
30-year-old woman after pneumatic retinopexy
Which of these drug classes does the nurse recognize are used for Crohn disease treatment? Select all that apply. 1.5-aminosalicylates 2.Biologic response modifiers 3.Corticosteroids 4.Diuretics 5.Immunomodulators 6.Laxatives
5-aminosalicylates, Biologic response modifiers, Corticosteroids, and Immunomodulators
What is the therapeutic level for valproic acid (Depakote)?
50-100 mcg/mL
What is the prevalence of osteoporosis?
54 million people have it (women are at greatest risk) (Healthy People 2020 objective: Reduce proportion of adults over age 50 with osteoporosis from 5.9% to 5.3%.)
What is the therapeutic level for carbamazepine (Tegretol)?
6-12 mcg/mL
What is an obese BMI?
>30 kilogram per square meter
What is the ideal waist circumference for women?
>35 inches
What is the ideal waist circumference for men?
>40 inches
The nurse is planning a teaching session for a patient with a peptic ulcer. Which of these would the nurse include in the teaching plan as the primary cause of peptic ulcers? 1. Eating spicy foods 2. A stressful life 3. A bacterial infection 4. Excessive caffeine intake
A bacterial infection
What is Angular Cheilosis?
A condition known as angular cheilosis (red, raw corners of the mouth) develops more often in older adults. It may be from infection, deficiency of riboflavin (vitamin B2), or loss of facial profile caused by worn-down or damaged dentures or the patient not wearing his or her dentures. It is treated with anti-infective medications, vitamins, or new dentures.
What causes lactose intolerance?
A deficiency in lactase, an enzyme that breaks down lactose (milk sugar)
What are the complications of appendicitis?
Abscess
Acute liver failure is most often caused by which of the following? 1. Antibiotic use 2. Daily vitamins 3. Alcohol use 4. Acetaminophen (Tylenol) overdose
Acetaminophen (Tylenol) overdose
Which of the following is the transmitter at neuromuscular junctions? 1. Sodium ions 2. Acetylcholine 3. A nerve impulse 4. Cholinesterase
Acetylcholine
What are neoplastic disorders?**
Acoustic neuroma (which is a conductive tumor of the eighth cranial nerve/vestibulocochlear nerve that is Benign)
What is included in range of motion of the musculoskeletal system?
Activities of daily living and Hands (Opposition, fist)
What is the nursing process for myasthenia gravis?
Activity intolerance (Teach methods to conserve energy, Teach avoidance of infection, Teach signs and symptoms of crisis, and Teach medications to avoid) and Support group
Which of these is the priority nursing diagnosis for acute pancreatitis? 1.Acute Pain 2.Risk for Deficient Fluid Volume 3.Risk for Impaired Skin Integrity 4.Ineffective Breathing Pattern
Acute Pain
What are the nursing diagnoses for gastric surgery?
Acute Pain and Fear
What are the nursing diagnoses for gallbladder disorders?
Acute Pain and Risk for Deficient Fluid Volume
What are the nursing diagnoses for inflammatory or infectious disorders?
Acute Pain and Risk for Deficient Fluid Volume
What are the nursing diagnoses for osteoarthritis?
Acute Pain, Activity Intolerance, Chronic Sorrow, Disturbed Body Image, Impaired Physical Mobility, and Self-Care Deficit (Bathing, Dressing, Feeding, Toileting)
What is a medical emergency?******
Acute angle-closure glaucoma (AACG)
What is a bone scan?
After injection, a radioisotope is taken up by bone and 2 hours later a camera scans the body front and back
The nurse is caring for a patient with chronic pancreatitis. While reviewing laboratory data, the nurse would expect an elevation in which serum laboratory value? 1. Albumin 2. Amylase 3. Bilirubin 4. Calcium
Amylase
Which pancreatic enzyme Digests starch to maltose?
Amylase
Why was an angiogram planned for Mrs. Beason?
An angiogram can be used to check the carotid arteries for occlusion, which can increase risk of stroke. Mrs. Beason may have been having warning signs of an impending stroke.
Which of the following nursing interventions should be included in the plan of care for a patient at risk for foot drop? 1. Position the patient in the left lateral position. 2. Provide daily foot massage. 3. Apply high-top tennis shoes. 4. Maintain the patient in an upright position as much as possible.
Apply high-top tennis shoes.
What is the pathophysiology of osteoarthritis?
Articular cartilage/joints bone ends deteriorate causes Joint space narrows, bone spurs develop, joint inflamed resulting in Joint deformities, pain, and immobility (affects Weight-bearing joints such as knees and hips) (Affects entire joint)
What is Gingival Recession?
As people age, it is not unusual for their gingivae (gums) to recede or shrink, exposing the root surfaces of the teeth. This can lead to root sensitivity, tooth decay, or both. To protect the teeth from tooth decay as a result of dry mouth or gingival recession, a fluoride gel (Gel-Kam), rinse (ACT), or a prescription toothpaste with high fluoride is strongly recommended.
What is the collection of fluid in abdominal cavity?
Ascites
The nurse is to gather subjective visual patient data. What action should the nurse take? Select all that apply. 1.Check visual fields by confrontation. 2.Check six cardinal fields of gaze. 3.Ask visual symptoms. 4.Perform cover test. 5.Obtain health history. 6.Check pupillary reflexes.
Ask visual symptoms and Obtain health history.
What are the complications of myasthenia gravis?
Aspiration, Respiratory infection and failure (LEADING CAUSE OF DEATH), Myasthenic crisis (sudden onset of muscle weakness resulting from not enough medication) , and Cholinergic crisis (overmedication with anticholinesterase drugs)(Sludge for CC)
Which of the following medications should a patient with gout be encouraged to avoid in order to prevent a gout attack? (select all that apply) 1. Aspirin 2. Acetaminophen 3. Motrin 4. Codeine 5. Excedrin 6. Percodan
Aspirin, Excedrin, and Percodan
What should be done for a pt with a self-care deficit?
Assess ability to perform activities of daily living, Encourage independence by placing objects in reach and providing assistive devices, Assist to learn use of nondominant side, and Involve and educate family.
What should be done for a pt with disturbed sensory perception?
Assess for sensory deficits, Teach patient to scan environment, and Protect skin.
What is the risk for caregiver role strain?
Assess impact of patient's needs on caregiver., Assist caregiver to identify resources, Consult social worker or case manager, and Consider skilled nursing facility as needed.
The nurse is caring for a patient who has normal saline infusing. The patient suddenly requests assistance to the bedside commode and has bright red liquid stools and reports feeling weak and having visual disturbances. Which actions should the nurse take immediately? Rank these nursing actions in order of priority. 1. Notify health care provider. 2. Measure output. 3. Obtain vital signs. 4. Check patency of intravenous site and infusion. 5. Assist patient into bed. 6. Cover with warm blankets. 7. Identify level of consciousness. 8. Perform rapid head-to-toe assessment.
Assist patient into bed. Cover with warm blankets. Check patency of intravenous site and infusion. Obtain vital signs. Identify level of consciousness. Perform rapid head-to-toe assessment. Measure output. Notify health care provider.
What is the self-care for a total hip replacement?
Assistive dressing devices, Raised toilet seat (to prevent hyperflexion), and Rehabilitation
What is the preprocedure care for an electroencephalogram?
Assure hair is clean and dry and Check medication orders
What is the preprocedure care for magnetic resonance imaging (MRI)?
Assure no pacemaker or metal on patient. (tattoos need to be covered), Administer analgesic or sedative as ordered, and Teach relaxation (b/c procedure is very loud)
What is the Liver flap?
Asterixis
What are the therapeutic interventions for ulcerative colitis?
Avoid offending foods, take Medications (including 5-aminosalicylates, Antidiarrheals, Biologic response modifiers, Corticosteroids, and Immunomodulators), and Surgery if necessary
The nurse is caring for a patient who is 72 years old, postmenopausal, has osteoporosis, lost 2 inches of height, is thin, and has never exercised regularly. Which of these interventions should be included in the plan of care to prevent further bone loss? 1. Avoid weight-bearing activities. 2. Avoid smoking. 3. Encourage muscle strengthening exercise. 4. Encourage weight gain. 5. Encourage calcium 1,000 milligrams daily 6. Encourage vitamin D 800 IU daily
Avoid smoking, Encourage muscle strengthening exercise, and Encourage vitamin D 800 IU daily
The nurse is caring for a patient after cataract surgery. Which safety instruction should the nurse give this patient? Select all that apply. 1. Elevate the head of your bed 45 degrees. 2. Avoid swimming after surgery. 3. Avoid caffeinated beverages. 4. Report sudden sharp pain to the health care provider. 5. Report increased drainage to the health care provider. 6. Keep follow-up appointment after surgery.
Avoid swimming after surgery, Report sudden sharp pain to the health care provider, Report increased drainage to the health care provider, and Keep follow-up appointment after surgery.
How often will pin care be done typically?
BID (never apply any ointment to the pin sites unless ordered by physician. never use any betadine or iodine products unless ordered by physician b/c this is an open wound typically he/she will order normal saline)
What are the s/s of osteoporosis?
Back pain, Height decreases, Fracture, and Kyphosis (a forward curvature of the spine/hunch back)
What are some causes of hepatitis?
Bacterial infection, Drugs, alcohol, chemicals toxic to the liver, Metabolic or vascular disorders, and OFTEN CAUSED BY A VIRUS
What are the causes of diarrhea?
Bacterial/viral infection and Food allergies
A patient with ascites is placed on a low-sodium diet. The nurse knows that diet teaching has been successful if the patient selects which of the following meals? 1. Cottage cheese and peaches with tomato juice 2. Frankfurter on a bun with pickle relish and skim milk 3. Baked chicken, brown rice, and apple juice 4. Turkey and lettuce sandwich on whole-wheat bread with tomato soup
Baked chicken, brown rice, and apple juice
What is replantation?
Because in these patients the amputated part is usually healthy, attempts at replantation can occur. One of the most common replantations is one or more fingers. Prehospital care of the severed body part includes rinsing if dirty and wrapping in a clean, moist cloth that is placed in a sealed plastic bag. The bag should then be placed into ice cold water until the body part is transported to the hospital. The surgical procedure is performed by specialists who operate using a microscope. Nerves, vessels, and muscle must be reattached.
What is Melena?
Blood in stool
What are the diagnostic tests for encephalitis?
C T scan, M R I, Electroencephalogram (E E G), and Lumbar puncture with cerebrospinal fluid (C S F) analysis
What is a Sump tube?
Double lumen with one lumen; an air vent prevents tube adherence to the stomach lining. That is used for decompression, irrigation, lavage, and medication administration. (nursing considerations May be used with continuous suction because of air vent. Air vent must not be plugged off. Can remain in place for 30 days.)
What is ptosis?
Drooping of the upper eyelid as a result of paralysis.
What is Endoscopic retrograde cholangiopancreatography (ERCP)?
Endoscopy allowing visualization of pancreatic and biliary ducts, and x-rays with contrast media. Normal findings: normal structures without obstruction. (abnormal findings indicate Gallstones, bile duct or pancreatic disease) Pretest: See EGD. Teach: Fast 6 hours, restrict clear fluids 2 hours before exam, and avoid anticoagulants as ordered. Posttest: Keep NPO until swallow and gag reflex returns, then eat lightly for 24 hours. Monitor vital signs, contrast reaction signs, and intake and output. Teach: Throat will be sore with hoarseness.
The nurse is assisting with a Romberg test. What is the most important nursing action during the Romberg test? 1. Ensure a quiet environment. 2. Ensure patient safety. 3. Remove all cerumen from ear canal. 4. Whisper softly into each ear.
Ensure patient safety.
What are the normal results of an assessment of the visual fields?
Equal to health care provider's
What is diarrhea?
Fecal matter passes rapidly causing Decreased absorption of water, nutrients (Prevention important)
What are the s/s of restless legs syndrome?
Feeling of Creeping crawly, Feeling of Throbbing, Feeling of Pulling, Feeling of Pins and needles, Daytime fatigue, and Insomnia
What is intestinal obstruction?
Flow of intestinal contents is blocked (can be Partial or complete blockage)
What is Cholelithiasis?
Gallstones within the gallbladder
Which nursing interventions are appropriate for the patient with a neurodegenerative disorder who has difficulty swallowing? 1. Have the patient tuck his or her chin down during swallowing. 2. Provide clear to full liquids and avoid solid foods. 3. Place the patient in semi-Fowler's position for eating. 4. Provide adaptive eating utensils.
Have the patient tuck his or her chin down during swallowing.
What are the complications of ulcerative colitis?
Hemorrhage, Toxic megacolon, Perforation, Peritonitis, Osteoporosis, and Increased risk for colorectal cancer
What are some anorectal problems?
Hemorrhoids, Anal fissures (aka tear), and Anorectal abscess
What are the risk factors for osteoarthritis?
Heredity, Aging, Obesity, and Excessive "wear and tear" on synovial joints
What are the s/s of severe gastric bleeding?
Hypovolemic shock, weak pulse, chills, and palpitations
What are the therapeutic interventions for hepatitis?
Identify cause, Monitor liver function, Relieve symptoms, Prevent cirrhosis, Educate on hydration and nutrition, Rest, Avoid alcohol and liver-toxic drugs, supportive care (for HAV & HEV aka fecal-oral route), PEGylated interferon therapy (used for HBV &HDV to kill virus aka blood transmission), antivirals (B), PEGylated interferon therapy (B), and liver transplant (all for HBV), direct-acting antiviral medications such as Sofosbuvir and Sofosbuvir/ledipasvir (Harvoni) (for HCV), and certain genotypes (interferon therapy) (for HCV)
What is the nursing diagnosis for obesity?
Imbalanced Nutrition: More Than Body Requirements
When caring for a patient admitted with Guillain-Barré syndrome, which nursing diagnosis should take priority? 1. Anxiety 2. Imbalanced Nutrition 3. Impaired Gas Exchange 4. Impaired Physical Mobility
Impaired Gas Exchange
What are the effects of age-related changes to the musculoskeletal system?
Impaired mobility, Increased risk for falls, and Pain
What is the nursing diagnosis for diabetic retinopathy?
Ineffective Health Management
How should one enter the room of a person who is blind?
Knock before entering. Always state who you are and what you are doing.
What are the s/s of a complex partial seizure?**
LOSE CONSCIOUSNESS AND LASTS 2-15 MINUTES**
What is part of the assessment for a pt with a cerebrovascular disorder?
Level of consciousness, Restlessness, Dizziness, Vision changes, Pupil changes, Vital signs, Pain, Peripheral oxygen saturation (S p O subscript 2) (should be 92 or above), Paresthesias, Weakness, Paralysis, Seizures, Respiratory status, and Swallowing
How is a brain tumor diagnosed?
M R I, Angiogram, Magnetic resonance angiogram, and Hormone levels
What are the causes of spinal cord injury?
M V C's, Falls, Sports injuries, and Assault
What is the emergency care for seizures?
MONITOR AIRWAY (important), Turn on side to prevent aspiration, Pad side rails, Prevent injury, Do not restrain, Suction as needed, and Observe and document. (Ex. did they have aura? How long did the seizure last? and Describe what you saw.)
What is the significance of abnormal findings in an Alanine aminotransferase (ALT)? (seen in CMP)
Most specific enzyme for liver damage. Can elevate 50 times normal with death of liver cells.
What is the pathophysiology of Amyotrophic Lateral Sclerosis (ALS)/Lou Gehrig disease?
Motor neurons degenerate causing Nerve impulse transmission to be blocked resulting in Muscle weakness and atrophy
What should a pt never do if they have an itch in their cast?
NEVER put anything in the cast (if they break the skin they could not know it and get a serious infection)
What is the purpose of aqueous humor?**
Nourishes lens/cornea
What is thrush?
Older adults are susceptible to oral yeast infections (caused by Candida albicans) caused by certain medications, systemic conditions, or chemotherapy. Nystatin oral rinse treats this infection.
What are the s/s of spinal cord injury that causes thoracic/lumbar injury?
Paraplegia/paresis and Altered bowel and bladder control
What is the preoperative care for an intracranial surgery?
Patient education, Anxiety control, and Intensive care unit visit
What is nonmechanical intestinal obstruction?*****
Peristalsis impaired with Bowel sounds absent
What is the nursing care for the gastrointestinal feedings?
Placement check, Head of bed elevation 30 to 45 degrees, and Monitor for tolerance
The health care provider documents that the patient has a progressive hearing loss and loss of high frequency sounds. Which term does the nurse understand describes this condition? 1.Deafness 2.Pitch 3.Presbycusis 4.Presbyopia
Presbycusis
What is the pathophysiology of Alzheimer's disease?
Progressive degenerative disease with Neurofibrillary tangles and Neuritic plaques
What are the s/s of stage 2 of Alzheimer's disease?
Progressive memory loss, Irritability, Depression, Aphasia, Sleep disruption, Hallucinations, and Seizures
The nurse is caring for a patient who is undergoing an arthroscopy of the knee with ligament repair. Which of the following would be included in nursing preoperative care for the patient the morning of surgery? Select all that apply. 1. Provide toast and clear juice 6 hours before surgery. 2. Provide clear liquids up to 2 hours before surgery. 3. Explain the surgical procedure. 4. Explain the anesthetic agents. 5. Reinforce how to perform coughing and deep-breathing exercises. 6. Teach the patient to perform straight-leg raises.
Provide clear liquids up to 2 hours before surgery and Reinforce how to perform coughing and deep-breathing exercises.
What is the function of the articular cartilage?
Provides a smooth surface on the joint surfaces of bones
What are the triggers for IBS?
Psychological stress/food intolerances, Infection, and Menstruation
The nurse shines a penlight in the patient's eyes and finds the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the nurse asks the patient to focus on a far object, then on the nurse's finger as it is brought in from a distance of 3 feet to 5 inches. The pupils constrict bilaterally, and the eyes turn inward. Which would be the correct documentation of these findings? 1. Pupils 2 mm 2. Pupils constricted 3. Pupils equal, round, and reactive to light and accommodation (PERRLA) 4. Pupils normal
Pupils equal, round, and reactive to light and accommodation (PERRLA)
What is the treatment for Barrett's esophagus?
Radiofrequency ablation removes Barrett's tissue
What is a therapeutic measure for GERD?
Raise head of bed on 4- to 6-inch blocks
What can be done for tumors in the tail of the pancreas?
Rarely a distal pancreatectomy along with spleen removal is done, in which the tail or the tail and some of the pancreas body is removed.
What are the s/s of stage 3 of Guillain-Barre syndrome?**
Recovery (lasts 6 to 24 months)
A patient comes to the health clinic for a suspected ear infection. Which of these data collection findings does the nurse expect with an external ear infection? Select all that apply. 1. Dizziness 2. Fullness in ears 3. Redness 4. Pain 5. Pruritus 6. Swelling
Redness, Pain, Pruritus, and Swelling
What is the etiology of gallbladder disorders?
Risk increases with age, Family history, Bile stasis, High cholesterol intake, Fasting, Sedentary lifestyle, and More often in women (acronym Fat, Fair, Forty, and Female)
What are the diagnostic tests for the musculoskeletal system?***
Serum laboratory tests (including Alkaline phosphatase, Calcium, Phosphorus, Myoglobin, Muscle enzymes, and Uric acid), Arthrocentesis, Arthroscopy, Bone or muscle biopsy, Bone density scan, Computed tomography (C T) scan, Magnetic resonance imaging (M R I), Myelography, Nerve conduction studies (aka Electromyography), Nuclear medicine scans (which is NOT an x-ray**), Radiographs (x-rays), and Ultrasonography
What are the complications of abdominal hernias?
Strangulated incarcerated hernia (a medical emergency b/c you can lose a part of the bowel)
What is the fibularis longus?
Superficial muscle of lateral compartment.
What is the LogMAR chart?
The chart was created to provide better visual acuity measurement than the other visual acuity charts. It is similar to the Snellen chart and measures distance acuity.
True or false: Replace worn inserts and liners when they become too soiled to clean.
True
What are symptoms of cholinergic crisis? Select all that apply. 1.Constipation 2.Urination 3.Vomiting 4.Spasticity 5.Headache 6.Lacrimation
Urination, Vomiting, and Lacrimation
What is included in palpation of the musculoskeletal system?
Warmth, Tenderness, and Neurovascular checks
What is Jaundice?
Yellowing of the sclerae and skin from excess bilirubin
What is spinal stenosis?
a condition in which the spinal canal compresses the spinal cord
Where is the diencephalon?
between the cerebrum and the midbrain
What does decreased dopamine as we age result in?
decreased motor function (which results in more accidents and falls)
What is pancreatic trypsin?
digests polypeptides into peptides
What are the components of a total knee replacement?
femoral, tibial, and patellar button
What is included in the FODMAP diet?**
fermentable oligosaccharides, disaccharides, monosaccharides, and polyol
What does decreased acetylcholine and progressive loss of dendrites as we age result in?
impaired short-term memory
Where is the stomach?
in the upper left abdominal quadrant, to the left of the liver and in front of the spleen.
What occurs as color vision fades?
lesser discrimination of blue, green, and violet colors and red, yellow, and orange colors are seen best
An early symptom of myasthenia gravis is drooping eyelids, also called ____________.
ptosis
What is amputation?
removal of a body part
What is photophobia?
sensitive to light
The process of mechanical digestion is accomplished by the _______ and _______ in the mouth.
teeth, tongue
What lobe is responsible for visual recognition?
temporal lobe
What is true of amputation?
the more of the limb that you can salvage, the easier it is to use a prosthetic and/or move around
What is RICE used to treat?
the therapy for strain injuries
What is ineffective airway clearance a nursing diagnosis for?
traumatic brain injury and spinal cord injury
A 90-year-old nursing home resident with stage 2 Alzheimer disease is found alone and crying in the dining room. She says she lost her mother and doesn't know what to do. Which response by the nurse will help calm the resident? 1. "Remember your mother has been dead for 30 years. You forgot again, didn't you?" 2. "I'm sorry you lost your mother. Let's go and try to find her." 3. "Are you feeling frightened? I'm here and I will help you." 4. "You are 90 years old. It is impossible for your mother to still be living."
"Are you feeling frightened? I'm here and I will help you."
A patient with trigeminal neuralgia asks the nurse why carbamazepine (Tegretol) has been ordered. Which response is best? 1. "It will help decrease the inflammation in your nervous system." 2. "It will depress your immune system, which can slow the progression of the disease." 3. "Carbamazepine is used to help relieve nerve pain." 4. "It is an anticonvulsant to prevent seizures."
"Carbamazepine is used to help relieve nerve pain."
Which instruction would the nurse provide for the patient when testing the trigeminal nerve? 1. "Stick out your tongue." 2. "Turn your head side to side." 3. "I am going to shine a light into your eyes and observe your pupils." 4. "Close your eyes and tell me where you feel the cotton touching your face."
"Close your eyes and tell me where you feel the cotton touching your face."
A patient newly diagnosed with amyotrophic lateral sclerosis verbalizes not wanting to be "kept alive on machines." Which response by the nurse is most appropriate? 1. "I'm sorry to hear that. Your family might feel differently." 2. "Do you have your advance directive prepared?" 3. "I will request a hospice referral for you." 4. "It is too early to make such decisions. Don't think about it yet."
"Do you have your advance directive prepared?"
Which of the following dietary instructions is most important to include in the plan of care to prevent complications for a patient with an ileostomy? 1. "Drink adequate fluids to prevent dehydration." 2. "Avoid fruits and vegetables to prevent diarrhea." 3. "Avoid milk products to prevent gas." 4. "Eat plenty of fiber to prevent constipation."
"Drink adequate fluids to prevent dehydration."
The nurse provides teaching for a patient with a peptic ulcer. Which patient statement would the nurse evaluate as indicating understanding of the purpose of histamine 2 (H2)-receptor antagonists? 1. "H2-receptor antagonists neutralize gastric acid." 2. "H2-receptor antagonists form a protective paste." 3. "H2-receptor antagonists determine gastric pH levels." 4. "H2-receptor antagonists inhibit secretion of gastric acid."
"H2-receptor antagonists inhibit secretion of gastric acid."
Which subjective data question should the nurse ask while collecting data about the patient's eye health? 1. "Have you had any recent upper respiratory infections?" 2. "Have you been on an airplane recently?" 3. "Have you been scuba diving lately?" 4. "Have you seen halos around lights?"
"Have you seen halos around lights?"
A 72-year-old man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath and then says to the licensed practical nurse in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best? 1. "The next time he tries to touch you inappropriately, lightly smack his hand and tell him NO!" 2. "His stroke has made him less inhibited. We'll see if we can find a male assistant to help him." 3. "We have to take care of all patients equally, even the dirty old men." 4. "He didn't mean anything by it; just ignore it."
"His stroke has made him less inhibited. We'll see if we can find a male assistant to help him."
The nurse knows that the patient understands instructions for getting magnetic resonance imaging when the patient makes which statement? 1. "I will have a small Band-Aid on the puncture site." 2. "I will need to wash my hair following it." 3. "I should avoid eating or drinking for 4 hours after the procedure." 4. "I should be sure to remove all metal jewelry."
"I should be sure to remove all metal jewelry."
The nurse would evaluate the patient who is age 60 as requiring further teaching if the patient states which of these prevents osteoporosis? Select all that apply. 1."I should avoid alcohol." 2."I should avoid smoking." 3."I should consume vitamin D 600 I U daily." 4."I should consume calcium 1,000 milligram daily." 5."I should increase my vitamin A intake." 6."I should limit weight-bearing exercise."
"I should consume calcium 1,000 milligram daily.", "I should increase my vitamin A intake." , and "I should limit weight-bearing exercise." (1,000 mg is a high dose of calcium the average is 600)
The nurse teaches a patient about ear care. Which patient statement indicates to the nurse that the patient understands the ear care teaching? 1. "I should insert a cotton swab into my ear canal for cleaning." 2. "I should not get my external ear wet during bathing." 3. "I should not block one nostril when blowing my nose." 4. "I should not need to routinely remove wax from the ear canal."
"I should not block one nostril when blowing my nose."
The nurse provides teaching on prevention of hepatitis. The nurse recognizes the patient requires further instruction if the patient states which of the following? Select all that apply. 1. "I should receive the vaccine for hepatitis A virus." 2. "I should receive the vaccine for hepatitis B virus." 3. "I should receive the vaccine for hepatitis C virus." 4. "I should receive the vaccine for hepatitis D virus." 5. "Hand washing is important after use of the bathroom." 6. "I can share my razor."
"I should receive the vaccine for hepatitis C virus.", "I should receive the vaccine for hepatitis D virus.", and "I can share my razor."
The nurse is reinforcing teaching for the patient with vertigo. Which of the following statements by the patient for actions to take for vertigo would indicate that further teaching is needed? Select all that apply. 1. "I will avoid noise." 2. "I should avoid sudden movements." 3. "I will increase my fluid intake." 4. "I will take analgesics." 5. "I will lie down for safety." 6. "I should walk frequently."
"I will avoid noise.", "I will increase my fluid intake.", "I will take analgesics.", and "I should walk frequently."
The nurse participated in a patient's teaching session for care to prevent respiratory complications after a hernia repair. Which statement by the patient would indicate to the nurse that the patient understood the teaching? 1. "I will cough every hour while awake." 2. "I will deep breathe four times daily." 3. "I will cough and deep breathe every hour." 4. "I will deep breathe every hour while awake."
"I will deep breathe every hour while awake."
A patient is taught preventive measures for gastroesophageal reflux disease. Which statement by the patient indicates that teaching has been effective? 1. "I need to eat large meals." 2. "I will sleep without pillows." 3. "I need to lie down for 2 hours after each meal." 4. "I will identify foods that cause discomfort."
"I will identify foods that cause discomfort."
The nurse is providing care for a patient scheduled for a computed tomography scan of the brain with contrast media. Which of the following statements should be included in the patient teaching? Select all that apply. 1. "You will need to lie still for 1 to 2 hours during the exam." 2. "Notify the staff if you have any nausea, sweating, or itching during the exam." 3. "Mild sedation can be given if you become uncomfortable." 4. "You may have a feeling of warmth throughout your body after the dye is injected." 5. "The table may be moved to various positions during the test." 6. "This test can't be used if you have any metal in your body."
"Notify the staff if you have any nausea, sweating, or itching during the exam.", "Mild sedation can be given if you become uncomfortable.", "You may have a feeling of warmth throughout your body after the dye is injected.", and "The table may be moved to various positions during the test."
The nurse is assisting a patient who has recently received a hearing aid. Which response by the patient would indicate further teaching is required about the care of the hearing aid? 1. "Turning off the hearing aid when not in use saves the battery." 2. "The hearing aid can be washed daily in a basin of warm water." 3. "A small brush can be used to clean in the ear mold." 4. "I should remove the hearing aid before showering."
"The hearing aid can be washed daily in a basin of warm water."
The nurse is teaching a patient with newly diagnosed glaucoma. The nurse would evaluate the patient as understanding the teaching if the patient stated which of these definitions for glaucoma? 1. "The rate of production of aqueous humor decreases." 2. "There is an increase in the pressure within the eye." 3. "There is a decrease in the amount of aqueous humor." 4. "There is an increase in the amount of vitreous humor."
"There is an increase in the pressure within the eye."
Which of the following explanations by the nurse to reinforce the patient's preoperative education for a loop ostomy would be correct? 1. "You will have a stoma in the middle of your abdomen that will constantly drain liquid stool." 2. "You will have a looped bag system to collect stool from your stoma." 3. "You will have a loop of bowel on your abdomen, but it will not drain stool." 4. "You will have a loop of bowel on your abdomen that can be returned to your abdomen after your bowel has healed."
"You will have a loop of bowel on your abdomen that can be returned to your abdomen after your bowel has healed."
The nurse is caring for a patient who is diagnosed with a refractive error and asks what this means. What would be the appropriate explanation by the nurse? 1. "You are losing your vision and will become blind." 2. "You will need corrective lenses to see clearly." 3. "The pressure in your eyes is higher than normal." 4. "Your vision was measured as 20/20."
"You will need corrective lenses to see clearly."
What is the Romberg test?
(falling test) is another simple test to assess vestibular function. If a fall appears likely, be prepared to support the patient during the test to prevent injury. Instruct the patient to stand with feet together, first with eyes open and then with eyes closed. Normally, the patient has no difficulty maintaining a standing position with only minimal swaying. If the patient has difficulty maintaining balance or loses balance (a positive Romberg test), the patient may have an inner ear problem.
What is impacted cerumen?
(occurs in external ear) Normally ear self-cleaning, Older adult at risk, Hearing loss, and Feeling of fullness
What is the etiology of primary gout?
(the most common type of gout) is caused by an INHERITED problem with PURINE METABOLISM.
What is status epilepticus?**
*at least 30 minutes of continuous seizure activity* (extremely dangerous)
The nurse is to administer promethazine 12.5 mg intramuscularly and has 50 mg/mL on hand. How many milliliters should be drawn up? Fill in the blank. Answer: ______________ mL
0.25 mL
A nurse is preparing an intramuscular injection of prednisolone acetate, 30 mg. It is supplied as 50 mg/mL. How many milliliters should the nurse prepare? ________________
0.6 mL
A patient with Crohn disease is to receive sulfasalazine (Azulfidine) 500 mg oral suspension four times daily. The oral suspension is available as 250 mg/5 mL. How many milliliters should the nurse give for the 0800 dose? 1. 5 mL 2. 10 mL 3. 20 mL 4. 50 mL
10 mL
When does postpolio syndrome affect polio victims?
10 to 40 years later
After a liver biopsy, the patient lies on the right side for the first _____ hours.
2
What is the moderate low vision for a Snellen chart/E chart/Rosenbaum card?
20/70 to 20/160
To deliver 1,000 mL of 5% dextrose in 0.45 normal saline at 150 mL per hour using 10 drop tubing, the nurse would monitor the intravenous infusion at how many drops per minute? Fill in the blank. Answer: ______________ drops per minute
25
What are Nuclear medicine scans?
A bone scan allows visualization of the entire skeleton. The patient is injected with a radioisotope. The radioisotope is attracted to bone and travels to bone tissue. Images are taken at various intervals to see how the radioisotope has collected in the bone. (NOT an x-ray)
A patient is diagnosed with acute diverticulitis. Which of the following collected data does the nurse recognize may have placed the patient at risk for developing diverticulitis? 1. A low-fiber diet 2. Chronic diarrhea 3. Nonsteroidal anti-inflammatory drug use 4. Family history of colon cancer
A low-fiber diet
The nurse is planning care for a team of patients. To provide patient-centered care safely, for which patients should the nurse use specialized mobility equipment designed for the patient who is obese? Select all that apply. 1. A woman with body weight 22% above ideal body weight 2. A man with body weight 30% above ideal body weight 3. A man with body mass index of 31 4. A woman with a body mass index of 24 5. A woman with waist measurement of 36 inches 6. A man with waist measurement of 44 inches
A man with body weight 30% above ideal body weight, A man with body mass index of 31, A woman with waist measurement of 36 inches, and A man with waist measurement of 44 inches
What is the vastus lateralis?
A muscle toward the outer side of the leg. Part of the quadriceps that flex/extend the leg at the knee.
A college student is admitted to the hospital with a severe headache. Which finding in the student's history is consistent with the diagnosis of meningitis? 1. A sore throat for 3 days. 2. A history of migraine headaches. 3. A muscle injury in the neck. 4. A recent motor vehicle accident.
A sore throat for 3 days
What is the rectus abdominis?
A trunk muscle that helps flex the trunk, assists breathing, and supports the spine. (abs)
What are the fat soluble vitamins?***************
A, D, E, AND K
What are the s/s of acute pancreatitis?
Abdominal pain (SEVERE****, radiates to Chest, back, flank), Guarding, Rigid abdomen, Hypotension or shock, Shallow respirations, Low-grade fever, Tachycardia, Nausea and vomiting, and Jaundice
What are the s/s of Crohn's disease?
Abdominal pain or cramping, Weight loss, Diarrhea, and Fluid and electrolyte imbalance
What are the s/s of ulcerative colitis?
Abdominal pain, 5 to 10 liquid stools daily, Rectal bleeding, fecal urgency, Anorexia, Weight loss, Cramping, Vomiting, Fever, and Dehydration
What are the s/s of peritonitis?
Abdominal pain, Abdominal rigidity, Nausea/vomiting, and Fever
What are the s/s of intestinal obstruction?
Abdominal pain, Blood and mucus per rectum, Feces and flatus cease, Fecal vomiting may occur, Abdominal distention, and Fluid/electrolyte imbalance
What are the s/s of constipation?
Abdominal pain, Distention, Indigestion, Intestinal rumbling, Rectal pressure, Incomplete emptying, Hard stool, Headache, Fatigue, Decreased appetite, and Straining
What are the s/s of gastritis?
Abdominal pain, Nausea, vomiting, Anorexia, Abdominal tenderness, Feeling of fullness, Reflux, and Belching
What are the diagnostic tests for intestinal obstruction?
Abdominal x-ray (BIG ONE), CT scan, and CBC and electrolytes
The nurse is gathering functional data on a patient with arthritis. The nurse would collect data in which of these areas? Select all that apply. 1. Ability to feed self 2. Appearance of joints 3. Bathing practices 4. Dressing ability 5. Pain level 6. Response to treatment
Ability to feed self, Bathing practices, and Dressing ability
What are the s/s of stage 1 of Guillain-Barre syndrome?**
Abrupt onset weakness and paralysis that May affect respiration and Autonomic nervous system effects (lasts 24 hours to 3 weeks)
What is Chalazion?
Abscess in Meibomian glands
What are the complications of chronic pancreatitis?
Abscesses, Fistulas(a wound that goes through and through), Pleural effusion (VERY DANGEROUS), Malabsorption, Diabetes, and Cancer
The nurse auscultates the patient's abdomen and finds it to be silent. The nurse would document the bowel sounds findings as which of these? 1. Absent 2. Hyperactive 3. Hypoactive 4. Normal
Absent
The nurse is collecting data on a patient with a left tibia fracture. Which of the following findings is a priority finding? 1. Increased red blood cell count 2. Decreased body temperature 3. Decreased lymphocyte count 4. Absent left pedal pulse
Absent left pedal pulse
What are the nursing diagnoses for inflammatory bowel disease?
Acute Pain, Diarrhea, Risk for Deficient Fluid Volume, Anxiety, Impaired Skin Integrity, and Ineffective Nutrition: Less Than Body Requirements
What are the nursing diagnoses for hepatitis?
Acute Pain, Imbalanced Nutrition, Risk for Impaired Liver Function, Risk for Impaired Skin Integrity, and Ineffective Health Management
What are the nursing diagnoses for cranial nerve disorders?
Acute Pain, Imbalanced Nutrition, and **Risk for Injury to Eyes (Bell Palsy)**
What are the nursing diagnoses for fractures?
Acute Pain, Impaired Physical Mobility, and Risk for Peripheral Neurovascular Dysfunction
What are the nursing diagnoses for peptic ulcer disease?
Acute Pain, Risk for Injury, and Deficient Knowledge
What are the nursing diagnoses for the external ear?
Acute Pain, Risk for Injury, and Deficient Knowledge
What are the nursing diagnoses for glaucoma?
Acute Pain, Self-Care Deficit (Bathing, Dressing, Feeding, Toileting), Risk for Injury, and Deficient Knowledge
Which type of gastritis is Can lead to peritonitis associated with?
Acute gastritis
Which type of gastritis is Heartburn or indigestion associated with?
Acute gastritis
Which type of gastritis is Often caused by overeating associated with?
Acute gastritis
Which type of gastritis is associated with treatment is to avoid alcohol and irritating foods?
Acute gastritis
Which nursing interventions are appropriate for the patient with Bell palsy? Select all that apply. 1. Administer moisturizing eye drops. 2. Apply an eye patch. 3. Avoid touching the patient's face. 4. Apply warm compresses. 5. Provide facial massage. 6. Teach the patient to protect the face from cool breezes.
Administer moisturizing eye drops, Apply an eye patch, Apply warm compresses, and Provide facial massage.
What is the prevalence of osteoarthritis?
Affects more than 30 million people (Common)
What occurs before and after a percutaneous liver biopsy?
After a local anesthetic, the HCP makes a small incision over the liver. Ultrasound may be used to guide the insertion of the hollow needle through the skin and into the liver. Tissue samples are withdrawn for examination. This procedure places the patient at risk for bleeding because the liver is highly vascular and because many patients with liver disease have reduced clotting ability. During the procedure, the nurse assists the patient onto his or her back or left side and instructs the patient to hold very still. The patient is instructed to exhale and hold the breath while the needle is being inserted. After the needle is removed, pressure is applied on the site up to 5 minutes, followed by application of a pressure dressing. After the biopsy, the patient lies on the right side for 2 hours to prevent bleeding. Vital signs are monitored as well as the site for signs of bleeding for several hours. The patient is advised to avoid coughing or straining and to avoid exercise and heavy lifting for one week. Analgesics are offered for comfort as ordered.
What is punctal occlusion?
After eye drop administration, the eyelids should be closed for 2 minutes without blinking, which is about the time it takes for absorption of the medication into the eye. During this same time period, the puncta (tear duct) on the eyelid of the eye in which medication was administered should have pressure applied to it, by either the nurse wearing gloves or the patient. The index finger is placed on the corner of the eye. Pressure is applied against the bone along the nose (not into the eye). This allows the eye drop to remain in the eye longer for greater effect. It also reduces systemic absorption and side effects of the medication. Some eye medications can have serious cardiac or respiratory effects. Teach the patient the proper instillation of eye medications.
what are some nonmodifiable risk factors for a stroke?
Age, Gender, Heredity, and Prior stroke or heart attack
What are the therapeutic interventions for acute pancreatitis?
Aggressive I V fluids, Nutrition (either Mild as Oral or Severe as Enteral), Analgesics, and Antibiotics for sepsis
What are the normal results of the Rinne test?
Air conduction greater than bone conduction
Which finding would the nurse understand is normal when checking auditory acuity using the Rinne test? 1. The patient perceives sound equally in both ears. 2. Air conduction is heard longer than bone conduction in both ears. 3. Bone conduction is heard longer than air conduction in both ears. 4. The patient's left ear will perceive the sound better than the right ear.
Air conduction is heard longer than bone conduction in both ears.
What are the diagnostic serum tests for acute liver failure?
Alanine aminotransferase, Aspartate aminotransferase, Bilirubin, Prothrombin time (P T), Potassium, and Blood glucose
How can chronic pancreatitis be prevented?
Alcohol abstinence, Avoid smoking, and Biliary disease treatment
What is the etiology of chronic pancreatitis?
Alcohol abuse, Idiopathic, Genetic, Obstructive biliary disease (involving liver, pancreas, and gallbladder), Autoimmune, and Hyperlipidemia
What are the risk factors for esophageal cancer?
Alcohol and/or tobacco use, Being overweight or obese, and Barrett's esophagus
What are some of the causes of gastritis?
Alcohol use Endoscopic procedures Microorganisms (e.g., Helicobacter pylori, Salmonella) Medications (e.g., aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], corticosteroids, digitalis, chemotherapy agents) Nasogastric suctioning Radiation Reflux of bile Smoking Stress (emotional, physiological) Trauma
What is the etiology of acute pancreatitis?
Alcohol, Gallstones, Elevated triglycerides, Endoscopic retrograde cholangiopancreatography (E R C P)-induced pancreatitis, Medications, and Idiopathic
The nurse teaches the patient with liver disease that which of these should be avoided for safety? Select all that apply. 1.Alcohol 2.Antibiotics 3.Narcotics 4.Sedatives 5.Tranquilizers
Alcohol, Narcotics, Sedatives, and Tranquilizers
What nursing intervention is most important for the patient with myasthenia gravis? 1.Allow frequent rest periods. 2.Encourage daily exercise. 3.Administer lubricating eye drops. 4.Avoid touching the patient.
Allow frequent rest periods.
The nurse teaches a patient with cirrhosis functions of the liver. Which of these would the nurse include as functions of the liver? Select all that apply. 1.Bile storage 2.Amino acid metabolism 3.Lipid metabolism 4.Synthesis of plasma proteins 5.Phagocytosis by Kupffer cells 6.Deactivation of vitamin C
Amino acid metabolism, Lipid metabolism, Synthesis of plasma proteins, and Phagocytosis by Kupffer cells
What is a dental implant?
An implant is an artificial root placed in the jawbone. The implant is usually tubular and made of titanium. Implants can be used to replace one tooth, multiple teeth, or an entire arch. They can also be used to stabilize a complete denture.
What are the therapeutic interventions for encephalitis?
Analgesics, Anticonvulsants, Antipyretics, Corticosteroids, Antivirals, Sedatives, Neurological assessment, and Symptomatic care Copyright ©2019 F.A. Davis CompanyIncreased Intracranial PressurePathophysiology•Increase in‒Brain‒Blood‒C S F
What are the therapeutic interventions for gallbladder disorders?
Analgesics, Bile acid sequestrants, Antiemetics, and Nothing by mouth (N P O), advancing to low-fat diet
What treatment was used for Alex's phantom pain?
Analgesics.
What is Fluorescein and Indocyanine green angiography?
Angiography with dye is a test using special cameras to find leaking or damaged blood vessels in the retinal or deeper choroidal circulation. Fluorescein is a yellow dye that glows in visible light and is useful for showing the retinal circulation. Indocyanine green is a green dye that shows up with invisible infrared light to highlight the choroidal circulation.
Which of these signs/symptoms would the nurse expect during data collection for a patient with ulcerative colitis? Select all that apply.***** 1.Anorexia 2.Calf pain 3. 5 to 20 stools daily 4.Rectal bleeding 5.Urinary urgency
Anorexia, 5 to 20 stools daily, and Rectal bleeding
What are the s/s of peptic ulcer disease?
Anorexia, Nausea/vomiting, and Bleeding
What are the therapeutic interventions for wet macular degeneration?
Antiangiogenesis medication aka meds that prevent formation of new, fragile blood vessels such as Ranibizumab (Lucentis) and Aflibercept (Eylea)
The nurse understands that labyrinthitis is treated primarily with which drug category? 1. Antihistamines 2. Antispasmodics 3. Anti-inflammatories 4. Antiemetics
Antihistamines
What are the therapeutic interventions for Huntington's disease?
Antipsychotics, Antidepressants, Antichoreic agents, and Stem cell transplants (which are Experimental)
What are the nursing diagnoses for the inner ear?
Anxiety, Risk for Injury, and Imbalanced Nutrition: Less Than Body Requirements
Patients with Guillain-Barré syndrome should be closely monitored. Which of the following lab results is most important to monitor for acute complications? 1. Blood urea nitrogen and creatinine 2. Arterial blood gases 3. Hemoglobin and hematocrit 4. Serum potassium
Arterial blood gases
What is Xerostomia (Dry Mouth)?
As people age, it is not unusual for them to experience a condition known as xerostomia (dry mouth). Some medications and radiation treatment of the head and neck can cause it. Xerostomia can lead to rampant tooth decay in older adults, putting their dentition at risk. Before any radiation therapy of the head or neck area, a thorough oral examination and any needed restorative dental procedures should be completed. Although water is used as a common substitute for saliva, it does not contain the necessary compounds, such as lubricants, to protect the teeth. There are many products available for dry mouth, such as Biotene gel, ACT rinse, and sprays to help with the discomfort of dry mouth. Brushing with a high fluoride toothpaste that is available by prescription is also recommended.
A patient is scheduled for magnetic resonance imaging of the pelvis. Which of the following actions would the nurse take if during data collection it was revealed that the patient had had a previous surgery for heart problems? 1. Ask if there is any metal in the patient's body. 2. Obtain an order for a chest x-ray 3. Cancel the magnetic resonance imaging. 4. Inform the physician.
Ask if there is any metal in the patient's body.
Why did Betty ask if Mrs. Beason knew where she was?
Asking where she is can determine orientation to place.Disorientation can signal many neurological and non-neurological disorders.
What should be done for a pt with impaired verbal communication?
Assess verbal ability, Consult speech pathologist, Answer call light in person, Listen patiently, Provide communication aids, Keep communication appropriate, and Don't assume patient does not understand.
9. The nurse is caring for a patient recently admitted with a stroke. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first? 1. Call for an aide to get suction set up. 2. Assist the patient to turn to his side. 3. Give an antiemetic as ordered. 4. Perform a test for blood on the emesis.
Assist the patient to turn to his side.
What are the s/s of chronic pancreatitis?
Asymptomatic, Epigastric or left upper quadrant (L U Q) pain worsens after eating (involved in SATA**), Nausea and vomiting, Weight loss, Steatorrhea, Fatty food intolerance, and Remissions and exacerbations
A patient with acute angle-closure glaucoma reports use of the following medications. The use of which of these medications indicates to the nurse that the patient requires further instruction? Select all that apply. 1. Acetaminophen 2. Atropine (Isopto Atropine) 3. Diphenhydramine (Benadryl) 4. Digoxin (Lanoxin) 5. Furosemide (Lasix) 6. Timolol (Timoptic)
Atropine (Isopto Atropine) and Diphenhydramine (Benadryl)
What diagnostic tests are done for the ear and hearing?
Audiometric testing, Tympanometry, Caloric test, Electronystagmogram, Computed tomography (C T) scan, Magnetic resonance imaging (M R I), Culture of drainage, and Pathology
What are the s/s of seizures?**
Aura (such as Visual distortion, Odor, or Sound)
What are the components of the outer ear?
Auricle, Ear canal, and Cerumen
What are the s/s of a partial seizure?**
Automatisms (repetitive, purposeless behaviors), Maintain consciousness, Usually <1 minute, Paresthesias, and Visual disturbances (aka DON'T LOSE CONCIOUSNESS AND TYPICALLY LASTS LESS THAN A MINUTE)
__________ alcohol.
Avoid
__________ diuretics.
Avoid
Which patient behaviors would the nurse expect to find in the health history of a patient who has a hearing loss? Select all that apply. 1. Answers questions appropriately 2. Avoids group activities 3. Has difficulty hearing high-frequency consonants 4. Is irritable or sensitive in interpersonal relations 5. Mentions that people talk too loudly 6. Turns head to one side during conversations
Avoids group activities, Has difficulty hearing high-frequency consonants, Is irritable or sensitive in interpersonal relations, and Turns head to one side during conversations
When will wound care typically be ordered on a pt with external fixation?
BID (if there is a lot of drainage possibly TID in the beginning) (drainage could indicate infection)
What is Ménière Disease?****
Balance disorder due to fluid disturbance (think of the ocean) (Episodic bouts Two to three times a year)
What is the purpose of the Romberg test?
Balance/vestibular function
For which complication does the nurse monitor that can occur following a barium enema? 1.Barium impaction 2.Diarrhea 3.Anorexia 4.Reflux
Barium impaction
What are the diagnostic tests for esophageal cancer?
Barium swallow, Biopsy, and Endoscopy (Ex. Esophagogastroduodenoscopy (EGD) and Mediastinoscopy (endoscopic examination of mediastinum))
When teaching patients about diagnostic procedures, the nurse would include food and fluid restrictions prior to the test for which of these? Select all that apply. 1. Barium swallow 2. Flat plate of the abdomen 3. Esophagogastroduodenoscopy 4. Magnetic resonance imaging 5. Endoscopic retrograde cholangiopancreatography 6. Barium enema
Barium swallow, Esophagogastroduodenoscopy, Endoscopic retrograde cholangiopancreatography, and Barium enema
What are the diagnostic tests for Gastroesophageal reflux disease (GERD)?
Barium swallow, Esophagoscopy, and pH monitoring
What is a partial seizure?
Begin on one side of cerebral cortex
What are the levels of amputation?
Below the knee (BKA), Above the knee (AKA), Below the elbow (BEA), and Above the elbow (AEA)
The nurse is caring for a patient after eye surgery. Which activities would the nurse teach a patient to avoid so that intraocular pressure is not increased after eye surgery? Select all that apply. 1. Bending over 2. Chewing food vigorously 3. Coughing 4. Reading 5. Sitting upright in bed 6. Sneezing
Bending over, Coughing, and Sneezing
What are the early s/s of rheumatoid arthritis?
Bilateral, symmetrical joint inflammation, Reddened, warm, swollen, stiff, painful, Stiffness after resting (called morning stiffness but can occur at any time)***, Activity decreases pain and stiffness**, Low-grade fever, weakness, fatigue, and anorexia
What functions in the small intestine?
Bile from the liver and enzymes from the pancreas
What are proton pump inhibitors?
Bind to an enzyme in the presence of acidic gastric pH, preventing final transport of hydrogen ions into the gastric lumen. Examples dexlansoprazole (Dexilant) esomeprazole (Nexium) lansoprazole (Prevacid) omeprazole (Prilosec) pantoprazole (Protonix) rabeprazole (Aciphex)
What are the diagnostic tests for oral cancer?
Biopsies
What are the complications of peptic ulcer disease?
Bleeding (pt can bleed to death), Perforation, and Obstruction
What are the complications of absorption disorders?
Bleeding due to hypoprothrombinemia and Bone pain and neuromuscular hyperirritability due to calcium deficiency
The nurse understands that which of these occurs with a mechanical bowel obstruction? Select all that apply. 1.Blockage occurs within the intestine. 2.Peristalsis decreases or stops. 3.Bowel sounds are high pitched. 4.Diarrhea occurs. 5.Bowel sounds are absent.
Blockage occurs within the intestine and Bowel sounds are high pitched
What is mechanical intestinal obstruction?*****
Blockage occurs within the intestine with Bowel sounds high-pitched/tinkling
What is a carcinoembryonic antigen (CEA)?
Blood test to detect glycoproteins produced during rapid multiplication of epithelial cells. Normal range for Nonsmoker: Less than 2.5 ng/mL and for Smoker: Less than 5 ng/mL abnormal findings: Identifies stage of colorectal cancer. Tests for recurrence or metastasis of colon or liver cancer. Monitors response to liver and gastrointestinal (GI) cancer therapy. Elevated: benign tumors, cirrhosis, GI cancer, inflammatory bowel disease, pancreatitis.
The nurse is collecting data on a patient with a cataract. What is usually the first symptom of a cataract that the nurse would expect a patient to report? 1. Dry eyes 2. Eye pain 3. Blurring of vision 4. Loss of peripheral vision
Blurring of vision
What is a greenstick fracture?
Bone is bent and fractures on the outer arc of the bend. Often seen in children.
What is an Impacted fracture?
Bone is forcibly pushed together, resulting in bone being pushed into bone.
What is a depressed fracture?
Bone is pushed inward. Often seen with skull and facial fractures.
What is a Comminuted fracture?
Bone is splintered or shattered into numerous fragments. Often occurs in crushing injuries.
What is a displaced fracture?
Bone pieces are out of normal alignment. One or more pieces may be out of alignment.
What are the components of the inner ear?
Bony labyrinth, Perilymph, Endolymph, Cochlea, Utricle canals, saccule canals, and semicircular canals
What is a generalized seizure?
Both hemispheres involved
Which assessment findings does the nurse expect in a patient with Parkinson disease? Select all that apply. 1.Intention tremor 2.Bradykinesia 3.Depression 4.Involuntary movements 5.Muscle rigidity
Bradykinesia, Depression, Involuntary movements, and Muscle rigidity
What are the complications of a traumatic brain injury?
Brain herniation (can lead to DEATH), Diabetes insipidus, Acute hydrocephalus, Labile vital signs (aka fluctuation), Post-traumatic stress disorder, and Cognitive and personality changes
What is the etiology of increased intracranial pressure?
Brain trauma, Brain tumor, and Intracranial hemorrhage
The nurse is collecting data on a patient with hepatitis. Which of the following signs or symptoms are a priority for the nurse to report? Select all that apply. 1. Bruising 2. Fever 3. Nausea 4. Malaise 5. Pruritus
Bruising and Fever
A patient is in skin traction using a foam boot with Velcro fasteners for a fractured hip. The nurse would document this type of skin traction as which of the following? 1. Gardner tongs 2. Buck traction 3. Crutchfield tongs 4. Steinmann pin
Buck traction
How can osteoporosis be prevented?
Build bone through age 30 (last day of 30th year), Obtain adequate calcium and vitamin D, Do weight-bearing exercise (especially childhood), and Avoid alcohol and smoking.
What is a Hernia?
Bulging of abdominal contents through abdominal wall
What are the symptoms of a gastric ulcer?
Burning, gnawing pain in the high-left epigastric region. Pain when food is eaten or 1 to 2 hours after eating. Anorexia, nausea, and vomiting also may occur.
The nurse is assessing a patient admitted to a long-term care facility following a motor vehicle accident. The patient is unable to breathe without a ventilator. which levels of the spinal cord are most likely involved?
C4 and C5
What are the diagnostic tests for ulcerative colitis?
CBC, Stool specimen, Electrolytes, Protein level (Ex. albumin), Colonoscopy with biopsy, and Leukocyte scintigraphy (Leukocyte scintigraphy, a noninvasive imaging test, uses the patient's WBCs tagged with a radioactive material to detect infection and inflammation in the colon.)
Which of these serum blood tests would the nurse review as an indicator of bone health? 1.Calcium 2.Muscle enzymes 3.Myoglobin 4.Uric acid
Calcium
A nurse is doing an afternoon assessment on a patient transferred to a medical unit from intensive care following a subarachnoid hemorrhage. The patient was alert and oriented during the morning assessment but reported being very tired. Now the patient is difficult to arouse. What action should the nurse take? 1. Let the patient sleep; transferring from the ICU can be very strenuous. 2. Reassess the patient in an hour. If the sleepiness continues, notify the RN. 3. Call the RN immediately. 4. Call a code.
Call the RN immediately.
What is obesity? (definition)
Caloric intake exceeds energy expenditure
During a visit with the health care provider, the patient asks for guidance in losing some weight. The patient is currently 310 pounds with a height of 5 foot 7 inches. When contributing to the plan of care, the nurse would recognize that the initial treatment for obesity would include which of these? Select all that apply. 1. Biofeedback 2. Calorie restriction 3. Counseling 4. Healthy diet 5. Exercise 6. Fasting
Calorie restriction, Healthy diet, and Exercise
What are the functions of the liver?
Carbohydrate metabolism, Amino acid metabolism, Lipid metabolism, Synthesis of plasma proteins, Phagocytosis by Kupffer cells, Formation of bilirubin, Storage, Detoxification, and Activation of vitamin D
What are the complications of acute pancreatitis?
Cardiovascular failure, Acute respiratory distress syndrome, Acute kidney injury (can often be resolved), Hemorrhage (with Turner sign and Cullen sign), and Infection
What is the patient education for fractures?
Cast care (Ex. try to keep cast clean and dry), Pin care (Ex. cleaning pins), and Nutrition (very important for healing)
What are the types of absorption disorders?
Celiac disease (aka Gluten sensitivity) and Lactose intolerance (aka Lactase deficiency)
What can a traumatic brain injury cause?
Cerebral edema, Hyperemia, Hydrocephalus, Brain herniation, and Death
What are the s/s of colorectal cancer?
Change in bowel habits, Blood or mucus in stools, Abdominal or rectal pain, Weight loss, Anemia , and Obstruction
What is the preprocedure care for a myelogram?
Check allergies to contrast and shellfish, Assess history of seizures, and Verify informed consent.
A patient is admitted following a T4 spinal injury. When taking morning vital signs, the nurse notes that the patient appears restless and that blood pressure is elevated. Which of the following actions by the nurse is appropriate? 1. Recheck the patient's blood pressure in 30 minutes. 2. No action is necessary. This is an expected finding. 3. Check for a full bladder or bowel. 4. Encourage the patient to express any anxiety.
Check for a full bladder or bowel.
Prior to administering medications via a percutaneous endoscopic gastrostomy (P E G) tube, which of these actions does the nurse take? Select all that apply. 1.Check placement. 2.Observe for abdominal distention. 3.Provide skin care. 4.Check allergies. 5.Verify tube length.
Check placement, Observe for abdominal distention, Check allergies, and Verify tube length.
Which data collection activity will help the nurse determine if the patient with Bell palsy is receiving adequate nutrition? 1. Monitor meal trays. 2. Measure intake and output. 3. Check twice-weekly weights. 4. Evaluate swallowing reflex.
Check twice-weekly weights.
What are the complications of gallbladder disorders?
Cholangitis (inflammation of the bile ducts), Necrosis/perforation of gallbladder, Empyema (a collection of purulent drainage in the gallbladder), Fistulas, Adenocarcinoma of gallbladder, and Acute pancreatitis
What is the treatment for cholelithiasis?
Cholecystectomy (via Laparoscopic surgery which is Most common or Traditional surgery‒T-tube) and Medication to dissolve stones
What are the therapeutic interventions for Alzheimer's disease?
Cholinesterase inhibitors, N M D A antagonists, Antidepressants, Antipsychotics, and Antianxiety agents
What are the priority nursing diagnoses for osteoarthritis?
Chronic Pain Impaired Physical Mobility Disturbed Body Image
What are the priority nursing diagnoses for rheumatoid arthritis?
Chronic Pain Self-Care Deficits Ineffective Health Maintenance
What is the etiology of cirrhosis/chronic liver disease?
Chronic alcohol use (Most common), Chronic *H B V* or *H C V*, and Nonalcoholic steatohepatitis (NASH is also known as fatty liver disease due to the buildup of fat in the liver. It is common in those with diabetes, obesity, heart disease, or elevated cholesterol levels.)
What are the causes of diverticulosis/diverticulitis?
Chronic constipation and Decreased intake of dietary fiber
Which of the following organ systems are directly necessary for muscle contraction? Select all that apply. 1. Circulatory system 2. Digestive system 3. Respiratory system 4. Nervous system 5. Sensory system
Circulatory system, Respiratory system, and Nervous system
What is the progressive, irreversible replacement of liver tissue with scar tissue called?
Cirrhosis
What signs of cirrhosis and hepatic encephalopathy (HE), a complication of cirrhosis, is Mr. Guido exhibiting?
Cirrhosis signs include jaundiced sclerae and skin, several bruises, itching, a much-distended abdomen, and pitting ankle edema. Hepatic encephalopathy signs include lethargy, confusion, and difficulty communicating, all of which indicate the involvement of the central nervous system.
What is an Ultrasound?
Classic test done to detect gallstones
What is the postoperative care for gastric surgery?
Clear, liquid diet which Progresses to full liquids, pureed foods and finally Regular foods at 6 weeks
What are the complications of cirrhosis/chronic liver disease?
Clotting defects, Portal hypertension (including Varices‒ dilated veins and Ascites- fluid in abd.), Hepatic encephalopathy, Hepatorenal syndrome, and Wernicke-Korsakoff syndrome (Wernicke-Korsakoff syndrome may be a complication of alcoholic liver disease. It is a brain disorder caused by thiamine (B1) deficiency. Wernicke encephalopathy and Korsakoff psychosis often occur together. They are primarily diagnosed in those who abuse alcohol and occasionally in malnourished patients with no history of alcohol abuse. Wernicke encephalopathy is an acute condition resulting in confusion, delirium, visual disturbances, and ataxia. When caused by dietary deficiency, this encephalopathy can usually be successfully treated with oral or subcutaneous thiamine. Korsakoff psychosis is the result of permanent damage to the brain tissue. Administration of thiamine will not reverse this brain damage. Patients with Korsakoff psychosis display an abnormal mental state in which memory and learning are affected in an otherwise alert and responsive patient.)
The nurse provides discharge teaching for the patient with gout. The nurse would evaluate the patient as understanding if the patient says which of the following can be eaten? Select all that apply. 1. Cod 2. Chicken 3. Eggs 4. Liver 5. Sardines 6. Cherries
Cod, Chicken, Eggs, and Cherries
The nurse is teaching a patient with dumping syndrome about food choices. Which of these foods would the nurse instruct the patient to avoid? 1. Spinach and avocado salad 2. Coffee and glazed doughnut 3. Sausage and liver 4. Creamed chipped beef
Coffee and glazed doughnut
What are the complications of encephalitis?
Cognitive disabilities, Personality changes, Ongoing seizures, Motor deficits, and Blindness
What care for feeding tubes and enteral tube-feeding systems was used to prevent complications?
Collects data on abdominal status—nausea or a full feeling, soft, flat, not distended. Changes and labels enteral tube feeding administration set every 24 hours, practices appropriate hand hygiene, avoids contamination of feeding tube and feeding formula.
What is a barium enema?
Colon filled with barium. X-rays visualize position, movement, and filling of colon. Normal findings: colon structures normal. (abnormal findings indicate Diverticula, inflammation, obstructions, polyps, stenosis, tumors, and ulcerative colitis) Pretest: Low-residue diet several days before test; clear liquids 24 hours before test; NPO 8 hours before test. Laxative and enema the evening before the test; enema the morning of test as needed. Posttest: Encourage fluids. Laxatives may be ordered. Monitor for constipation.
Which of the following structures are connected by the ileocecal valve? 1. Duodenum to the stomach 2. Colon to the small intestine 3. Stomach to the esophagus 4. Ileum to the jejunum
Colon to the small intestine
What are the diagnostic tests for colorectal cancer?
Colonoscopy with biopsy, Sigmoidoscopy with biopsy, Proctosigmoidoscopy, C T scan, Abdominal and rectal examination, Immunological tests, Fecal occult blood, and Carcinoembryonic antigen
What does the FOUR Score tool evaluate? 1.Mental status 2.Confusion 3.Cranial nerves 4.Coma
Coma
Which of the following structures carries bile and pancreatic juices to the duodenum? 1. Pancreatic duct 2. Cystic duct 3. Hepatic duct 4. Common bile duct
Common bile duct
What are the diagnostic tests for appendicitis?
Complete blood count (C B C), Ultrasound, computed tomography (C T) scan, or magnetic resonance imaging (M R I)
What are the laboratory tests for the gastrointestinal system?
Complete blood count, Electrolytes, Carcinoembryonic antigen, Bilirubin, Liver enzymes, Pancreatic enzymes, Stool tests, and Gastric analysis
What are the s/s of stage 3 of Alzheimer's disease?
Complete dependency, Bowel and bladder control lost, Emotional control lost, Inability to recognize significant others, and Death
How are thromboemboli prevented after a total hip replacement?
Compression devices (SCDs), Leg exercises, and Anticoagulants (Example: Enoxaparin (Lovenox))
What are the diagnostic tests for a stroke?
Computed tomography (C T) scan, Electrocardiogram, Complete blood count, electrolytes, glucose, Metabolic panel, International normalized ratio/prothrombin time, National Institutes of Health Stroke Scale, and Carotid Doppler
The nurse is counseling a young woman with a spinal cord injury at C7. Which of the following birth control options would the nurse recommend for this client? Select all that apply. 1. Condom 2. Oral contraceptives 3. Diaphragm 4. Implantable device 5. Intrauterine device 6. No birth control is needed because she will be infertile.
Condom and Implantable device
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid? 1. Conductive 2. Sensorineural 3. Mixed 4. Central
Conductive
The nurse is to collect data on a patient who reports diarrhea. What data should the nurse collect? Select all that apply. 1. Bruising 2. Consistency of stools 3. Color of stools 4. Frequency of stools 5. Antibiotic use 6. Body piercings
Consistency of stools, Color of stools, Frequency of stools, and Antibiotic use
The nurse would evaluate the patient as understanding teaching if the patient replied that which of the following can occur following a barium swallow? Select all that apply. 1. Dysphagia 2. Constipation 3. Diarrhea 4. Pain 5. White stool
Constipation and White stool
What are the nursing diagnoses for IBS?
Constipation, Diarrhea, and Readiness for Enhanced Health Management
**The nurse is caring for a patient with acute- angle closure glaucoma. Atropine 0.4 milligramI M is ordered now. What action should the nurse take? 1.Give the atropine now. 2.Consult the health care provider. 3.Hold the atropine. 4.Contact the pharmacist.
Consult the health care provider.
What is the synovial joint?
Contains synovial fluid (Many contain bursae)
What is the axon terminal?
Contains the transmitter acetylcholine in vesicles and Located at the end of the motor neuron
What are the methods of stroke prevention?
Control Weight, control Hypertension, control Cholesterol, Smoking cessation, Aspirin or warfarin (Coumadin), and Early recognition and treatment
What are the types of ileostomy?
Conventional ileostomy (Small stoma in right lower quadrant with Continuous flow of liquid effluent), Continent ileostomy/Kock pouch (Internal reservoir with nipple valve that needs Empty reservoir 3 to 4 times daily), and Ileoanal or ileorectal anastomosis
In what order does a beam of light pass through the refractive structures in the eye? (Use all items, and place them in the correct order.) 1. Aqueous humor 2. Cornea 3. Lens 4. Vitreous humor
Cornea, Aqueous humor, Lens, then Vitreous humor
What are the therapeutic interventions for seizures?
Correct the cause, Anticonvulsant medication (to help maintain a high seizure threshold), and Surgical resection
What are the therapeutic interventions for a Cerebral Aneurysm/ Subarachnoid Hemorrhage?
Craniotomy (either Clamp, Wrap, or Remove) and Nonsurgical measures such as Thrombose aneurysm, Monitoring, and Blood pressure control
The nurse is inspecting the knee of a patient who reports pain and stiffness. As the patient moves the knee, the nurse hears a grating sound. The nurse correctly documents the grating sound as which of the following? 1. Friction rub 2. Crepitation 3. Effusion 4. Subcutaneous emphysema
Crepitation
The nurse is collecting data on a patient who has fallen. Which patient data would alert the nurse to a possible hip fracture? Select all that apply. 1.Crepitation 2.Deformity 3.Groin pain 4.Increased range of motion 5.Limb rotation 6.Lengthening of limb
Crepitation, Deformity, Groin pain, and Limb rotation
What is the pathophysiology of restless legs syndrome?**
DOPAMINE AND SEROTONIN IMBALANCE
What is the importance of daily oral care?
Daily and ongoing oral care is important throughout life and has been found to have a link to cardiac health.
The nurse teaches the patient, who has risk factors for osteoporosis, prevention methods. The nurse evaluates the patient as understanding the teaching if the patient states lifestyle changes will include which of these? Select all that apply. 1. Daily walking 2. Increased milk intake 3. Limited dark green leafy vegetables 4. Weight training 5. Maintaining normal weight 6. Calcium supplement
Daily walking, Increased milk intake, Weight training, and Calcium supplement
What is the pathophysiology of a spinal cord injury?
Damage to nerve fibers that causes interference with communication between brain and body
A patient with meningitis has photophobia and a severe headache. Which nursing interventions will be most helpful to relieve symptoms? 1. Administer antibiotics as ordered, and prepare the patient for a lumbar puncture. 2. Darken the room and administer analgesics. 3. Administer acetaminophen as ordered and maintain isolation. 4. Check level of consciousness with the Glasgow Coma Scale and monitor vital signs.
Darken the room and administer analgesics.
What is the postoperative ostomy care?
Data collection (i.e. Vital signs, Stoma Pink to red, moist = normal Bluish = inadequate blood supply Black = necrosis, Skin around stoma monitored for irritation and Stoma shrinks over weeks), Ostomy care, Appliance change, and Teaching
Why did Selena take the time to obtain the hearing aid for Ted?
Deafness or decreased hearing acuity is one of the main reasons that older adults withdraw from social activities. Selena wanted to prevent that from occurring.
A patient is admitted with an order for a nasogastric sump tube. The nurse knows this tube is used for which of the following purposes? Select all that apply. 1. Supplemental feeding 2. Decompression 3. Irrigation 4. Lavage 5. Gavage 6. Parenteral nutrition
Decompression, Irrigation, and Lavage
Which of these are age-related changes to the musculoskeletal system? Select all that apply. 1.Increased muscle strength 2.Increased elasticity of ligaments, tendons, cartilage 3.Decrease in intervertebral space 4.Changes in posture and gait changes 5.Decreased muscle mass
Decrease in intervertebral space, Changes in posture and gait changes, and Decreased muscle mass
What are corticosteroids?
Decrease inflammation and suppress immune system. Examples prednisone (Deltasone) methylprednisolone (Medrol, Solu-Medrol) Nursing Implications Teach patient not to stop taking medication abruptly.
What are the 5-aminosalicylates?
Decrease intestinal inflammation. Examples mesalamine (Asacol, Canasa, Pentasa, Rowasa) olsalazine (Dipentum) balsalazide (Colazal) sulfasalazine (Azulfidine) Nursing Implications Monitor for signs of reduced kidney function. Take with food. Take with food. Contraindicated in sulfa allergy.
What is the significance of abnormal findings of albumin?
Decreased because of impaired liver protein synthesis. Maintains plasma oncotic pressure, so low levels can cause edema and ascites.
The nurse is assisting with data collection for a patient with macular degeneration. Which symptoms would the nurse expect to be present? Select all that apply. 1. Decreased distinction of colors 2. Sudden loss of vision 3. Loss of near vision 4. Loss of central vision 5. Loss of peripheral vision 6. Increased periodic dizziness
Decreased distinction of colors, Loss of near vision, and Loss of central vision
What are the nursing diagnoses for an ostomy?
Deficient Knowledge (r/t Appliance change, Daily care and hygiene, and Dietary considerations), Readiness for Enhanced Health Management, Sexual Dysfunction, and Risk for Injury (r/t Peristomal skin irritation, Peristomal hernia, Stomal prolapse, Stomal necrosis, and Ileostomy blockage)
What is osteoarthritis?
Degenerative joint disease (that Increases with age)
What are the triggers for aphthous stomatitis (canker sores)?
Dental work, Vitamin B12, zinc, folate, or iron deficiency, Helicobacter pylori (H. pylori), and Stress
What are the acute s/s of a stroke?
Depend on area of brain affected, One-sided weakness/paralysis (opposite side affected), Dysphagia, Sensory loss, Mental status changes, Visual disturbance, and Speech disturbance
What is urine bilirubin?
Detects liver disorders. normal range: Negative abnormal findings: Present in cirrhosis, hepatitis, and biliary obstruction
What is macular degeneration?**
Deterioration in macula (can be Wet or Dry) (Common over age 64) Slow, progressive loss of central/near vision
What is tropia?
Deviation of the eye away from the visual axis.
What are modifiable risk factors of stroke? Select all that apply. 1.Age 2.Diabetes mellitus 3.Obesity 4.Hyperkalemia 5.Gender
Diabetes mellitus and Obesity
What are the symptoms of autonomic nervous system dysfunction?
Diaphoresis, Constipation, Orthostatic hypotension, Drooling, Dysphagia, Seborrhea, and Frequent urination
What are the nursing diagnoses for diarrhea?
Diarrhea, Risk for Deficient Fluid Volume, and Deficient Knowledge
What is the the purpose of the Rinne test?
Differentiate between conductive and sensorineural hearing loss
What are the s/s of esophageal cancer?
Difficulty swallowing, Feeling full, Pain in chest, Foul breath, and Food regurgitation
What is digital imaging?
Digital imaging is a newer way of viewing most of the retina without requiring the use of dilating eye drops.
What is esophageal varices?
Dilated blood vessels in esophagus (Rupture can be life-threatening)
The enzymes of the small intestine contribute to the digestion of which of the following types of nutrients? 1. Starch 2. Fats 3. Disaccharides
Disaccharides
What is the pt education for rheumatoid arthritis?
Disease process, Medication management, Rest and exercise, Vocational counselor, and Community resources
What is the pt education for acute liver failure and cirrhosis?
Disease process, Signs and symptoms to report, Adequate rest, Avoid narcotics, sedatives, tranquilizers, alcohol. and Follow-up care
What is the symphysis?
Disk of fibrous cartilage between bones
What is a gastroduodenostomy/Billroth one?
Distal stomach removed and the remaining portion is Anastomosed (joined to) to duodenum this surgery is used to Treats gastric problems
What are the causes of lower gastrointestinal bleeding?
Diverticulitis, Polyps (usually not cancerous), Anal fissures, Hemorrhoids, Inflammatory bowel disease, and Cancer
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse in the morning. Early in the afternoon, the patient's daughter runs out of the room and says, "My mother can't talk. Somebody help!" Which response by the nurse is best? 1. Explain to the daughter that this is not uncommon, especially in the afternoon when the patient is tired from morning care activities. 2. Do a quick assessment to confirm the change in the patient's status and then notify the registered nurse or physician immediately. 3. Calm the daughter and then call the speech therapist to come and do a comprehensive speech assessment. 4. Show the daughter how to help her mother do the speech exercises that were provided by the therapist.
Do a quick assessment to confirm the change in the patient's status and then notify the registered nurse or physician immediately.
What are the therapeutic interventions and nursing care for eye trauma involving a penetrating object?
Do not remove.
What is an Optometrist?
Doctor of optometry who diagnoses and treats certain eye conditions and diseases.
What are the therapeutic interventions for Parkinson's disease?
Dopamine agonists, Monoamine oxidase B inhibitors, Catechol-O-methyltransferase (C O M T) inhibitor, Pallidotomy, and Deep brain stimulation
A patient has returned from having a computed tomography scan with contrast. Which of the following should be a priority in the hours after the scan? 1. Ambulation 2. Drinking fluids 3. Turning side to side 4. Coughing and deep breathing
Drinking fluids
What is the etiology of acute liver failure?
Drug toxicity (typically Acetaminophen (Tylenol)) and Hepatitis
What is Keratoconjunctivitis sicca?***
Dry eye disease
What are the diagnostic tests for osteoporosis?**
Dual-energy x-ray absorptiometry (DEXA), Serum calcium and vitamin D decreased, Serum phosphorus increased, and Serum alkaline phosphatase increased
What is cancer of the pancreas?
Ductal adenocarcinoma of exocrine pancreas
The nurse is collecting data for a patient with acute pancreatitis. Which of these descriptions of pain would the nurse associate with acute pancreatitis? 1. Dull, boring, beginning in the mid-epigastrium and radiating to the back 2. Knifelike, centered in the left lower quadrant 3. Burning, focused over the left flank and radiating to the shoulder 4. Sharp, severe pain that begins in the right upper quadrant
Dull, boring, beginning in the mid-epigastrium and radiating to the back
What is an arthrogram?
Dye used to view joint structures (tendons, ligaments, cartilage)
What are some communication problems related to neurological disorders?
Dysarthria (difficultly speaking), Expressive aphasia, and Receptive aphasia
The nurse is collecting data on a patient who recently returned from surgery after fundoplication. Which symptom is essential to report to the health care provider? 1. Nausea 2. Pain rated as 4 out of 10 3. Dysphagia 4. Thirst
Dysphagia
After a fundoplication, which of these is a priority for the nurse to report to the health care provider? 1.Temperature of 99 degrees Fahrenheit 2.Dysphagia with eating 3.Pain of 2 on scale of 0 to 10 4.Heart rate 100 beats per minute
Dysphagia with eating
The nurse is asked to assist with the assessment of a patient's visual acuity. Which assessment methods would the nurse anticipate could be used? Select all that apply. 1. E chart 2. Fluorescein angiography 3. Inspection with ophthalmoscope 4. Confrontation test 5. Rosenbaum card 6. Snellen chart
E chart, Rosenbaum card, and Snellen chart
What are the diagnostic tests for seizures?
EEG and looking for the underlying cause
What are the diagnostic tests for Mallory-Weiss tear?
EGD and Hemoglobin and hematocrit
What are the components of the middle ear?
Eardrum, Malleus, incus, stapes, Oval window, and Eustachian tube
A 19-year-old student develops trigeminal neuralgia. Which of the following actions is most likely to trigger pain? 1. Sleeping 2. Eating 3. Reading 4. Cooking
Eating
In what drug class is edrophonium (Tensilon)? What happens when it is injected?
Edrophonium (Tensilon) is an anticholinesterase medica-tion. By inhibiting cholinesterase, more acetylcholine remains at the neuromuscular junction, which increasesthe muscle response to nerve impulses.
What is the nursing care for abdominal hernias?
Education (Ex. No coughing or lifting, Complication signs, and Support garments) and Postoperative (Ex. No coughing or lifting, Activity limits, and Education)
What is the nursing care for GERD?
Education (such as Lose weight, Eat a low-fat, high-protein diet., and Avoid caffeine, milk products, spicy foods.)
Which of the following nursing interventions will help prevent a further increase in intracranial pressure? 1. Encourage fluids. 2. Elevate the head of the bed. 3. Provide physical therapy. 4. Reposition the patient frequently.
Elevate the head of the bed.
What are the diagnostic tests for cancer of the liver?
Elevated alkaline phosphatase (A L P), Abdominal x-ray, Liver scan, and Biopsy
A post-myocardial infarction patient experiencing atrial fibrillation is most at risk for which type of stroke? 1. Hemorrhagic stroke 2. Embolic stroke 3. Thrombotic stroke 4. Cerebral aneurysm
Embolic stroke
What are the s/s of liver cancer?
Encephalopathy, Bleeding, Jaundice, and Ascites
What is the function of the joint capsule?
Encloses the joint similar to a sleeve
The nurse is caring for a patient who had a barium enema. Which of the following actions should the nurse implement? Select all that apply. 1. Have patient cough and deep breathe hourly while awake. 2. Encourage fluids. 3. Monitor for return of swallow and gag reflex. 4. Maintain the patient in semi-Fowler position. 5. Keep NPO, or nothing by mouth. 6. Provide ordered laxative.
Encourage fluids and Provide ordered laxative.
What is the postprocedure care for a computed tomography (CT) scan?
Encourage fluids if contrast dye used.
What should be done regarding the activities of daily living for a person with neurological disorder?
Encourage independence based on functional level, maintain routine, and provide assistance as needed.
What is uric acid?
End product of purine metabolism
What is Esophagogastroduodenoscopy (EGD)?
Endoscopy allowing visualization of esophagus, stomach, and upper duodenum. Biopsy or cytology specimens can be obtained. Normal findings: normal structures. (abnormal findings indicate Inflammation, cancer, bleeding, injury, or infection) Pretest: Laxative and enema the evening before the test; enema the morning of test as needed. NPO 6 hours before test. Posttest: Monitor vital signs. Keep NPO until swallow and gag reflex present. Monitor for pain, bleeding, fever, and dysphagia.
What interventions can help prevent aspiration in a poststroke patient with dysphagia? Select all that apply. 1. Ensure that patient is fully alert before feeding. 2. Place the patient in high-Fowler's position or chair for meals. 3. Use straws for thin liquids. 4. Use a thickening agent. 5. Place food on affected side of mouth.
Ensure that patient is fully alert before feeding, Place the patient in high-Fowler's position or chair for meals, and Use a thickening agent.
What is the significance of abnormal findings in an Aspartate aminotransferase (AST)? (seen in CMP)
Enzyme found in liver and heart. Over 500 units/L seen with acute hepatitis.
What is the significance of abnormal findings in an Alkaline phosphatase (ALP)? (seen in CMP)
Enzyme found in liver and other areas; released and elevates greatly with severe liver damage.
What is a cholesteatoma?
Epithelial cystlike sac filled with skin and sebaceous material
What is peptic ulcer disease?
Erosion of gastrointestinal lining (Curable)
Which of the following procedures does the nurse understand is done palliatively for the dysphagia that occurs in inoperable esophageal cancer? 1. Gastrectomy 2. Esophageal dilation 3. Radical neck dissection 4. Modified neck dissection
Esophageal dilation
What data needs to be collected on a pt with constipation?
Establish rapport, Determine history, Auscultate bowel sounds, and Inspect/palpate abdomen.
What is the most malignant primary malignant tumor?
Ewing sarcoma
What are some causes of ulcerative colitis?
Exact cause unknown however Infection, allergy, and autoimmune response possible causes
What is Proctosigmoidoscopy?
Examination of distal sigmoid colon, rectum, and anal canal using a rigid or flexible endoscope (sigmoidoscope). Normal findings: normal mucosa. (abnormal indicate Ulcerations, punctures, lacerations, tumors, hemorrhoids, polyps, fissures, fistulas, early malignancies, and abscesses) Pretest: Low-residue diet for 3 days before test; clear liquids evening before test; NPO 8 hours before test. Laxative and enema the evening before the test; enema morning of test as needed. Posttest: Monitor vital signs and for rectal bleeding.
What are the nursing diagnoses for acute liver failure and cirrhosis?
Excess Fluid Volume, Imbalanced Nutrition, Acute Pain, Acute Confusion, Ineffective Breathing Pattern, and Risk for Deficient Fluid Volume
Patients with a history of pancreatitis commonly have a history of which of the following? 1. High-protein diet 2. Very-low-fat diet 3. Excessive alcohol consumption 4. Excessive intake of vitamin K
Excessive alcohol consumption
What care and teaching would you provide for a patient having an angiogram?
Explain that an angiogram uses injected dye to viewblood vessels. Include the following:a. Administer clear liquids prior to the procedure.b. Explain that dye will be injected into an artery in the groin.c. Explain that dye may cause flushing and a feeling of warmth in the groin that can feel like she has wet her pants.d. Advise that she will need to lie flat after the test to prevent bleeding.e. Advise that she will need to drink fluids to flush dyefrom her system following the test.f. Explain that her nurse will do frequent checks following the procedure.
What are the infections of the external ear?
External otitis (the infection that most often occurs. Exposure to moisture, contamination, or local trauma provides an ideal environment for pathological growth in the external ear.), Ear canal furuncle (results when a hair follicle becomes infected), Otomycosis (an infection caused by fungal growth. It is typically seen after topical corticosteroid or antibiotic use.), and Perichondritis (An infection of the auricle)
What is the purpose of an assessment of the cardinal fields of gaze?
Extraocular movement
What are the diagnostic tests for the eyes?
Exudate culture, Digital imaging, Optical coherence tomography, Angiography (either Fluorescein or indocyanine green to check blood vessels), electroretinography, Ultrasonography, and Imaging tests
What assessments are included in the FOUR score coma scale? Select all that apply. 1. Eye response 2. Motor response 3. Brainstem reflexes 4. Respiration 5. Verbal response
Eye response, Motor response, Brainstem reflexes, and Respiration
What is the mnemonic for the warning signs of a stroke?
Face Arms Speech Time to call 911 (aka FAST)
What does the acronym FAST stand for?
Face, Arms, Speech, Time.
What is a safety concern for those with Ménière disease?
Falling without warning.
True or false: Oil the mechanical parts as instructed by the physician.
False. Grease the parts as ordered by the prosthetist.
True or false: Replace worn shoes with ones of a different height and type.
False. New shoes should be the same height as well as type.
What are the diagnostic tests for Huntington's disease?
Family history, M R I, C T scan, Genetic testing, and Counseling
The nurse notes frequent muscle twitching when collecting admission data on a patient admitted for increasing muscle weakness. Which of the following terms should be used to document this? 1. Fasciculation 2. Atrophy 3. Chorea 4. Neuropathy
Fasciculation
What is Steatorrhea?
Fatty, foul-smelling stools
What are the nursing diagnoses for colorectal cancer?
Fear and Imbalanced Nutrition: Less Than Body Requirements
What are the nonmodifiable risk factors for osteoporosis?
Female gender, Aging, Caucasian or Asian, Small boned, petite body build, Postmenopausal status, Low testosterone and estrogen in men, Family history of osteoporosis or fractures, and History of fractures
What are the s/s of diarrhea?
Fever, Foul odor, Abdominal cramping, Distention, Anorexia, and Intestinal rumbling (aka hyperactive bowel sounds)
What is otitis media?
Fever, earache, and feeling of fullness
What are the s/s of appendicitis?
Fever, nausea/vomiting, anorexia, and Pain right lower quadrant (known as McBurney point**) (Within hours of onset, the pain usually becomes localized to the right lower quadrant at the McBurney's point, midway between the umbilicus and the right iliac crest)
Absorbing shock between adjacent vertebrae is the function of disks made of which of the following? 1. Smooth muscle 2. Synovial fluid 3. Fibrous cartilage 4. Adipose tissue
Fibrous cartilage
What are the radiographic tests for the gastrointestinal system?
Flat plate of the abdomen, Barium swallow, Barium enema (worry about Barium impaction), and Computed tomography (C T) scan
What is the semitendinosus?
Flexes leg at the knee and extends thigh at the hip; belongs to the hamstring group
What are the diagnostic tests for diverticulosis/diverticulitis?
Flexible sigmoidoscopy or colonoscopy and C T scan
What are the s/s of hepatitis in the prodromal stage?
Flu-like symptoms and right upper quadrant (R U Q) pain (Lasts 1 week)
Which of the following drugs would the nurse expect to be prescribed for a woman with irritable bowel syndrome and constipation? Select all that apply. 1. Desipramine (Norpramin) 2. Dicyclomine (Bentyl) 3. Fluoxetine (Prozac) 4. Hyoscyamine (Levbid) 5. Nortriptyline (Pamelor) 6. Paroxetine hydrochloride (Paxil)
Fluoxetine (Prozac) and Paroxetine hydrochloride (Paxil)
What is the physiology of vision?
Focusing of light rays on retina and Transmission of subsequent nerve impulses to visual areas of cerebral cortex
The neurologist tests the fourth (trochlear) and sixth (abducens) cranial nerves together by having a patient do which of the following? 1. Turn the head to the right and left. 2. Identify whispering in the ears. 3. Say "Aaaah." 4. Follow a finger with the eyes.
Follow a finger with the eyes.
The nurse is caring for a patient with an external fixation device. Which of the following actions should the nurse implement? Select all that apply. 1. Avoid touching the pins. 2. Follow agency protocol for pin care. 3. Cleanse pins with hydrogen peroxide four times daily. 4. Loosen screws holding the pins during cleaning. 5. Monitor pin sites at least daily. 6. Use strict aseptic technique for pin care.
Follow agency protocol for pin care, Monitor pin sites at least daily, and Use strict aseptic technique for pin care.
What are the normal results of an assessment of the cardinal fields of gaze?
Follows in all fields without nystagmus
What is true for a patient with a disease process that could lead to dislocation or fracture?
For patients with disease processes that could result in a dislocation or fracture, careful moving is essential. Use lifting devices such as draw sheets and mechanical devices when moving a patient rather than pulling on the patient's extremities to avoid patient injury. Follow institutional policy for moving patients to avoid patient injury and liability for a patient's injury.
How can you keep a patient safe from dislocation or fracture?
For patients with disease processes that could result in a dislocation or fracture, careful moving is essential. Use lifting devices such as draw sheets and mechanical devices when moving a patient rather than pulling on the patient's extremities to avoid patient injury. Follow institutional policy for moving patients to avoid patient injury and liability for a patient's injury. (USE LIFTING DEVICES AND AVOID PULLING UP ON PATIENT'S ARMS TO AVOID PATIENT INJURY)
What is Fetor hepaticus?
Foul breath
What is a spiral fracture?
Fracture curves around the shaft of the bone.
What is an Interarticular fracture?
Fracture involves bones within a joint.
What is a longitudinal fracture?
Fracture occurs along the length of the bone.
What is an oblique fracture?
Fracture occurs diagonally or at an oblique angle across the bone.
The nurse is reinforcing patient teaching. Which of the following foods would the nurse reinforce that the patient with ulcerative colitis is to avoid? 1. Fresh fruits 2. White bread 3. Sweet dessert 4. Meat
Fresh fruits
What is the pathophysiology of chronic gastritis type B?
From infection with H. pylori affects the Lower stomach
Which of the following is the part of the brain that initiates muscle contraction? 1. Parietal lobe 2. Cerebellum 3. Frontal lobe 4. Temporal lobe
Frontal lobe
What is irritable bowel syndrome?
Functional problem (Bowel mucosa not changed) Altered intestinal motility
What is Barrett's esophagus?
G E R D can change epithelium of esophagus (Precancerous) it is an Esophageal cancer risk factor
What is the progression of primary open-angle glaucoma (POAG) like?****
GRADUAL and painless
What are the comorbidities for obesity?
Gallbladder disease, Heart disease, Hypertension, Sleep apnea, Type 2 diabetes mellitus, and Depression
What are the s/s of IBS?
Gas, Bloating, Constipation, Diarrhea, Abdominal pain, Depression, and anxiety
Which of the following surgical procedures is the most likely treatment for a patient with gastric cancer? 1. Gastrectomy 2. Gastric stapling 3. Gastroplasty 4. Gastrorrhaphy
Gastrectomy
What is the pathophysiology of Gastroesophageal reflux disease (GERD)?
Gastric secretions reflux into esophagus causing Esophagus damage and Lower esophageal sphincter does not close tightly
What are the therapeutic measures for the gastrointestinal system?
Gastrointestinal intubation such as Tube feedings (via Gravity, Pump, Bolus, Intermittent, and Continuous), enteral feedings, gastrointestinal decompression, and parenteral nutrition
A patient is being treated with gold therapy for rheumatoid arthritis. Which of the following interventions is essential when gold therapy is started? Select all that apply. 1. Remove all metal objects patient is wearing. 2. Check allergies to iodine. 3. Give a test dose of gold. 4. Plan a biweekly dosing schedule. 5. Monitor the patient after the injection. 6. Teach the patient to obtain daily weight.
Give a test dose of gold and Monitor the patient after the injection.
In planning safe care for the older adult, which of these conditions does the nurse recognize would cause visual problems? Select all that apply. 1. Glaucoma 2. Cataracts 3. Arcus senilis 4. Macular degeneration 5. Esotropia 6. Presbycusis
Glaucoma, Cataracts, Macular degeneration, and Esotropia
The nurse prepares to provide an eye irrigation to a patient with a methicillin-resistant Staphylococcus aureus infection. Contact precautions are ordered. Which protective items will the nurse need while performing this procedure? Select all that apply. 1. Gloves 2. Gown 3. Goggles 4. Mask 5. Shoe protectors 6. Sterile gloves
Gloves, Gown, and Goggles
What is crepitation?
Grating sound as joint or bone moves
What is glaucoma?
Group of diseases in which Most have elevated pressure within eye and Damage is silent, progressive, irreversible (can lead to blindness and optic nerve is damaged)
What are the most common types of hepatitis in the United States?
H A V, H C V, and H B V
What are the diagnostic tests for peptic ulcer disease?
H. pylori can be diagnosed with several tests. The urea breath test is performed by having the patient drink carbonlabeled urea. The urea is metabolized rapidly if H. pylori is present, allowing the carbon to be absorbed and measured in exhaled carbon dioxide. An immunoglobulin G antibody detection test for H. pylori identifies whether the patient is infected with H. pylori. These are both noninvasive detection tests. Biopsy specimens for the Campylobacter-like organism (CLO) biopsy urease test and a histological examination can be obtained during EGD. Biopsy is the most conclusive test for H. pylori. Cultures of the biopsy specimen may also be done to determine antimicrobial susceptibility. Peptic ulcers are diagnosed on the basis of symptoms, upper GI series (barium swallow), and EGD. (Urea breath test•Immunoglobulin G antibody detection test •Upper gastrointestinal series•E G D)
What is the primary cause of peptic ulcer disease?************
H. pylori****
What is the abbreviation for infectious hepatitis?
HAV
What is the abbreviation for serum hepatitis?
HB
How can the nurse help to prevent a debilitating bone infection?
Hand hygiene and use of sterile technique for dressingchanges.
The nurse would evaluate the patient as understanding diet teaching for celiac disease if the patient selected which of the following breakfast foods to eat? Select all that apply. 1. Fresh fruit and oatmeal with milk 2. Tomato juice and waffles 3. Hard-boiled egg, bacon, and blueberries 4. Banana, cream of wheat cereal, and coffee 5. Scrambled eggs and orange juice 6. Protein smoothie with carrots and spinach
Hard-boiled egg, bacon, and blueberries, Scrambled eggs and orange juice, and Protein smoothie with carrots and spinach
The nurse is caring for a patient with left-sided paresis and inability to walk following a stroke. Which intervention will help increase the possibility of the patient walking again? 1. Have the family bring high-top tennis shoes for the patient to wear in bed. 2. Administer muscle relaxants as ordered to maintain comfort. 3. Position the patient to reduce pressure on bony prominences. 4. Provide assistive devices so the patient can manage personal care independently.
Have the family bring high-top tennis shoes for the patient to wear in bed.
A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. 1. Place the patient in a semi-Fowler position. 2. Encourage the use of a straw for liquids. 3. Provide clear liquids only until the patient can swallow solid foods. 4. Have the patient swallow twice after each bite. 5. Place food on the unaffected side of the patient's mouth. 6. Check the patient's mouth for pocketing of food.
Have the patient swallow twice after each bite., Place food on the unaffected side of the patient's mouth, and Check the patient's mouth for pocketing of food.
What positioning was used during the feedings?
Head of Mrs. Patel's bed was elevated to 30 degrees to prevent aspiration.
What is done for pneumonia prevention during the feedings?
Head of bed elevated to 30 to 45 degrees to prevent aspiration, appropriate patient hand hygiene practiced, and oral care administered four times daily to remove bacteria.
What are the s/s of encephalitis?
Headache, Fever, Nausea and vomiting, Nuchal rigidity, Confusion (fogginess to severe), Decreased level of consciousness (L O C), Seizures, Photophobia, Ataxia, Hemiparesis, Tremors, Coma, and Death
The nurse is collecting data for a patient with suspected acute hepatitis A infection. Which clinical manifestations would the nurse expect the patient to report? Select all that apply. 1. Headache 2. Flu-like symptoms 3. Light-colored stools 4. Nausea 5. Abdominal pain 6. Brown-colored urine
Headache, Flu-like symptoms, and Nausea
What are the therapeutic measures for hearing loss?
Hearing aid and Cochlear implants
What is presbycusis?
Hearing loss caused by aging
The nurse is reinforcing teaching for a patient with Ménière disease. Which of the following would the nurse explain to the patient is the triad of symptoms associated with Ménière disease? Select all that apply. 1. Hearing loss 2. Headache 3. Nausea 4. Tinnitus 5. Vertigo 6. Vomiting
Hearing loss, Vertigo, and Tinnitus
What are the s/s of Gastroesophageal reflux disease (GERD)?
Heartburn, Regurgitation, Sour taste, and Dysphagia
What is collected during a physical exam of the gastrointestinal system?
Height and weight, Body mass index, Oral cavity, Abdomen, Inspection (for Jaundice), Auscultation, Percussion, and Palpation (Abdominal girth)
The most common cause of peptic ulcers whose discovery revolutionized treatment and cure of most peptic ulcers. _____
Helicobacter pylori
A patient with a history of seizures reports experiencing an aura and is concerned about an impending seizure. Place the nurse's interventions in the correct order. 1. Protect the patient from injury during the seizure. 2. Document the events of the seizure. 3. Help the patient lie down in a safe place. 4. Turn the patient on his or her side to sleep.
Help the patient lie down in a safe place. Protect the patient from injury during the seizure. Turn the patient on his or her side to sleep. Document the events of the seizure.
What are the diagnostic tests for absorption disorders?
Hematocrit (Decreased if anemia is present.), Mean corpuscular volume (Decreased values are found with malabsorption of vitamin B12.), Upper gastrointestinal series (Thickening of the intestinal mucosa, narrowed mucosa of the terminal ileum, or a change in fecal transit time are indicative of malabsorption syndrome.), D-xylose absorption test (Decreased excretion of xylose after 5 hours is indicative of malabsorption.), Sudan stain (Malabsorption can be distinguished from maldigestion if this test shows abnormally large numbers of fat droplets.), Stool collection ( 72-hour stool collection for fat Stool fat greater than 5 g per 24 hours after ingestion of 80 g of fat in 2 days implies a fat digestion disorder.), and Biopsy (Shows flattened mucosa and loss of villi with celiac disease.)
Following a patient's bone biopsy, the nurse inspects the biopsy site. The nurse is monitoring for what complication that may occur immediately following a biopsy? 1. Joint dislocation 2. Crepitation 3. Infection 4. Hematoma formation
Hematoma formation
What are the indications for intracranial surgery?
Hematoma, Tumor, Arteriovenous malformation, Trauma, and Seizures
What is the postoperative nursing care for an amputation?
Hemorrhage prevention, Infection (BIG ONE), Pain control: ****Phantom pain****, ****phantom sensation****, Mobility and ambulation, and Patient education (such as Prosthesis (comes after stump is healed) and Lifestyle adaptation)
What are some traumas that can lead to a traumatic brain injury?
Hemorrhage, Contusion, and Laceration
What are the complications of gastric surgery?
Hemorrhage, Gastric distention, Dumping syndrome (food goes straight through the alimentary canal/happens very quickly after eating), Nutritional problems (Ex. Pernicious anemia), Steatorrhea, and Pyloric obstruction
What are the complications of surgery for a herniated disk?
Hemorrhage, Nerve root damage, Reherniation, and Herniation of another disk
A patient with cirrhosis has asterixis and fetor hepaticus and is confused. The nurse recognizes these as symptoms of which complication? 1. Hepatic encephalopathy 2. Hepatorenal syndrome 3. Portal hypertension 4. Ascites
Hepatic encephalopathy
What are the s/s of cirrhosis/chronic liver disease?******
Hepatic encephalopathy (which causes behavior changes, flapping tremor, confusion, fetor hepaticus, and gradual progression to coma), portal hypertension (which causes hemorrhoids, ascites, caput medusae, enlarged spleen, esophageal varices, and spider angiomas), hepatorenal syndrome (which causes oliguria and sodium retention and is secondary to failure of the kidneys from cirrhosis), hematologic s/s are bruising, abnormal bleeding, anemia, and petechiae, skin s/s including jaundice and itching, gastrointestinal s/s include diarrhea, constipation, RUQ pain, anorexia, nausea, and clay-colored stools, and reproductive s/s include amenorrhea (female), testicular atrophy, gynecomastia (male), and erectile dysfunction
What are the types of viral hepatitis?
Hepatitis A virus (H A V), Hepatitis B virus (H B V), Hepatitis C virus (H C V), Hepatitis D virus (H D V), and Hepatitis E virus (H E V)
How does the liver function in formation of bilirubin?
Hepatocytes form bilirubin from the heme portion of hemoglobin removed from worn erythrocytes and collect bilirubin from the spleen.
What syndrome causes oliguria?
Hepatorenal
What is the pathophysiology of a herniated disk?
Herniation of nucleus pulposus causes compression of nerve root(s)
Which of these patient's dietary habits does the nurse understand may increase the risk for development of colon cancer? 1. Low meat and protein intake 2. High intake of milk and milk products 3. High-fat, low-fiber intake 4. Low-fat, high-carbohydrate intake
High-fat, low-fiber intake
What are the therapeutic interventions for constipation?
High-fiber diet, 2 to 3 liters fluid daily, Strengthen abdominal muscles, Activity, Bulk-forming agents (Metamucil), Stool softeners, and Education
Which of these interventions should the nurse contribute to the plan of care for constipation prevention? Select all that apply. 1.High-fiber diet 2.Fluids 3.Exercise 4.High-carbohydrate diet 5.Low-protein diet
High-fiber diet, Fluids, and Exercise
How can constipation be prevented?
High-fiber diet, fluids, and exercise
What lowers your risk for dementia?
Higher education, Higher socioeconomic status, and Engagement in simulating intellectual and leisure activities
What are the diagnostic tests for myasthenia gravis?
History and physical, ***********Tensilon test (injecting edrophonium (Tensilon) an *anticholinesterase* drug IV if muscle strength improves dramatically the pt (Ex. pt can suddenly open the eyes wide) this disease is diagnosed but improvement is only TEMPORARY), Anti-A C h receptor antibodies (increased antibodies in blood are present in 90% of pts with this disease), and Electromyography (E M G) (instrument that converts the electrical activity associated with functioning skeletal muscle into a visual record or into sound)
What are the diagnostic tests for multiple sclerosis?
History and physical, Cerebrospinal fluid (C S F) analysis (via lumbar puncture), and Magnetic resonance imaging (M R I)
What are the diagnostic tests for Amyotrophic Lateral Sclerosis (ALS)/Lou Gehrig disease?
History and physical, Lumbar puncture with CSF analysis, Electroencephalogram, Nerve biopsy, and E M G
What are the diagnostic tests for Alzheimer's disease?
History, Physical examination, M R I, P E T scan/ single-photon emission computed tomography (S P E C T) scan, and Autopsy
What is the purpose of vitreous humor?**
Holds retina in place
What is the etiology of dementia?
Huntington disease, Parkinson disease, Alzheimer disease, Vascular dementia, Chronic alcoholism, and Medications
The nurse is caring for a patient who is receiving a parenteral nutrition infusion. The nurse performs blood glucose monitoring every 6 hours to detect which complication? 1. Hypocalcemia 2. Hyponatremia 3. Hyperglycemia 4. Hyperkalemia
Hyperglycemia
What are the modifiable risk factors for a stroke?
Hypertension, Smoking, Diabetes mellitus, Cardiovascular disease, Atrial fibrillation, Carotid stenosis, TIA, Sickle cell anemia, Dyslipidemia, and Obesity
What is an exudate culture?
If exudate from any portion of the eye or surrounding structure is present, an eye culture may be ordered
What are the types of abdominal ostomies?
Ileostomy, Colostomy, and Urostomy
What actions should the nurse take after observing a joint that has a grating sound with movement? Select all that apply. 1. Abduct the extremity. 2. Adduct the extremity. 3. Immediately stop joint movement. 4. Flex the joint. 5. Protect the joint. 6. Maintain joint immobilization.
Immediately stop joint movement, Protect the joint, and Maintain joint immobilization.
What are the complications of constipation?
Impaction, Ulcers, Straining, and Megacolon (Grossly dilated loops of the colon, known as megacolon, can occur proximal to the dry fecal mass and obstruct the colon. Abdominal distention occurs. In severe cases, loops of bowel can be palpated through the abdominal wall.)
What are the long-term effects of a stroke?
Impaired motor function, Impaired sensation, Dysphagia, Aphasia, Pseudobulbar affect (can manifest as emotional lability, or instability, in which pt may move rapidly from profound sadness to almost euphoric state and back again Ex. laughing at a funeral), Impaired judgment, and Unilateral neglect
The nurse would teach the nursing assistant that the benefits of providing oral care daily include which of these? Select all that apply. 1.Important to overall health 2.Prevents pneumonia 3.Reduces ventilator-associated pneumonia 4.Provides patient comfort 5.Prevents aspiration
Important to overall health, Prevents pneumonia, Reduces ventilator-associated pneumonia, and Provides patient comfort
Which of the following problems during the immediate postoperative course following lumbar microdiskectomy should be reported to the physician immediately? 1. Incisional pain 2. Two-inch area of bleeding on dressing 3. Inability to move affected leg 4. Muscle spasm of affected leg
Inability to move affected leg
What is Murphy sign?
Inability to take a deep breath when fingers are pressed under liver margin
What is the pathophysiology of increased intracranial pressure?
Increase in Brain, Blood, and or C S F (swelling or irritation in the brain)
What is the significance of abnormal findings of ammonia?
Increased because liver cannot metabolize this protein end product; contributes to hepatic encephalopathy.
What is the significance of abnormal findings of total bilirubin?
Increased because the liver is unable to use it to produce bile.
Decreasing level of consciousness is a symptom of which of the following physiological phenomena? 1. Increased intracranial pressure 2. Sympathetic response 3. Parasympathetic response 4. Increased cerebral blood flow
Increased intracranial pressure
Wht is the intraocular pressure for primary open-angle glaucoma (POAG)?****
Increased intraocular pressure >20 millimeters of mercury
What is the intraocular pressure for acute angle-closure glaucoma (AACG)?***
Increased intraocular pressure may be >50 millimeters of mercury
What is Portal hypertension?
Increased pressure in the portal circulation
What are the s/s of stage 1 of Alzheimer's disease?
Increasing forgetfulness
The nurse must collect data for dye allergies for the patient undergoing which of these diagnostic tests? 1.Exudate culture 2.Ultrasonography 3.Optical coherence tomography 4.Indocyanine green angiography
Indocyanine green angiography
What are the nursing diagnoses for neuromuscular disorders?
Ineffective Airway Clearance, Impaired Physical Mobility, Imbalanced Nutrition, and Impaired Verbal Communication
What do we worry about postoperatively with pancreatic cancer?
Infection, Fistula formation, Malabsorption syndrome and Thrombophlebitis (Dangerous b/c could likely go into lungs)
What is the pathophysiology of meningitis?
Infection/inflammation of brain and spinal cord with Purulent exudate, Increased intracranial pressure, and Possible cranial nerve involvement
What is Bell Palsy?
Inflammation and edema of facial nerve and Loss of motor control
What is bursitis?
Inflammation of a bursa
What is the pathophysiology of encephalitis?
Inflammation of brain tissue that can cause Nerve damage, edema, and/or necrosis and result in Increased intracranial pressure (I C P)
What is Colitis?
Inflammation of colon
What is the pathophysiology of cirrhosis/chronic liver disease?
Inflammation of liver cells causes Infiltration with fat and white blood cells (W B C's) and Fibrotic scar tissue replaces liver tissue which results in Abnormal regeneration, impaired liver blood flow, and Impaired liver function
What is appendicitis?
Inflammation of the appendix
What is hepatitis?
Inflammation of the cells of the liver
What is conjunctivitis?
Inflammation of the conjunctiva (pink eye)
What is Keratitis?***
Inflammation of the cornea
What is blepharitis?
Inflammation of the eyelid margins
What is Cholecystitis?
Inflammation of the gallbladder
What is the pathophysiology of acute pancreatitis?
Inflammation of the pancreas appears to be caused by a process called autodigestion. ***Recall that the pancreas normally secretes digestive enzymes. For reasons not fully understood, pancreatic enzymes can be activated while they are still in the pancreas and begin to digest the pancreas.****** (Inflammation that results in Autodigestion, Elevated enzymes, and Fluid loss)
What is gastritis?
Inflammation of the stomach (can be Acute or chronic) that can cause Abdominal pain, nausea, anorexia treatment is to remove irritating substance and Antacids are a temporary solution
What is labyrinthitis?
Inflammation or infection of inner ear that causes Vertigo, tinnitus, sensorineural hearing loss
What is Peritonitis?
Inflammation or infection of peritoneum
What is labyrinthitis?
Inflammation or infection of the inner ear
What is diverticulitis?
Inflammation/infection of diverticulum
What is ulcerative colitis?
Inflammatory bowel disease that affects large intestine and rectum (Remissions and exacerbations occur)
What is the pathophysiology of rheumatoid arthritis?
Inflammatory cells cause synovitis. Synovium becomes thick and fluid accumulates, causing swelling and pain. Destructive pannus erodes joint cartilage and destroys joint bone. Joint becomes deformed. other connective tissue is affected.
What are the H2 receptor antagonists?
Inhibit gastric acid secretion by blocking H2-receptors on gastric parietal cells. Examples cimetidine (Tagamet) famotidine (Pepcid) nizatidine (Axid) ranitidine (Zantac)
What are the early s/s of acute liver failure?
Initial symptoms include fatigue, gastrointestinal (GI) upset, and diarrhea, are vague and make detection difficult. (early symptoms are vague)
What is Nuclear scanning: cholescintigraphy, diisopropyl iminodiacetic acid (DISIDA) scintigraphy, hepatobiliary iminodiacetic acid (HIDA) scan, or iminodiacetic acid (IDA) scan?
Injection of small amount of intravenous radioactive isotope. Serial images of gallbladder, bile duct, and duodenum are recorded. Normal findings: normal structures and function. (abnormal findings indicate Cholecystitis, biliary ejection problem, or obstruction) Pretest: NPO 4-6 hours before test. Posttest: Discard urine in first 24 hours. Wash gloved hands and then wash ungloved hands. Teach: Increase fluids to flush isotope. Flush toilet immediately and wash hands well for 24 hours.
What is arthrocentesis?
Insertion of a needle into a joint space to aspirate fluid, obtain a specimen, or instill medication
What is included in a physical examination of the musculoskeletal system?
Inspection, Palpation, Range of motion, and Muscle tone (always look then touch)
What should be done for the pt with GERD?
Instruct the patient to sleep with head of bed elevated 4 to 6 inches and avoid eating 3 hours before bedtime
How are eye drops given to a patient?
Instruct the patient to tilt the head backward and look up toward the ceiling. Hold the medication bottle in one hand and use the other hand to pull the lower eyelid down and out to form a pocket. Then use the patient's forehead to steady your hand and release an eye drop into the pocket. Avoid touching the tip of the dropper to anything to keep from contaminating it. Have the patient close the eye and apply gentle pressure with a tissue over the tear duct for at least 2 minutes, which is the amount of time it takes for the eye drop to be absorbed to keep the medication from being absorbed systemically and causing potentially serious side effects.
The nurse is caring for a patient with a small-bowel obstruction who is NPO (nothing by mouth) with an orogastric tube on low intermittent suction. Which of the following ongoing data would be a priority for the nurse to monitor and collect? Select all that apply. 1. Intake and output 2. Pain level 3. Temperature 4. Pulse rate 5. Edema 6. Firmness of abdomen or distention
Intake and output, Pain level, Temperature, Pulse rate, and Firmness of abdomen or distention
What is conductive hearing loss?
Interference with sound conduction to external auditory canal, eardrum, middle ear
What are the s/s of gastric ulcers (book)?
Intermittent high-left epigastric or upper abdominal burning or gnawing pain, increased 1 to 2 hours after meals or with food Variable pain pattern possibly made worse by food Antacids ineffective Possible malnourishment Hematemesis more common than melena
What are the s/s of duodenal ulcers (book)?
Intermittent mid-epigastric or upper abdominal burning or cramping pain, increased 2 to 4 hours after meals or in the middle of the night Relieved by food or antacids Patient usually well nourished Melena more common than hematemesis Anorexia Nausea and vomiting Bleeding (stomach secretions or stool positive for occult blood)
What are some examples of internal fixation?
Intertrochanteric fracture of the hip with fracture fixation via a side plate and screw combination device and Side plate and screw fixation of radial fracture
What is Flatulence?
Intestinal gas expelled via the rectum
What are the complications of peritonitis?
Intestinal obstruction, Hypovolemia (aka Fluid shift into peritoneal cavity), and Sepsis
What treatment was ordered for Mrs. Kirk?
Intravenous (IV) fluids, laboratory work, and packed red blood cells.
What is sensorineural hearing loss?
Involves hair cells and nerve endings
A pattern of alternating constipation and diarrhea is most characteristic of which of the following gastrointestinal tract disorders? 1. Crohn disease 2. Ulcerative colitis 3. Irritable bowel syndrome 4. Large-bowel obstruction
Irritable bowel syndrome
What are the bowel patterns associated with IBS?
Irritable bowel syndrome (I B S) with diarrhea, I B S with constipation, and I B S with mixed diarrhea and constipation
What is the pathophysiology of trigeminal neuralgia?
Irritation of the trigeminal nerve** that affects sensory portion of nerve only
What is the etiology of trigeminal neuralgia?
Irritation or chronic compression
What are primary and secondary surveys?
It is a quick set of assessments using the ABCDs for organization. A primary survey conducts an initial assessment of the patient's airway, breathing, circulation, and disability. (E can also be included for exposure). A secondary survey identifies medical problems or injuries that are not immediately life-threatening but require treatment.
What is Morgan lens?
It is essentially a plastic contact lens with IV tubing attached which allows IV fluids to flow directly over the surface of the eye
What is helpful for someone who wears dentures?
It is helpful to have the dentist place a small identity tag in the acrylic of the denture with the person's name on it to avoid lost or mixed-up dentures, especially when the person lives in a long-term care facility. Those with complete dentures still need to be routinely screened by a dentist or dental hygienist for proper denture fit, sore areas, oral fungal infections, and oral cancer detection.
What are the complications of acute pancreatitis? (book)
It may be useful to think of severe AP as a chemical burn to the organ. As with severe burns, death is likely to occur from organ failure. From the onset of symptoms, cardiovascular, pulmonary (including acute respiratory distress syndrome), and acute kidney injury are the most likely causes of death. Electrolyte imbalance, hemorrhage, peripheral vascular collapse, and infection are also major concerns. The presence of Chvostek sign (twitching of facial muscles with tapping in front of ear over facial nerve) indicates neuromuscular irritability and decreased calcium levels. A purplish discoloration of the flanks (Turner sign) or a purplish discoloration around the umbilicus (Cullen sign) may occur with extensive hemorrhagic destruction of the pancreas.
What level of spinal injury would render Jack quadriplegic?
Jack likely has a cervical injury below C3. If it were C3 or above, he would not have survived.
What are the late s/s of rheumatoid arthritis?
Joint deformity and Secondary osteoporosis
What are the s/s of osteoarthritis?
Joint pain (**that Intensifies AFTER physical activity aka aggravating factor), Stiffness, and Heberden and Bouchard nodes (aka Bony nodes on joints of fingers)
What is the patient education for headaches?
Keep diary, Record triggers, timing, symptoms, Teach relaxation and stress reduction, and Teach about medications.
What is the postprocedure care for an angiogram?
Keep flat in bed 4 to 6 hours, Keep pressure (sandbag) on site for 3 to 6 hours, Monitor Vital signs, monitor Catheter insertion site, monitor Pulses, and Encourage fluids.
What should be done for a pt with imbalanced nutrition?
Keep nothing by mouth (NPO) until swallowing evaluated, Perform dysphagia screen, Try sip of water, Request speech therapist swallowing evaluation, Implement aspiration precautions, and Consider tube feeding if necessary.
Which nursing interventions can help prevent falls in a patient with Parkinson disease? Select all that apply. 1. Keep the patient's call light within reach. 2. Apply a soft vest restraint when the patient is in bed. 3. Avoid use of throw rugs. 4. Maintain the patient's bed in a low position. 5. Encourage the patient to be independent for as long as possible. 6. Provide a cane or walker for ambulation.
Keep the patient's call light within reach, Avoid use of throw rugs, Maintain the patient's bed in a low position, and Provide a cane or walker for ambulation.
What are the diagnostic test for Crohn's disease?
Laboratory testing, Endoscopy with biopsy, Ultrasound, Multiphase C T enterography, Magnetic resonance enterography (confirmed by granulomas in the biopsy specimen. Imaging tests include multiphase CT enterography and magnetic resonance enterography (MRE), which provide detailed images of the intestines.)
What is the major cause of colorectal cancer?
Lack of dietary fiber
What medication is ordered to reduce ammonia levels for Mr. Guido?
Lactulose
What are the therapeutic interventions for hepatic encephalopathy caused by cirrhosis/chronic liver disease?
Lactulose****, Rifaximin (Xifaxan), and Neomycin (Neo-Fradin)
What are the types of surgery for a herniated disk?
Laminectomy (removing one of the laminae, the flat pieces of bone on each side of a vertebra VERY COMMON), Diskectomy, Spinal fusion, and Artificial disk
What are the therapeutic interventions for retinal detachment?
Laser surgery (Laser surgery focuses a laser beam at the torn area of the retina. It causes a controlled burn. This forms scars around the tear and reattaches the retina to surrounding tissue.), Cryopexy (Cryopexy is the placement of a supercooled probe on the sclera over the affected area. The probe freezes and scars the tear or hole, a principle similar to the laser procedure.), Pneumatic retinopexy (Pneumatic retinopexy is done in the HCP's office. It is time-consuming for the patient. It involves injecting air or gas into the eye chamber to hold the retina in place. The patient must be extremely compliant with the treatment regimen. Reclining for about 16 hours** before the procedure is required to allow the retina to fall back toward the choroid. Because air rises, the patient must maintain a position that keeps the air bubble against the detached area for up to 8 hours a day for 3 weeks.***), and Scleral buckling (Scleral buckling is a surgical procedure for retinal detachment. A silicon buckle under a thin band of silicon around the sclera is used. It is tightened to create an indentation that brings the choroid in contact with the retina. Cryosurgery or laser surgery is usually used to permanently adhere the retina and choroid layers together. Vitrectomy is often done as well.)
What are the surgeries that can be done for glaucoma?**
Laser trabeculoplasty (a narrow laser beam opens drainage angle of eye is often used for POAG), Trabeculectomy (removes part of the trabecular meshwork), Glaucoma drainage devices (shunts) (Glaucoma drainage devices (shunts) carry aqueous humor away), Cyclocryotherapy (Cyclocryotherapy (in which a cryoprobe destroys part of ciliary body to reduce production of aqueous humor) is used less often.), Istent trabecular micro-bypass (the iStent Trabecular Micro-Bypass is implanted during cataract surgery. It creates a permanent opening in the trabecular meshwork for outflow of aqueous humor.), Laser peripheral iridotomy (For AACG, laser peripheral iridotomy or surgical iridectomy is performed. Laser iridotomy creates a small hole on the edge of the iris. This allows the aqueous fluid to flow out of the area. Prophylactic laser iridotomy may be performed on the other eye in order to prevent AACG), Surgical refectory, and Wicking
A patient who has had a generalized tonic-clinic seizure is sound asleep 30 minutes after the seizure. Meals are about to be delivered. Which nursing action is most appropriate? 1. Wake the patient because nourishment is essential following the seizure. 2. Wake the patient to do a neurological assessment before the meal. 3. Let the patient sleep during the postictal state, and keep the meal warm. 4. Do not attempt to wake the patient because of the risk of a repeat seizure
Let the patient sleep during the postictal state, and keep the meal warm.
What is an Carcinoembryonic antigen?
Levels may indicate colorectal or other cancer.
What is needed for glaucoma?
Lifelong treatment needed (NO CURE)
If documented in the patient's history, which physical examination finding would indicate that the patient has a normal corneal light reflex? 1. The eye focuses the image in the center of the pupil. 2. The eyes converge to focus on the light. 3. Constriction of both pupils occurs in response to bright light. 4. Light is reflected at the same spot in both eyes.
Light is reflected at the same spot in both eyes.
The nurse is to palpate the patient's abdomen during data collection. Which of the following techniques should the nurse use? 1. Firmly place hands on abdomen, depressing tissues 1 to 2 inches. 2. Lightly depress the abdomen 0.5 to 1 inch. 3. Randomly feel the patient's abdomen with fingertips. 4. Light palpation must be completed by an experienced practitioner.
Lightly depress the abdomen 0.5 to 1 inch.
What is the purpose of the retina?
Lines posterior eyeball, contains rods(light)**/cones (color)** for vision
What is the function of the synovial membrane?
Lines the joint capsule and secretes synovial fluid
Which pancreatic enzyme Digests emulsified fats to fatty acids and glycerol?
Lipase
What are the diagnostic tests for cirrhosis/chronic liver disease?
Liver enzymes (elevated), Bilirubin (elevated), Ammonia (elevated), PT, Abdominal x-ray, Abdominal ultrasound, Esophagogastroduodenoscopy, and Liver biopsy (will lay on left side after)
What are the complications of hepatitis?
Liver failure (either Acute or Chronic), Chronic infection, and Carrier of virus (which increases your Risk of liver cancer)
Who are the candidates for a liver transplant?
Liver failure, No cancer, No complications, and Otherwise stable
What is the pathophysiology of Mallory-Weiss tear?
Longitudinal tear in mucous membrane of esophagus at stomach junction Tears from sudden, powerful, or prolonged force Hiatal hernia present
What is a loop stoma?
Loop of bowel outside abdomen with bridge under it
What are the therapeutic interventions for IBS?
Low FODMAP diet***, Diet high in fiber and bran, Avoid trigger foods, Smaller, frequent meals, Stress management, Behavioral therapy, Exercise, and Medications depend on type of I B S
What are the modifiable risk factors for osteoporosis?
Low calcium and vitamin D intake, Excessive caffeine, protein, sodium, Sedentary lifestyle, Excessive alcohol use, and Cigarette smoking
The nurse is planning care for a patient with cirrhosis. For which condition would the nurse place the patient on bleeding precautions? 1. Encephalopathy 2. Low vitamin K 3. Elevated liver enzymes 4. Hepatorenal syndrome
Low vitamin K
What medications are given to pts with IBS who have diarrhea?
Low-dose tricyclic antidepressantsDesipramine (Norpramine), imipramine (Tofranil), nortriptyline (Pamelor) ‒Antispasmodics Hyoscyamine (Levbid), dicyclomine (Bentyl)** ‒AntibioticsRifaximin (Xifaxan): For those who do not respond to other treatments
A patient had a gastrectomy 2 months ago and is being seen in the clinic for greasy stools and frequent bowel movements. After the patient's surgical recovery and current eating habits are identified, which type of diet would be most appropriate for the nurse to teach the patient to use? 1. Soft diet 2. High-carbohydrate diet 3. Low-fat diet 4. Pureed diet
Low-fat diet
What are the risk factors for diverticulosis/diverticulitis?
Low-fiber and high animal-fat diet (Ex. keto), Obesity, Sedentary lifestyle, Smoking, and Medications
What is sliding hiatal hernia?
Lower esophagus/stomach slides up through hiatus of diaphragm into thorax
The nurse is caring for a patient with presbycusis. Which technique is most important for the nurse to use to increase communication with this patient? 1. Talk in a very loud voice. 2. Lower voice pitch. 3. Do not smile or chew gum when talking to the patient. 4. Allow extra time for patient to respond.
Lower voice pitch.
Which of the following nursing interventions will help prevent complications in the patient with Bell palsy? 1. Vitamin therapy 2. Elastic bandages 3. Application of ice to the affected area 4. Lubricating eyedrops
Lubricating eyedrops
What are the diagnostic tests for meningitis?**
Lumbar puncture, Culture and sensitivity (C&S), Computed tomography (C T) scan, and/or magnetic resonance imaging (M R I)
What are the diagnostic tests for a herniated disk?
M R I and Myelogram
A patient with osteoarthritis who had a right total knee replacement tells the nurse that the other knee is becoming painful. Which of the following is the most appropriate instruction to help the patient preserve function of the left knee? 1. Reduce dietary purines. 2. Maintain ideal body weight. 3. Maintain normal uric acid levels. 4. Begin a jogging program.
Maintain ideal body weight.
A patient is scheduled for a right total hip replacement. The nurse should teach which of the following postoperative leg positions? 1. Maintain legs in adduction. 2. Maintain legs in abduction. 3. Maintain internal leg rotation. 4. Maintain more than 90-degree hip flexion.
Maintain legs in abduction.
What are hte bones of the middle ear?
Malleus (hammer), Incus (anvil), and Stapes (stirrup) (three smallest bones in body that connect the eardrum to the inner ear)
What are the complications of Crohn's disease?
Malnutrition, Obstruction, Fissures, Abscess, Fistula, Perforation, and Bleeding
What do we worry about preoperatively with pancreatic cancer?
Malnutrition, Spread of cancer, and Gastric or duodenal obstruction
What is the patient education for pancreatic cancer?
Management of hyperglycemia, Pancreatic enzyme replacement, Dressing, Complications to report, and Hospice referral
What are the S&S of Parkinson's disease?
Mask-like facial expression, soft voice, drooling, dysphagia, hand tremors at rest, constipation, frequent urination, flexion of knees and hips, shift of center of gravity forwards, short, shuffling steps, Muscular rigidity, Bradykinesia, Change in posture, Pill-rolling tremor, Difficulty initiating movement, and Shuffling and freezing gait
What are the therapeutic measures for rheumatoid arthritis?
Medication • Antibiotics • NSAIDs • Biological response modifier • Prednisone • Disease-modifying antirheumatic drug (DMARD) • T-cell modulators Heat and cold Balanced rest and activity Surgery for total joint replacement
What are the therapeutic measures for osteoarthritis?
Medication • Nonsteroidal anti-inflammatory drugs (NSAIDs) • Acetaminophen • Muscle relaxants. Balanced rest and exercise Splinting of joint to promote rest Heat and cold Diet for weight loss Complementary therapies Surgery for total joint replacement
What are the therapeutic interventions for gout?
Medication (for an Acute flare up (Colchicine (Colcrys) and N S A I D's) and for Prevention (Febuxostat (Uloric), Allopurinol (Zyloprim) and Probenecid (Benemid))
What are the therapeutic interventions for rheumatoid arthritis?
Medication, Antibiotics, Disease-modifying antirheumatic drugs )DMARDs) can prevent joint destruction, deformity, and disability with early single or combination medication use (Ex.Leflunomide (Arava) andEtanercept (Enbrel))), Methotrexate***** VERY COMMON****, Gold (Ex. auranofin (Ridaura) and aurothiogllucose (Solganal) via injection Give test dose and monitor for allergic reaction for about 1 hour. Lab testing for gold toxicity recommended.) N S A I D's, and Prednisone, Heat/cold (20 minutes on and 20 minutes off), Balanced rest and activity, and Surgery: Total joint replacement
What are the therapeutic interventions for Crohn's disease?
Medications (such as 5-aminosalicylates, Antidiarrheals, Biologic response modifiers, Corticosteroids, and Immunomodulators), Avoid offending foods, Surgery if necessary, Elemental formula or parenteral nutrition if required, and Support and education
What are the therapeutic interventions for dementia?
Medications delay progression (Ex. Cholinesterase inhibitors and N-methyl-D-aspartate (N M D A) agonist) and End-of-life decision making
Which part of the brain controls breathing? 1. Medulla oblongata 2. Cerebellum 3. Cerebrum 4. Thalamus
Medulla oblongata
What results from slow bleeding in an upper GI area?
Melena
Which gender is a greater risk for gastric cancer?
Men greater than women
What is osteoporosis?
Metabolic disorder of low bone mass
The nurse would teach the patient that otitis media occurs in which part of the ear? 1. Outer ear 2. Inner ear 3. Middle ear 4. Semicircular canal
Middle ear
What are duodenal ulcers?
Midepigastric that cause Upper abdominal burning/cramping pain that is **Increased 2 to 4 hours after meal/middle of night** and Relieved with food or antacids***
What are the s/s of primary open-angle glaucoma (POAG)?****
Mild eye aching, Headache, Halos around lights, and Frequent visual changes
What is serum phosphorus?
Mineralizes bones and teeth
What are the medications given for glaucoma?
Miotics (such as Carbachol (Isopto Carbachol)* and Pilocarpine (Pilocar)*) and Agents to decrease production of aqueous fluid (such as Dipivefrin (Propine)* and Timolol (Timoptic)*)
What should be done for a pt with ineffective airway clearance?
Monitor lung sounds, cough, respirations, Position to maintain open airway., Encourage to cough and deep breathe, and Suction as needed.
What should be done for a pt at risk for injury?
Monitor neurological status and report changes, Monitor for hemorrhage, Administer anticonvulsant as ordered, Implement seizure precautions, and Assist with transfers and ambulation.
The nurse is caring for a patient with gastritis. Which intervention should the nurse implement for a patient with acute gastritis? 1. Monitor patient for bloody diarrhea. 2. Explain that aspirin rarely causes gastritis. 3. Administer phenothiazine to control vomiting. 4. Encourage a regular diet during the acute phase of gastritis.
Monitor patient for bloody diarrhea.
What should be done for a pt at risk for impaired skin integrity?
Monitor skin for breakdown, Keep perineal area clean and dry, Use barrier cream as needed, Turn patient every 2 hours, Use lift sheet to reposition, and Consider pressure-reducing mattress.
What is the nursing care for Guillain-Barre syndrome?
Monitor vital capacity and arterial blood gases, Provide supportive care, Manage pain, Maintain nutrition, Assist with communication, and Provide diversional activities.
Which interventions should the nurse include in the plan of care for a patient after gastric surgery? Select all that apply. 1.Monitor vital signs. 2.Encourage shallow breathing. 3.Manage pain. 4.Maintain bedrest. 5.Monitor incisional site
Monitor vital signs, Manage pain, and Monitor incisional site
What is the nursing care for gastric surgery?
Monitor vital signs, Monitor respiratory status, Control pain, Monitor intake and output, Check incisional site, NG tube care, Ambulate early, Monitor abdominal status, and Education
What are immunomodulators?
Most commonly used in immunosuppression to reduce inflammation. Examples azathioprine (Imuran) 6-mercaptopurine (6-MP, Purinethol) Methotrexate (Trexall) Nursing Implications Report symptoms of infection when taking an immunomodulator. Monitor for infections. Monitor for side effects. Teach: Grapefruit and grapefruit juice should be avoided. Take in morning. Swallow whole.
What is the etiology of a traumatic brain injury?
Motor vehicle collision (M V C) (most common), Falls, Assaults, and Sports-related injuries
What is Parkinson's disease?
Movement disorder caused by the death of cells that generate dopamine in the basal ganglia and substantia nigra. Characterized by resting tremor, slowed movement, rigidity of facial muscles, and shuffling gait, and reduction in capacity for language (DECREASED DOPAMINE PRODUCTION AND RELATIVE EXCESS OF ACETYLCHOLINE WITH IMPAIRMENT OF SEMIAUTOMATIC MOVEMENTS (resulting in tremors)
What is the ball and socket?
Movement in all planes
What is saddle?
Movement in several planes
What is the function of the abducens nerve?
Movement of eyeball
What is the function of the trochlear nerve?
Movement of eyeball
What are some therapeutic measures for the neurological system?
Moving and positioning such as maintain functional positions, avoid injury, prevent contracture, and mobilize ASAP.
What are the s/s of postpolio syndrome?
Muscle weakness, Fatigue, Pain, and Respiratory compromise
What are the s/s of multiple sclerosis?
Muscle weakness, Numbness, Fatigue, Slurred speech, Vision disturbances, Vertigo, Ataxia, Dysphagia, Bowel/bladder problems, Sexual dysfunction, and Mood alterations (symptoms will vary depending on disease stage)
What are the internal obliques?
Muscles deep to the external obliques whose *fibers run at right angles to the external oblique's*, originating on the iliac crest and inserting into the last three ribs
What is contraindicated in acute angle-closure glaucoma (AACG)?************
MyDriatics (Dilate the pupil, which leads to increased ocular pressure*) (Examples Atropine (Isopto Atropine), Diphenhydramine (Benadryl), and Hydroxyzine (Vistaril)) Can cause blindness!‒Always know medication action before giving!
Which type of eye drop does the nurse understand is given to constrict the pupil, permitting aqueous humor to flow around the lens? 1. Osmotic 2. Myotic 3. Mydriatic 4. Cycloplegic
Myotic
What are the therapeutic interventions for chronic pancreatitis?
N S A I D's or analgesics, Small low-fat meals, Pancreatic enzyme replacement, Stents (inserted into pancreas to allow things to flow the way they should/Procedures can be done to stent the pancreatic ducts or remove ductal stones (extracorporeal shock-wave lithotripsy)), and Surgery (Surgery may be necessary to treat biliary disease, repair fistulas, drain cysts, or remove part of the pancreas.)
Which tubes are usually temporary and which are for long-term use?
NG tubes are usually temporary and short term. Esophagostomy, gastrostomy, or jejunostomy tubes are generally used for longer-term nutrition delivery.
What is the only thing lipids can be hung with?
NORMAL SALINE
What are the therapeutic interventions for intestinal obstruction?
NPO with oral care, NG tube, Fluid and electrolyte replacement, Medications (such as Antibiotics, Antiemetics, and Analgesics), and Surgery
What are the therapeutic interventions for peritonitis?
NPO, Fluid/electrolyte replacement, Nasogastric (NG) or orogastric tube, Antibiotics, Surgery, and Pain management
What is Acute angle-closure glaucoma (A A C G)?**
Narrowed angle blocks aqueous fluid
What is Myopia?
Nearsightedness
What are some bacteria that cause meningitis?
Neisseria meningitidis (main), Streptococcus pneumoniae, Group B streptococcus (main), and Haemophilus influenzae type B
What is the pathophysiology of a brain tumor?
Neoplastic growth of the brain or meninges that is Primary or metastatic and can Compress or infiltrate brain tissue and Cause increased I C P
What is Encephalopathy?
Neurological changes from excess ammonia
What do you monitor for a pt at risk for ineffective cerebral tissue perfusion?
Neurological status, vital signs, S p O subscript 2, Blood glucose, Coagulation studies, Medication effects, Report changes., Keep head of bed up 20 to 30 degrees., and Monitor medication effects.
What are the diagnostic tests for dementia?
Neuropsychological testing, Depression testing, Medication review, and M R I, C T scan, or positron emission tomography (P E T) scan for underlying cause
What is the postoperative care to prevent neurovascular compromise after a total hip replacement?****
Neurovascular checks
What is otosclerosis?
New bone along stapes and causes Conductive hearing loss (More common in women than in men occurs in Both ears and is a Hereditary disease with No cure)
What are the s/s of gastric cancer?
No early symptoms Late symptoms are Indigestion, Anorexia, Pain relieved by antacids, Weight loss, Nausea and vomiting, and Anemia
What is the Postprocedure care for magnetic resonance imaging (MRI)?
No special care
How can cataracts be managed with surgery?
No stitch surgical removal of lens, Laser removal, and Lens implant (this is very common)
What are the s/s of pancreatic cancer?
None early is typically (which is what makes it so deadly) Early: Weight loss, Abdominal pain radiates to back that Worsens at night or with yawning (due to diaphragm compressing pancreas) that is gnawing, Anorexia, nausea and vomiting, fullness, Pruritus, Depression, Fatigue, and Jaundice
What are the therapeutic measures for abdominal hernias?
None, Observation, Support devices, and Surgery either Herniorrhaphy or Hernioplasty
What are the therapeutic interventions for nausea and vomiting?
None, Protect airway, Medications, IV fluids, Nasogastric (NG) tube (to decompress stomach and get rid of contents), and Clear liquids, dry toast
What are the complications of a fracture?
Nonunion (delayed or no healing), Neurovascular compromise, Hemorrhage, Infection, Thromboembolic complications (Deep vein thrombosis (DVT) or pulmonary embolus can develop in patients having orthopedic surgery.), Acute compartment syndrome (a limb-threatening condition in which pressure in limb compartments increases.), and Fat embolism syndrome (Small fat droplets are released from yellow bone marrow into the bloodstream)
The nurse provides teaching on medications that contain acetaminophen to use cautiously for a patient with cirrhosis. Which of these medications would the patient correctly state should be used cautiously? 1. Norco 2. NyQuil 3. Penicillin 4. Percocet 5. Tetracycline 6. Vicodin
Norco, NyQuil, Percocet, and Vicodin
What is Emmetropia?***
Normal vision
What are the therapeutic interventions for appendicitis?
Nothing by mouth (N P O) and Surgery
What are the therapeutic interventions for gastric bleeding?
Nothing by mouth (N P O), I V fluids, Urinary catheter (to monitor output), NG tube, and Oxygen
A patient who has a 36-hour-old fractured femur had morphine 5 mg intramuscularly 1 hour ago and is now reporting severe unrelieved pain. Which nursing action is most appropriate? 1. Administer an analgesic. 2. Apply Buck traction. 3. Raise head of bed. 4. Notify the health care provider.
Notify the health care provider.
The nurse is caring for a patient who has undergone a right knee arthroscopy. Two hours after the procedure, the patient's right pedal pulse is diminished compared with the previous assessment. What action should the nurse take? 1. Take vital signs. 2. Notify the surgeon. 3. Perform neurovascular assessment in 30 minutes. 4. Change the dressing and rewrap the elastic wrap.
Notify the surgeon.
What are the other diagnostic tests for the gastrointestinal system?
Nuclear (Cholescintigraphy, Diisopropyl iminodiacetic acid (D I S I D A), Hepatobiliary iminodiacetic acid (H I D A), Iminodiacetic acid (I D A)) Angiography, Liver scan, Endoscopy (Esophagogastroduodenoscopy (E G D), Endoscopic retrograde cholangiopancreatography (E R C P)), Lower gastrointestinal endoscopy (Proctosigmoidoscopy Colonoscopy), Ultrasonography, Endoscopic ultrasonography, and Percutaneous liver biopsy
What is it called when you break something and fix it internally?
ORIF open rotation internal fixation (surgery is done to put them in)
The nurse is collecting data for a patient admitted with possible cholecystitis. Which of the following does the nurse recognize as risk factors for gallbladder disease? Select all that apply. 1. Male gender 2. Obesity 3. Multiple pregnancies 4. Age 40 or older 5. Fasting 6. Diabetes mellitus
Obesity, Multiple pregnancies, Age 40 or older, Fasting, and Diabetes mellitus
What objective data is collected during an assessment of the hearing?
Observe patient behaviors., How does patient communicate?, Inspection, and Palpation
What actions should the nurse take for a patient's increased pain unresponsive to analgesics after a bone biopsy? Select all that apply. 1.Administer higher analgesic dose. 2.Observe site for hematoma. 3.Perform neurovascular checks. 4.Notify the health care provider. 5.Administer aspirin.
Observe site for hematoma, Perform neurovascular checks, and Notify the health care provider.
What is blindness?
Obstacle to rays of light/Disease of optic nerve or tract of brain connected with vision
The nurse assisted with inserting a flexible feeding tube into a patient. Which of the following actions should the nurse take to confirm tube placement? 1. Aspirate gastric contents to observe for green-colored fluid. 2. Measure the pH of secretions from tube. 3. Obtain ordered chest x-ray results. 4. Look in the back of the mouth for coiling of the tube.
Obtain ordered chest x-ray results.
The nurse is caring for a patient who has a sudden onset of diarrhea with black tarry stools. Which action should the nurse take? 1. Obtain vital signs. 2. Monitor output. 3. Ask about a history of food allergies. 4. Place the patient on nothing by mouth status.
Obtain vital signs.
What subjective data should the nurse collect for a patient with a fractured arm? Select all that apply. 1.Inspection of skin color at injury site 2.Palpation of skin temperature 3.Occupation 4.Family history 5.Nutritional history 6.Range of motion
Occupation, Family history, and Nutritional history
Which cranial nerve controls pupil constriction? 1.Optic 2.Oculomotor 3.Abducens 4.Facial
Oculomotor
What are the cranial nerves that innervate the eye muscles?*******
Oculomotor, trochlear, abducens
A patient with late stage 2 Alzheimer dementia is throwing half-eaten food from the meal tray onto the floor. Which response by the nurse is best? 1.Say, "That food cost good money. Please don't throw it on the floor." 2.Ask, "Why are you throwing the food on the floor? Don't you like it?" 3.Simply pick up the food and put it back on the tray. 4.Offer alternative foods and stay with the patient during mealtime.
Offer alternative foods and stay with the patient during mealtime.
What are the cranial nerves?
Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal
What is Hepatorenal syndrome?
Oliguria and sodium retention without kidney defects
What is mneumonic for the cranial nerves?
On (Olfactory) Old (Optic) Olympus' (Oculomotor) Towering (Trochlear) Top (Trigeminal) A (Abducens) Finn (Facial) Very (Vestibulocochlear) Graciously (Glossopharyngeal) Viewed (Vagal) A (Accessory) Hop (Hypoglossal)
How can vision and safety be enhanced for glasses wearers?
One of the most simple and effective ways to improve vision for older adults is to make sure their eyeglasses are clean. Clean glasses can improve safety by preventing falls or ingestion of a harmful substance.
What are the s/s of Bell Palsy?
One-sided facial Pain, Weakness, Speech difficulty, Drooling, Tearing of eye, and Inability to blink (all one sided)
What is cataracts?
Opacity in eye lens that causes Loss of visual acuity, Halos around lights, Difficulty reading, Sensitivity to glare, Double vision, and Decreased color vision
What is the nursing care for otosclerosis?
Operative ear is upward when lying, Insert earplug to protect, Administer antiemetics promptly (NO VOMITING), Promote safety, Teach not to Cough, sneeze, Blow nose, Vomit, Fly, Lift heavy objects, and Shower
What is the structure of the eyeball?
Orbit with six extrinsic muscles, Cranial nerves innervate muscles (Oculomotor, trochlear, abducens),Eyeball layers (Outer sclera,middle choroid,inner retina), Choroid layer (Prevents glare), Ciliary body(Circular muscle changes shape of lens), Circular iris (Dilates, constricts pupil), Retina (Lines posterior eyeball, contains rods(light)**/cones (color)** for vision), Fovea centralis (Most acute color vision), Optic nerve (Transmit images), and Eyeball cavities including Vitreous humor (Holds retina in place) and Aqueous humor (Nourishes lens/cornea)
Which term would the nurse use to document a finding that the patient's ear is draining? 1. Otorrhea 2. Otalgia 3. Ototoxic 4. Tinnitus
Otorrhea
Which term would indicate to the nurse that a substance is toxic to the ear? 1. Otoplasty 2. Otalgia 3. Ototoxic 4. Tinnitus
Ototoxic
What are the layers of the eyeball?
Outer sclera,middle choroid,inner retina
What is diverticulum?
Outpouching of bowel mucous membrane
A patient is admitted to the surgical unit following removal of a brain tumor. Which nursing intervention takes priority? 1.Assess speech and swallowing. 2.Pad side rails on bed. 3.Reorient to surroundings. 4.Administer medication for pain.
Pad side rails on bed.
A patient with a brain tumor is admitted to the medical unit to begin radiation treatments. Which nursing action should take priority? 1. Pad the patient's side rails. 2. Assess the patient's pain level. 3. Teach the patient what to expect during radiation treatments. 4. Place the patient in isolation.
Pad the patient's side rails.
Which patient data does the nurse recognize as a risk factor for a patient with a history of a pathological fracture? Select all that apply. 1. History of falling 2. Paget disease 3. Jogging 4. Cancer 5. Osteoporosis 6. Daily carbonated beverage intake
Paget disease, Cancer, and Osteoporosis
What are the therapeutic interventions for severe diverticulosis/diverticulitis?
Pain control, NPO, IV antibiotics, IV fluids/nutrition (Ex. TPN), and Surgery
What are the s/s of a fracture?
Pain, Decreased range of motion, Limb rotation, Deformity, shortening of limb, Swelling, and Bruising
What are the s/s of oral cancer?
Painless but Difficulty in chewing, swallowing, speaking
Which of the following does the nurse understand is a sign or symptom of oral cancer? 1. Painless ulcer 2. White painful ulcers 3. Feeling of fullness 4. Heartburn
Painless ulcer
The nurse is caring for a patient with a fractured left leg. Which of the following findings during a neurovascular assessment of the lower extremities would the nurse recognize as a priority to report to the health care provider? 1. Strong bilateral left leg post tibial pulse 2. Right foot capillary refill less than 2 seconds 3. Bilateral dorsal flexion 4. Pallor of the left leg
Pallor of the left leg
The nurse is caring for a patient being transferred into bed who has just had a plaster long-leg cast applied. The patient reports pain of 6 on a scale of 0 to 10. Place the nursing interventions in order of priority. 1. Expose cast to air dry. 2. Administer ordered analgesic. 3. Check circulation, sensory, and mobility status. 4. Palm cast as positioned upon pillow. 5. Obtain vital signs.
Palm cast as positioned upon pillow. Expose cast to air dry. Check circulation, sensory, and mobility status. Obtain vital signs. Administer ordered analgesic.
What are the s/s of spinal cord injury that causes cervical injury?
Paralysis, Paresthesias, Impaired respiration, Loss of bladder and bowel control, Quadriplegia/paresis, and C3 OR ABOVE IS FATAL
A patient who has ulcerative colitis is taken to the emergency department with severe rectal bleeding. Which of the following is the best option for maintaining nutritional status for this patient with ulcerative colitis who must be nil per os (NPO) for an extended period of time? 1. Nasogastric tube feedings 2. Percutaneous endoscopic gastrostomy tube feedings 3. Parenteral nutrition 4. Intravenous 5% dextrose and water
Parenteral nutrition
What is Paraesophageal hernia?
Part of the stomach squeezes through the hiatus and is at risk for strangulation (Rarer but serious)
What is a subtotal gastrectomy?
Partial removal of the stomach
The nurse is planning care for a newly admitted patient with acute pancreatitis. Which patient outcome should receive the highest priority in the plan of care? 1. Patient increases activity tolerance. 2. Patient maintains normal bowel function. 3. Patient verbalizes understanding of medications at discharge. 4. Patient expresses satisfaction with pain control.
Patient expresses satisfaction with pain control.
How is restless legs syndrome diagnosed?
Patient report of symptoms, Sleep history, Laboratory test for iron deficiency, and Medication history
Which data collection finding could indicate to the nurse that the patient has a hearing loss? Select all that apply. 1. Patient converses easily with nurse. 2. Patient answers questions appropriately. 3. Patient's face is relaxed during conversation. 4. Patient speaks in a very loud voice. 5. Patient turns toward person speaking. 6. Patient is withdrawn.
Patient speaks in a very loud voice., Patient turns toward person speaking, and Patient is withdrawn.
Which of the following foods might a patient with diverticulitis have been instructed to avoid, even though this has not been proven to prevent diverticulitis? Select all that apply. 1. Apples 2. Dairy products 3. Peanuts 4. Red meat 5. Raspberries 6. Whole grains
Peanuts and Raspberries
How is Antibiotic Prophylaxis used to treat oral conditions?
People who have artificial joints or certain heart conditions may need to take prophylactic antibiotics before certain dental procedures. This is to prevent bacteria from entering the circulation and causing bacterial endocarditis. The patient's health care provider identifies the length of time after a joint replacement (e.g., for 1 or 2 years, or for life) that antibiotics are required. The dentist is informed of the patient's history to prescribe appropriate antibiotics.
Which assessment should take priority in a patient with a cervical spine injury who suddenly exhibits a spike in blood pressure? 1.Perform a bladder scan. 2.Check hand grip strength. 3.Assess pulse rate. 4.Determine orientation.
Perform a bladder scan.
What should be done for a pt at risk for falls?
Perform fall risk assessment, Instruct to ask for help to get up, Keep call light within reach, Provide frequent toileting, and Avoid restraints.
The nurse is caring for a patient with an open fracture. Which of the following actions are essential for the nurse to perform to help prevent osteomyelitis? Select all that apply. 1. Perform hand hygiene before dressing change. 2. Wear a protective gown. 3. Use aseptic technique. 4. Wear goggles. 5. Wear sterile gloves to apply new dressing. 6. Wear mask.
Perform hand hygiene before dressing change, Use aseptic technique, and Wear sterile gloves to apply new dressing
What is the etiology of rheumatoid arthritis?
Periodontal disease/oral pathogens may be a cause. Is an autoimmune disease. (antibodies (rheumatoid factor causes local and systemic inflammation) and genetic predisposition Can occur at any age (including juvenile rheumatoid arthritis). Familial history possible.
What is the function of the bursae?
Permit tendons to slide easily across a joint
The nurse is caring for a patient with acute angle-closure glaucoma. Which symptoms would the nurse expect to find during data collection for this patient? Select all that apply. 1. Flashing lights 2. Lens opacity 3. Photophobia 4. Rainbows around lights 5. Severe pain over eye 6. Steamy-appearing cornea
Photophobia, Rainbows around lights, Severe pain over eye, and Steamy-appearing cornea
What is the postoperative care to prevent complication from ambulation (or lack thereof) after a total hip replacement?
Physical therapy and Walker/crutches
What is an ophthalmologist?
Physician trained to diagnose and treat eye conditions and diseases.
In providing patient teaching for acute bacterial conjunctivitis, the nurse would evaluate the patient as understanding the teaching if the patient stated that this condition is more commonly known as which of the following? 1. Astigmatism 2. Color blindness 3. Glaucoma 4. Pink eye
Pink eye
A patient who has just returned from surgery after a total gastrectomy begins to vomit bright red blood. What is the priority action for the nurse to take? 1. Increase the intravenous rate. 2. Take blood pressure. 3. Place patient onto side. 4. Administer oxygen.
Place patient onto side.
What is the Weber test?******
Place the vibrating tuning fork on the center of the patient's forehead or head. Verify that the patient can hear the tuning fork. If the patient says yes, ask the patient whether the sound is heard better in the left ear, better in the right ear, or the same in both ears. It is important to give the patient three choices from which to choose. Normally, the patient hears the sound the same in both ears
What are the therapeutic interventions for Guillain-Barre syndrome?
Plasmapheresis, Oxygen, Mechanical ventilation, Emotional support, and Rehabilitation
What are the s/s of stage 2 of Guillain-Barre syndrome?**
Plateau and Progression stopped (lasts 2 to 14 days) (aka this is the worst you are likely to get)
Which of these converting functions does the pancreatic enzyme trypsin have? 1.Starch to maltose 2.Emulsified fats to fatty acids 3.Emulsified fats to monoglycerides 4.Polypeptides to peptides
Polypeptides to peptides
How treatable is gastric cancer?
Poor prognosis as metastasizes
The nurse is assisting a patient to prepare for a lumbar puncture. Which of the following actions should the nurse take first? 1. Administer enemas until clear. 2. Remove all metal jewelry. 3. Position the patient on the side. 4. Remove the patient's dentures.
Position the patient on the side.
What are the therapeutic interventions for acute liver failure?
Possible dialysis for overdose, Supportive care, Decrease stimulation and provide rest, Eliminate all drugs (including meds even B/P), High-calorie, low-sodium, and protein diet, Decrease ammonia level (with Lactulose-******* Lactulose is given if ammonia is high), and Liver transplant
What is the nursing care for anorectal problems?
Postoperative (including Pain control, Sitz baths, Dressing changes, and Stool softeners)
What are the therapeutic interventions for Bell Palsy?
Prednisone, Analgesics, Antiviral medication, Moist heat, Gentle massage, and Facial sling
The nurse is caring for a patient who has a fractured ankle in a cast. The patient has morphine 5 to 10 mg intramuscularly ordered every 3 to 4 hours. The patient received morphine 5 mg 2 hours and 45 minutes ago. The patient is rating the pain at 10 and moans that the leg hurts. Vital signs are within normal limits. The patient has good capillary refill. Which of the following actions is most appropriate for the nurse to take next? 1. Apply ice to the cast. 2. Notify the health care provider immediately. 3. Remove the pillow under the cast. 4. Prepare morphine 10 mg for administration.
Prepare morphine 10 mg for administration.
Which term indicates that the patient has hearing loss caused by aging? 1. Otoplasty 2. Otalgia 3. Presbycusis 4. Tinnitus
Presbycusis
What is decreased elasticity of lens?
Presbyopia
What are the diagnostic tests for rheumatoid arthritis?
Presence of RF in serum Decreased red blood cell count Decreased C4 complement Increased ESR (The ESR test screens for inflammation. It measures the amount of time it takes for red blood cells to settle to the bottom of a test tube. In the presence of inflammation, red blood cells settle faster in the tube. Therefore, the ESR increases with the presence of inflammation. It also evaluates the effectiveness of treatment. If the disease responds to treatment, the ESR decreases.) Positive antinuclear antibody test Positive C-reactive protein test X-ray examination and MRI detect joint damage and bone loss, especially in the vertebral column.
Which of these differentiates diverticulitis from diverticulosis? Select all that apply. 1. Presence of weakness in bowel wall 2. Presence of outpouchings on bowel mucous membrane 3. Presence of inflammation and infection 4. Lack of symptoms 5. Involves the large intestine
Presence of inflammation and infection and Lack of symptoms
What are the diagnostic tests for acute pancreatitis?
Presence of two items: Abdominal pain, Serum amylase and/or lipase >3 times normal, and Abdominal imaging positive (either Ultrasound, Computed tomography (CT) scan, or Magnetic resonance imaging (M R I))
Which of the following is the function of synovial fluid in joints? 1. Exchange nutrients 2. Prevent friction 3. Absorb water 4. Wear away rough surfaces
Prevent friction
The nurse is contributing to the plan of care for a patient with Ménière disease. What is the primary goal for this patient that the nurse should recommend to include in the plan of care? 1. Prevent dehydration. 2. Decrease pain. 3. Prevent injury. 4. Preserve hearing.
Prevent injury.
What is the postoperative care to prevent skin breakdown after a total hip replacement?
Prevent pressure injury
What is the nursing care for osteomyelitis?
Prevention is key!********, Hand hygiene, Sterile dressing changes, and Medication teaching (Ex. do not skip your antibiotics)
What is the function of the synovial fluid?
Prevents friction within the joint cavity
What is the purpose of the choroid layer of the eye?
Prevents glare
What does mechanical oral hygiene do?
Prevents pneumonia and Reduces ventilator-associated pneumonia (Antibiotic prophylaxis for some conditions)
What is the etiology of osteoarthritis?
Primary (idiopathic): • Cause unknown. • Risk factors include age, obesity, activities causing joint stress. Secondary: • Causes include trauma, sepsis, congenital abnormalities, metabolic disorders (Ex. Paget's disease), rheumatoid arthritis.
What are the s/s of Amyotrophic Lateral Sclerosis (ALS)/Lou Gehrig disease?
Progressive muscle weakness and atrophy, Decreased coordination, Muscle spasm, Difficulty chewing and swallowing, Emotional lability, Speech difficulty, Pulmonary compromise, and Death due to pulmonary complications
What are the s/s of myasthenia gravis?
Progressive muscle weakness, Fatigue with activity, Ptosis, Difficulty chewing, difficulty swallowing, Difficulty breathing, Remissions, and Exacerbations (due to Stress)
What is cirrhosis/chronic liver disease?
Progressive, irreversible replacement of healthy liver tissue with scar tissue (Often irreversible unless early treatment)
What is obstipation?
Prolonged constipation
What is the postoperative care to prevent infection (Ex. osteomyelitis) after a total hip replacement?
Prophylactic antibiotic, Coughing and deep breathing, and Incisional care
The nurse is caring for a patient who is vomiting. What is the priority action for the nurse? 1.Give an antiemetic drug. 2.Protect airway. 3.Administer I V fluids. 4.Insert a nasogastric tube.
Protect airway.
What is the pt education for osteoarthritis?
Protect joints and Conserve energy.
What is the pathophysiology of gastritis?
Protective mucosal barrier broken down and Autodigestion occurs (if Severe results in Perforation and/or Scarring) (results when the protective mucosal barrier is broken down and allows autodigestion from hydrochloric acid and pepsin to occur.)
Gastric juice contributes to the digestion of which of the following types of nutrients? 1. Proteins 2. Fats 3. Starch
Proteins
What is prothrombin time (PT)?
Prothrombin is a vitamin K-dependent protein produced by the liver. PT is a coagulation test measuring time for a fibrin clot to form. Normal range: 10-13 seconds abnormal findings: ↑ in biliary obstruction, cirrhosis, and vitamin K deficiency
How can the nurse best modify the environment for a patient admitted with nuchal rigidity and positive Kernig sign? 1.Provide distraction with music or television. 2.Provide a dark, quiet room. 3.Provide a continuous-motion bed. 4.Provide a room humidifier.
Provide a dark, quiet room.
The nurse is caring for a patient who had an open cholecystectomy 24 hours ago. Which actions should the nurse take to assist the patient to maintain an effective breathing pattern? Select all that apply. 1. Place in a supine position. 2. Provide analgesics for pain relief. 3. Encourage coughing and deep breathing. 4. Monitor bowel sounds. 5. Assist with splinting during coughing. 6. Maintain bedrest for 48 hours after surgery.
Provide analgesics for pain relief, Encourage coughing and deep breathing, and Assist with splinting during coughing.
What are Anti-Inflammatory Synthetic Corticosteroids?
Reduce inflammation locally for Crohn disease. Examples budesonide (Entocort EC) Nursing Implications Teach: Grapefruit and grapefruit juice should be avoided. Take in morning. Swallow whole.
What are the therapeutic interventions for osteoporosis?
Reduce risk factors, Calcium supplements, Vitamin D supplements, Medications, Antiresorptive medications such as Bisphosphonates (Bisphosphonates bind to bone and suppress osteoclast activity. This prevents or reduces the bone breakdown process in osteoporosis) (Alendronate (Fosamax-pill), Ibandronate (Boniva-once a month pill), Risedronate (Actonel), and Zoledronic Acid (Reclast-IV)), Calcitonin (Fortical, Miacalcin) (The synthetic thyroid hormone calcitonin (Fortical, Miacalcin) treats osteoporosis by decreasing bone loss), Monoclonal antibody (Denosumab (Prolia)) (The monoclonal antibody denosumab (Prolia) inhibits the protein that signals bone removal), Selective estrogen receptor modulator (Raloxifene (Evista)) (Raloxifene (Evista) is a selective estrogen receptor modulator (SERM) that increases bone mass by 2 to 3% each year.), and Estrogen therapy, and Anabolic (bone forming) (Teriparatide (Forteo))
What should be done for a pt with impaired physical mobility?
Refer to physical therapy, occupational therapy, Consider constraint therapy (aka restrain good limb t to strengthen affected limb), Maintain good body alignment, Perform range-of-motion exercises, Mobilize via Chair or ambulate and Turn every 2 hours.
What is the nursing care for esophageal cancer?
Referral for Alcohol/tobacco cessation, and Postoperative (Airway, Pain management, Swallowing, and Nutrition)
What are the therapeutic measures for the eyes and vision?
Regular eye examinations, Eye hygiene, Nutrition for eye health, Eye safety and prevention of injury, Eye irrigation, Guide dogs, Medication administration (make sure to provide punctal occlusion), and Eye patching
What is a Laparoscopic cholecystectomy?
Removal of the gallbladder through a small abdominal incision
The nurse is collecting data on a patient admitted with a history of severe diarrhea. Findings include cool, pale skin, and red tongue with furrows. Vitals signs are blood pressure 102/74 mm Hg, pulse 106 beats per minute, respirations 20 breaths per minute, and temperature 99.9°F (37.7°C). Which action should the nurse take now? 1. Apply warm blankets. 2. Give acetaminophen (Tylenol) as ordered. 3. Obtain bedside commode. 4. Report findings to registered nurse.
Report findings to registered nurse.
The nurse is caring for a patient after eye surgery. Which nursing intervention would have the highest priority in the plan of care for the postoperative eye patient? 1. Do not leave the patient unattended at any time. 2. Teach the patient not to bend over. 3. Report sudden onset of acute pain. 4. Apply sandbags to either side of the head.
Report sudden onset of acute pain.
What is the emergency management of spinal cord injury?
Respiratory, Gastrointestinal (monitor for absent bowel sounds b/c feedings can not resume until bowel sounds do), Genitourinary (an indwelling catheter is placed to prevent bladder distension but need to monitor for skin breakdown), and Immobilization (pt will typically need to be moved q30 minutes)
What is RICE?
Rest to protect it Ice to decrease pain, swelling, and inflammation Compression with elastic bandage Elevating affected area (if appropriate) (used to treat strain injuries)
What are the therapeutic interventions for a herniated disk?
Rest, Physical therapy, Traction, Muscle relaxants, NSAID's, analgesics, Epidural anesthetic/steroid, and Surgery
An asymptomatic patient is admitted with gastric bleeding. For which of the following signs or symptoms of severe gastric bleeding should the nurse monitor? Select all that apply. 1. Restlessness 2. Diaphoresis 3. Bounding pulse 4. Hypotension 5. Confusion
Restlessness, Diaphoresis, Hypotension, and Confusion
What are the s/s of increased intracranial pressure?
Restlessness, Irritability, Decrease in LOC, Hyperventilation, Pupil changes, and Cushing triad (characterized by bradycardia, irregular respirations, and arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same) which results in widening pulse pressure)
What are the s/s of hepatitis in the convalescent stage?
Return to normal liver function (Lasts 2 to 6 weeks)
What action should the nurse take prior to initiating an enteral feeding using a newly inserted nasogastric feeding tube? 1. Auscultate bowel sounds. 2. Flush the feeding tube. 3. Review chest x-ray results. 4. Review abdominal x-ray results.
Review chest x-ray results.
What are the Postoperative nursing diagnoses for gallbladder disorders?
Risk for Impaired Skin Integrity and Ineffective Breathing Pattern
What are the nursing diagnoses for a pt with a cerebrovascular disorder?
Risk for Ineffective Cerebral Tissue Perfusion, Ineffective Airway Clearance, Risk for Injury, Impaired Physical Mobility, Imbalanced Nutrition, Disturbed Sensory Perception, Risk for Impaired Skin Integrity, Incontinence (Bowel or Overflow Urinary or Functional Urinary), Self-Care Deficit (Bathing, Dressing, Feeding, Toileting), Impaired Verbal Communication, Acute or Chronic Confusion, Risk for Falls, Deficient Knowledge, and Risk for Caregiver Role Strain
The nurse reinforces teaching for a patient after a cholecystectomy who is on a low-fat diet. The nurse will know that the patient understands the diet if which menu items are selected? 1. Roast chicken, rice, gelatin dessert 2. Cream of chicken soup, milk, gelatin dessert 3. Meat loaf, mashed potatoes with small amount of gravy, green beans 4. Turkey and cheese sandwich on whole-grain bread, apple, milk
Roast chicken, rice, gelatin dessert
What is Cirrhosis?
Scarring and hardening of the liver from inflammation
What forms the myelin sheath in the peripheral nervous system (PNS)?
Schwann cells
The nurse is caring for a patient with cirrhosis. The nurse would cautiously use sedatives for the patient due to which of the following? 1. The liver's ability to synthesize protein is altered. 2. Sedatives may increase the risk of jaundice. 3. Sedatives are potentially toxic to the cirrhosis patient. 4. Sedatives promote the conversion of ammonia to ammonium ion.
Sedatives are potentially toxic to the cirrhosis patient.
What medications are given for a patient with IBS who has constipation?
Selective serotonin reuptake inhibitorsParoxetine hydrochloride (Paxil), fluoxetine (Prozac, Sarafem) and medications to Increase fluid secretion into bowelLinaclotide (Linzess) Lubiprostone (Amitiza): For women (antidepressants to help relieve pain)
What are Biologic Response Modifers?
Selectively target inflammatory agents to interfere with inflammatory response. Examples adalimumab (Humira) certolizumab pegol (Cimzia) infliximab (Remicade) ustekinumab (Stelara) vedolizumab (Entyvio) Nursing Implications Tuberculosis test must be done before therapy begins and annually. Monitor for infections, bone marrow suppression, and central nervous system disorder.
What are the therapeutic interventions for Mallory-Weiss tear?
Self heals, PPI's, Antiemetics, Bleeding control (with Epinephrine or Endoscopy: Endoclips), and Avoid alcohol
What are the nursing diagnoses for macular degeneration?
Self-Care Deficit (Bathing, Dressing, Feeding), Risk for Injury, and Deficient Knowledge
What are the nursing diagnoses for patients with visual impairment?
Self-Care Deficit (Bathing, Dressing, Feeding), Risk for Injury, and Deficient Knowledge
What are the s/s of meningitis?**
Severe headache, Fever, Photophobia, Petechial rash, Nuchal rigidity, Positive Kernig (think K as in knee) and Brudzinski signs, Nausea and vomiting (to elicit the Kernig sign, the examiner flexes the patient's hip to 90 degrees and tries to extend the patient's knee. the sign is positive if the pt experiences pain and spasm of the hamstring. The Brudzinski sign is positive when flexion of hte pts neck causes the hips and knees to flex), and Encephalopathy
What are the s/s of gallbladder disorders?
Silent stones (Gallstones are asymptomatic (silent stones) and require no treatment in most people.), Elevated vital signs, Vomiting, Jaundice, Epigastric pain, Nausea, Indigestion, RUQ tenderness, Positive Murphy sign (The patient may have a positive Murphy sign, which is the inability to take a deep breath when an examiner's fingers are pressed below the liver margin.), and Biliary colic (The epigastric pain caused by cholelithiasis may also be called biliary colic.)
What is the postprocedure care for a myelogram?
Similar to lumbar puncture (i.e. maintain flat bedrest for 6-8 hours as ordered by HCP, encourage fluids, monitor the puncture site (Ex. for leaks), and monitor movement, sensation, and presence of headache), encourage fluids, and Head of bed elevated 30 degrees
What is a Levin tube?
Single lumen that May be used for gastric decompression, irrigation, lavage, and feeding. (nursing considerations Tube is not vented. Avoid use with continuous suction to prevent injury to stomach lining.)
A resident of a long-term care facility who has Alzheimer's disease is sitting in a corner, crying loudly that no one is paying attention. Several staff members have tried to find out what's wrong, but the patient won't answer and just keeps rocking back and forth and crying. Which approach by the nurse might best help the patient? 1. Say in a quiet voice, "What is wrong? We can't help you if you don't tell us what's wrong." 2. Sit quietly by the patient and say, "I'm here. You aren't alone." 3. Say in a firm voice, "Several staff members have asked what you need. Now it is time to stop crying." 4. Ignore the continued crying. Continuing to respond will encourage the behavior.
Sit quietly by the patient and say, "I'm here. You aren't alone."
What is fat embolism syndrome?
Small fat droplets are released from yellow bone marrow into the bloodstream. The droplets then travel to the lung fields, causing respiratory insufficiency. This can lead to respiratory failure. This process occurs with long bone fractures (especially the femoral shaft) and perhaps when the patient has multiple fractures. The older adult patient with a fractured hip is also at a high risk for fat embolism syndrome. This condition can occur up to 72 hours after the initial injury. The three primary manifestations of fat embolism syndrome are respiratory failure, cerebral involvement, and skin petechiae. Pulmonary dysfunction is the earliest sign and includes tachypnea, dyspnea, and cyanosis. Cerebral changes are often seen and include confusion or drowsiness. A petechial (red, measles-like) rash on the chest, neck, axilla, and conjunctiva appears in some patients. Other signs include tachycardia, fever, and retinal changes. If a fat embolism is suspected, notify the HCP immediately. Treatment interventions may include: Promote oxygenation by administering oxygen at 2 L/min via nasal cannula, and apply a pulse oximeter. Place the patient in high-Fowler position or raise the head of the bed as tolerated. Maintain bedrest, and minimize movement of the extremity. Obtain arterial blood gas. Initiate venous access for medications. Administer corticosteroids. Prepare patient for a chest x-ray and an MRI of the brain. Provide emotional support and calm environment.
What is a Weighted or nonweighted, flexible feeding tube, with or without stylets?
Small-bore tube for enteral feeding only. Less injury. Can remain in place for extended periods. (nursing considerations Suction collapses tube. Use 10-mL syringe or greater because smaller syringe creates too much pressure, leading to possible rupture of tube. Inject 30 mL of air with a 60-mL syringe immediately before withdrawing fluid to make it easier to withdraw.)
Who is a hiatal hernia most common in?
Smokers, Those over 50, Obesity, and Pregnancy (Gastroesophageal reflux disease (G E R D) often secondary aka hernia causes GERD)
What puts you at increased risk for peptic ulcer disease?
Smoking and N S A I D use
What are the risk factors for chronic pancreatitis?
Smoking and acute pancreatitis
What are the risk factors for pancreatic cancer?
Smoking, Obesity, Work exposure to chemicals, Diabetes mellitus, and Chronic pancreatitis
How can you relieve the inflammation and rest the wrist of a pt with carpal tunnel?
Splint, Anti-inflammatory (NSAIDS or cortisone injection), Surgery, and Teach prevention.
Which of the following precautions will protect the nurse who is caring for the patient with hepatitis B? 1. Reverse isolation 2. Standard precautions 3. Respiratory precautions 4. Enteric precautions
Standard precautions
What is hordeolum?
Staphylococcal abscess in sebaceous gland (aka a sty)
What are the therapeutic interventions for multiple sclerosis?
Steroids, Interferon therapy (also used for cancer), Immunosuppressant agents, Anticonvulsants, Muscle relaxants, Plasmapheresis (aka plasma exchange/removal), and Physical, occupational, speech therapies
Which of the following symptoms would the nurse most likely be told was the first symptom that caused a patient with rheumatoid arthritis to seek health care? 1. Cold intolerance 2. Stiff, sore joints 3. Shortness of breath 4. Crepitation
Stiff, sore joints
Which of the following diagnostic procedures on stool specimens must the nurse collect using sterile technique? 1. Stool for ova and parasites 2. Stool for occult blood 3. Stool for culture 4. Stool for lipids
Stool for culture
What is serum calcium?
Stored in bone to make bone rigid
The nurse is caring for a patient immediately after a below-the-knee amputation. Which data collection should the nurse consider a priority? 1. Sacral edema 2. Emotions 3. Stump dressings 4. Blood sugar level
Stump dressings
What are the types of gastric surgery?
Subtotal gastrectomy and Total gastrectomy
What are the s/s of retinal detachment?
Sudden change in vision, Flashing lights, floaters, Looking through a veil, Curtain being lowered over vision, and *NO* pain**
What is the pathophysiology of acute liver failure?
Sudden massive loss of liver tissue
What are the warning signs of a stroke?
Sudden numbness or weakness, Sudden confusion, Sudden change in vision, Sudden trouble walking/dizziness, and Sudden severe headache (if you experience any of these signs call 911!)
What are the external obliques?
Superficial muscles that compose the lateral walls of the abdomen - Their fibers run at an angle, *downward and medially* from the last 8 ribs and insert into the ilium
What is the pt education for Amyotrophic Lateral Sclerosis (ALS)/Lou Gehrig disease?
Support groups, Importance of avoiding infection, and Teach family to provide care.
What are the therapeutic interventions for pancreatic cancer?
Surgery (including Whipple procedure************ (pancreatoduodenectomy), Distal pancreatectomy, and Pancreatectomy (which is Rare)), Stent or bypass relieves biliary obstruction, Chemotherapy, and Radiation
What are the therapeutic interventions for liver cancer?
Surgery, Chemotherapy (Ex. Sorafenib (Nexavar)), and Radiation
what are the therapeutic interventions for gastric cancer?
Surgery, Chemotherapy, Radiation, and Biologic therapy (which Boosts immune system)
What are the therapeutic interventions for bone cancer?
Surgery, chemotherapy, and radiation
What are the therapeutic interventions for a traumatic brain injury?
Surgical removal of hematoma, Control increased I C P (with I C P monitoring, Osmotic diuretic, and Mechanical ventilation typically with HOB raised), and Therapeutic coma (to give body time to rest)
The nurse would evaluate the patient as understanding teaching for gastrointestinal changes that occur with aging if the patient included which of these? Select all that apply. 1.Tooth enamel softens 2.Increased gastric hydrochloride production 3.Sweet taste sensation lost 4.Saliva production increases by 33% 5.Esophagus motility lessens 6.Weaker gag reflex
Sweet taste sensation lost, Esophagus motility lessens, and Weaker gag reflex
What are the s/s of acute gout?*****
Swollen, red, hot, painful inflamed joints (**MOST COMMON SITE IS GREAT TOE****)
What are the s/s of rheumatoid arthritis??******
Symptoms vary according to disease process. Early symptoms: • Bilateral and symmetrical joint inflammation • Redness, warmth, swelling, stiffness, pain • Stiffness after resting (morning stiffness) • Activity decreases pain and stiffness • Low-grade fever, weakness, fatigue, anorexia (mild weight loss) • Organ system involvement Late symptoms: • Joint deformity • Secondary osteoporosis
Which of the following is a function of the liver? 1. Synthesis of plasma proteins 2. Elimination of carbohydrates 3. Concentration of bile 4. Secretion of cholecystokinin
Synthesis of plasma proteins
What is the term or acronym for a temporary impairment of cerebral circulation that causes symptoms lasting minutes to hours but results in no permanent neurologic changes? 1. TIA 2. CVA 3. SAH 4. Stroke
TIA
What is the abbreviation for liver shunt?
TIPS
A patient sees a health care provider because of extreme fatigue for 2 months and difficulty lifting even light objects. The health care provider suspects myasthenia gravis. Which of the following tests should the nurse anticipate assisting with to confirm this diagnosis? 1. Mestinon (pyridostigmine) test 2. Quinine tolerance test 3. Pulmonary function studies 4. Tensilon (edrophonium) test
Tensilon (edrophonium) test
What is a test of the Stool for occult blood?
Testing stool for blood that is not visible to the eye.
What is a test of the stool for fats/lipids?
Testing stool for excessive amounts of fat.
What is a test of the Stool for ova and parasites?
Testing stool for intestinal infections caused by parasites.
What is a stool culture?
Testing stool for the presence of pathogenic organisms in the GI tract.
What is the low FODMAP diet?****
The Low FODMAP diet restricts certain carbohydrates that are known to cause symptoms in patients with IBS because of their poor absorption, osmotic activity, and rapid fermentation. FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols. The Low FODMAP Diet has been shown to reduce IBS symptoms and is the primary diet therapy used internationally (St. Charles & O'Brien, 2015). High FODMAP foods include fermentable: Oligosaccharides: fructans (e.g., agave, wheat, onions, garlic, leeks, artichokes, asparagus, jicama) and galactans (GOSs; e.g., legumes [soybeans, beans, chickpeas, lentils]; cabbage, Brussels sprouts, wheat, rye, onions, garlic, inulin, artichokes, leeks, asparagus, broccoli) Disaccharides (lactose): milk, dairy products Monosaccharides (fructose): honey, apples, dates, mangoes, papaya, pears, prunes, watermelon, high-fructose corn syrup Polyols (sugar alcohols, i.e., sorbitol, mannitol, maltitol, xylitol, ismalt): low-calorie food products, sugar-free mints/gums/beverages Not all FODMAPs will trigger symptoms for all patients. Only those that are malabsorbed are likely to be clinically significant. Fructans and GOSs are always malabsorbed and fermented by intestinal bacteria, resulting in gas production and associated flatulence even in healthy people. The remaining FODMAP carbohydrates will only induce symptoms in the patients with IBS that malabsorb them. Identification of susceptible patients can be achieved by breath tests after ingestion of lactose or fructose or by eliminating all FODMAP foods and relating their reintroduction to returning symptoms. Individualizing the diet is important, particularly for vegetarians who may depend on legumes for protein intake, as it may show patients that they can cope with garlic as a minor ingredient or wheat products occasionally, which would expand the nutritional composition of their diet. The low FODMAP diet requires a registered dietitian's expertise both to maximize compliance with instigating the complete list of FODMAP sources and to avoid an overly restrictive approach unnecessarily. The latter is of great import in the event the diet is successful and likely to be followed long term.
Why does the small intestine have extensive folds?
The absorption of nutrients requires a large surface area
What is the seizure threshold?
The amount of stimulus necessary to produce a convulsive seizure. (aka stuff can go all the way up to the seizure threshold with no seizure but once it passes it they will have a seizure)
What happens to the GI tract as we age?
The liver and pancreas usually continue to function well into old age. Liver damage can occur from pathogens such as hepatitis viruses or toxins such as alcohol. Gallstone formation increases. Acute pancreatitis of unknown cause is more common.
How does the liver function in lipid metabolism?
The liver forms lipoproteins for the transport of lipids in the blood to other tissues. The liver also synthesizes cholesterol and excretes excess cholesterol into bile to be eliminated in feces. Beta oxidation is another task of the liver, in which fatty acid molecules are split into two-carbon acetyl groups. These acetyl groups may be used by the liver to produce energy, or they may be combined to form ketones to be transported to other cells for energy production.
How does the blood supply of the liver differ from the other organs?
The liver receives oxygenated blood by way of the hepatic artery. By way of the hepatic portal vein, blood from the abdominal digestive organs and the spleen is brought to the liver before being returned to the heart. This special pathway is called hepatic portal circulation. It permits the liver to regulate blood levels of nutrients or to remove potentially toxic substances such as alcohol from the blood before the blood circulates to the rest of the body.
How does the liver function in carbohydrate metabolism?
The liver regulates the blood glucose level by storing excess glucose as glycogen and performing glycogenolysis when the blood glucose level is low.
How does the liver regulate amino acid metabolism?
The liver regulates the blood levels of amino acids based on tissue needs for protein synthesis. Of the 20 amino acids needed for the production of human proteins, the liver is able to synthesize 12, called the nonessential amino acids,
What does the liver synthasize?
The liver synthesizes albumin, clotting factors, and globulins.
How does the liver function in detoxification?
The liver synthesizes enzymes that convert harmful substances to less harmful ones. Alcohol and medications are examples of potentially toxic chemicals. The liver also converts ammonia from protein metabolism to urea, a less toxic substance.
Which patients should be closely monitored by the nurse for symptoms of increased intracranial pressure? SELECT ALL THAT APPLY. 1. The patient who has a history of epilepsy. 2. The patient admitted with a high fever and severe headache. 3. The patient in the postanesthesia care unit following craniectomy. 4. The patient with a brain tumor who is admitted for radiation therapy. 5. The patient with a history of migraine headaches, admitted for orthopedic surgery. 6. The patient with Alzheimer's disease admitted with a urinary tract infection.
The patient admitted with a high fever and severe headache, The patient in the postanesthesia care unit following craniectomy, and The patient with a brain tumor who is admitted for radiation therapy.
How will the home health care nurse caring for a patient with myasthenia gravis and severe muscle weakness know if interventions have been effective? 1. The patient verbalizes satisfaction with the plan of care. 2. The patient states understanding of the medication regimen. 3. The patient and family state that no further home visits are needed. 4. The patient is able to perform activities of daily living with oxygen saturation remaining at 95%.
The patient is able to perform activities of daily living with oxygen saturation remaining at 95%.
What is preproliferative retinopathy?
The second stage. It is characterized by swollen and irregularly dilated veins. This results in sluggish or blocked blood flow. There are no symptoms. So, patients generally are not aware of this stage.
What is the etiology of chronic pancreatitis? (book)
The usual age when CP develops is between 43 and 62 years. It occurs in men more than women and predominately in Caucasians (Conwell et al., 2017). Causes of CP include alcohol abuse (most common), obstructive biliary disease, and hyperlipidemia. Causes may also be idiopathic, genetic, and autoimmune related. Cigarette smoking and repeated attacks of AP are risk factors.
What are causes of cirrhosis?
There are 10 possible causes of cirrhosis, such as alcoholuse (but not always), hepatitis B or C, right-sided heartfailure, hepatotoxic drugs or toxins, and nonalcoholicsteatohepatitis.
What is examined during a neurovascular check on an extremity?******
There are six areas for a neurovascular check: (1) movement, (2) sensation, (3) color, (4) temperature, (5) pulses, and (6) capillary refill.
What are some nutrition interventions for pts with neurological disorders with impaired swallowing?
Thicken liquids, Position upright for eating, Monitor meals, and Provide enteral (tube) feedings.
What is the Rinne test?*****
This test is performed with a tuning fork. It is useful for differentiating between conductive and sensorineural hearing loss. To perform the test, strike the tuning fork and place it on the patient's mastoid process. Verify that the patient is able to hear the tuning fork. Then instruct the patient to say immediately when the sound is no longer heard. When the patient indicates that the sound is not heard, place the vibrating tuning fork 2 inches in front of the ear. Ask the patient whether he or she hears the tuning fork and then to indicate when the sound is no longer heard. Normally, air conduction (AC) is heard twice as long as bone conduction (BC). The patient reports this by hearing the tuning fork when placed in front of the ear (AC) after it is no longer heard on the mastoid process (BC). Normal results are recorded as "AC greater than BC." The test is repeated on the other ear. Abnormal findings can indicate conduction or sensorineural problems.
A patient is taking aspirin. Which finding would indicate to the nurse that the patient is experiencing a toxic effect related to the medication? 1. Halos around lights 2. Decreased night vision 3. Tinnitus 4. Vertigo
Tinnitus
The nurse is reviewing an erythrocyte sedimentation rate for a patient. Which of the following does the nurse understand is the purpose of this test? 1. To identify the number of red blood cells the patient has 2. To determine sedimentation found in red blood cells 3. To identify the presence of systemic inflammation 4. To diagnose various types of arthritis
To identify the presence of systemic inflammation
How can you assess for jaundice?
To observe for jaundice in a patient with dark skin, look at the sclerae, conjunctivae, palms of hands, soles of feet, and in the buccal mucosa for patches of yellow bilirubin pigment.
A patient is unable to control his bowels after a subarachnoid hemorrhage. Which intervention by the nurse can help reduce episodes of bowel incontinence? 1. Ask the patient frequently if he has to have a bowel movement. 2. Place incontinence pads on the patient's bed and chair. 3. Toilet the patient according to his pre-illness schedule, whether or not he feels the urge. 4. Take care not to embarrass the patient when incontinent episodes occur.
Toilet the patient according to his pre-illness schedule, whether or not he feels the urge.
What happens to the gastrointestinal system as we age?
Tooth enamel harder/more brittle, Tongue atrophy, Sweet taste sensation lost, Saliva production decreased 33%, Esophagus motility less, emptying slower, Weaker gag reflex, Decreased motility of stomach, Decreased gastric hydrochloric acid production, Fat absorption slower, Atrophy of large/small intestine, Decreased mucous secretions, Decreased elasticity of rectal wall, Weakness of intestinal wall, Faulty absorption of vitamins B1and B2, calcium, and iron
What is a total gastrectomy?
Total removal of the stomach
What are the postemergent interventions for a stroke?
Treat cause of stroke, Physical, occupational, speech therapy, Antiplatelet agent (Ex. Plavix), Anticoagulant agent, Antihyperlipidemic agent, Antiarrhythmic agent, and Maintain patent airway
What are the therapeutic interventions for gastritis?
Treat cause, Avoid alcohol, Avoid irritating foods, take Antacids, and take Antiemetics (Antacids and/or histamine 2 (H2)-receptor antagonists are given to control pain.)
True or false: Use garters to keep socks or stockings in place.
True
Which pancreatic enzyme Digests polypeptides to short chains of amino acids?
Trypsin
A nurse is caring for a patient who is recovering from an ischemic stroke. Upon entering the room to pick up the supper tray, the nurse notes that the patient has only eaten food on the left side of the tray. What should the nurse do? 1. Turn the plate 180 degrees and observe the patient's response. 2. Remove the tray and do not comment. 3. Encourage the patient to eat the rest of the meal. 4. Assist the patient by providing finger foods and feeding the patient items that require a utensil.
Turn the plate 180 degrees and observe the patient's response.
What is Volvulus?
Twisting of bowel
What are the therapeutic interventions for mild diverticulosis/diverticulitis?
Tylenol, antibiotic, and liquid diet (to allow colon to rest)
What are some types of ear trauma?
Tympanic membrane perforation and Middle ear ossicle fracture
What is Gardner-Wells tongs traction?
U-shaped tongs used for spinal traction, having pressure--controlled pins that are inserted into the skull at opposite ends to permit application of a longitudinal force to the axis of the spinal column.
What are the diagnostic tests for gallbladder disorders?
Ultrasound (Endoscopic-An ultrasound of the gallbladder is the classic test done to detect stones, inflamed walls of the gallbladder, and dilated ducts. An endoscopic ultrasound can provide more detailed images of the gallbladder and bile ducts.), C T scan (A CT scan may also be done.), Magnetic resonance cholangiopancreatography, E R C P (ERCP that directly visualizes the pancreatic ducts and bile ducts for the presence of stones to then remove them), Hepatobiliary iminodiacetic acid scan (a hepatobiliary iminodiacetic acid (HIDA) scan in which the patient is given an IV injection of a radioactive isotope that is metabolized by the liver and excreted in the bile. The scanning camera then traces the path of the isotope as it travels through the bile ducts, gallbladder, and intestines to identify blockages.), Elevated W B C count, and Elevated direct bilirubin
What is Astigmatism?
Unequal curvatures in cornea (which can make wearing contacts difficult)
What is the etiology of Guillain-Barre syndrome?
Unknown but Possible autoimmune response to virus
What is the etiology of Amyotrophic Lateral Sclerosis (ALS)/Lou Gehrig disease?
Unknown but Possible genetic predisposition
What is the etiology of myasthenia gravis?
Unknown but linked to Autoimmune, Thymus disorders (BIG ONE), and Possible viral origin
What is the etiology of Alzheimer's disease?
Unknown but may be genetic an is linked to down syndrome
The nurse is caring for a male patient with gout. Which of the following lab values would be a priority for the nurse to report to the physician? 1. White blood cell count 6.2 cells/mL 2. Potassium 5 mEq/L 3. Uric acid 10.2 mg/dL 4. Ammonia 34 (mol/L
Uric acid 10.2 mg/dL
what is the etiology of secondary gout?
Uric acid is also increased in this condition. However, the increase is related to a health issue. Examples include renal insufficiency or medications, such as diuretic therapy and certain chemotherapeutic agents.
What actions can the nurse take to ensure patient safety when providing an enteral feeding? Select all that apply. 1. Use adequate room lighting. 2. Trace all lines back to their origins. 3. Check connections during patient handoff. 4. Reconnect a patient's tubing to assist another nurse. 5. Route all tubes in the same direction. 6. Do not interfere with equipment safety features.
Use adequate room lighting, Trace all lines back to their origins, Check connections during patient handoff, and Do not interfere with equipment safety features.
What are some interventions for people with neurological disorders?
Use care with yes/no questions (Ex. if you ask a pt if they are Mrs. Gomez they may say yes even if that isn't their name; instead ask them to state their name), Correct substituted words, Anticipate needs, Use gestures, and Be patient!
How should the nurse communicate with the patient experiencing receptive aphasia? 1. Be patient as the patient tries to speak 2. Listen carefully, while making eye contact 3. Speak loudly toward the patient's good side 4. Use gestures, standing where the patient can see
Use gestures, standing where the patient can see
The nurse is caring for a patient who has presbycusis. Which action should the nurse take to communicate with the patient? Select all that apply. 1.Stand on patient's reduced hearing side. 2.Stand in front of bright background light. 3.Speak softly and overarticulate words. 4.Use lower tones when speaking. 5.Face patient when speaking. 6.Use appropriate nonverbal gestures.
Use lower tones when speaking, Face patient when speaking, and Use appropriate nonverbal gestures.
What is Choledochoscopy?
Use of an endoscope to explore the common bile duct
A patient sustains a closed fracture of the right tibia and is placed in a long-leg plaster cast, which is still damp. Which of the following methods should the nurse use to move the cast to prevent complications? 1. Have patient reposition own leg. 2. Use palms to move the cast. 3. Use fingertips to grasp cast. 4. Do not move the cast until it is dry.
Use palms to move the cast.
When a neurologist asks a patient to smile, which cranial nerve is being tested? 1. II, optic 2. VII, facial 3. X, vagus 4. XI, accessory
VII, facial
Which of the following is a treatment for bleeding esophageal varices? Select all that apply. 1. Variceal ligation (banding) 2. Octreotide (Sandostatin) intravenously 3. Soft diet 4. Clear liquid diet 5. Transjugular intrahepatic portosystemic shunt
Variceal ligation (banding), Octreotide (Sandostatin) intravenously, and Transjugular intrahepatic portosystemic shunt
What are the therapeutic interventions for esophageal varices caused by cirrhosis/chronic liver disease?
Vasoconstrictor, Variceal ligation (shown in illustration), Transfusion, and Antibiotic prophylaxis
The nurse is to administer alendronate (Fosamax) to a patient. Which of the following actions should the nurse implement to safely administer the medication? Select all that apply. 1. Verify allergies. 2. Administer at bedtime. 3. Give on an empty stomach. 4. Give with 6 to 8 ounces of water only. 5. After administration, wait 1 hour before giving other medication. 6. Instruct patient to remain upright for 30 minutes.
Verify allergies, Give on an empty stomach, Give with 6 to 8 ounces of water only, and Instruct patient to remain upright for 30 minutes.
What symptoms of Ménière disease did Jan experience?
Vertigo, unsteadiness, and nausea.
What is the etiology of encephalitis?**
Viruses such as West Nile, Infectious mononucleosis, and Herpes simplex virus
What is a colonsoscopy?
Visualization of lining of the lower colon through a flexible endoscope. Biopsy specimen may be obtained or polyps removed. Normal findings: normal mucosa. (abnormal indicate Colon cancer, polyps, or inflammation) Pretest: Low-residue diet for several days before test; clear liquids evening before test; fast for 6 hours and restrict fluids 2 hours before test. Laxative and enema the evening before the test; enema morning of test as needed. Posttest: Monitor vital signs and for rectal bleeding.
What are the complications of gastric restrictive surgeries?
Vomiting, Erosion of the gastric tissue, Breakdown of staple line, Leaking of stomach secretions, and Infection or death
A nurse approaches a hospitalized post-stroke patient from the patient's left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse's presence or voice. Which action should the nurse take first? 1. Walk to the other side of the bed and try again. 2. Speak more loudly and clearly. 3. Wave a hand in front of the patient's face. 4. Use a picture board to explain to the patient what the nurse is going to do.
Walk to the other side of the bed and try again.
What is the postprocedure care for an electroencephalogram?
Wash hair.
How can you prevent acute liver failure?
Wash hands after using the bathroom and before handling food. Do not share personal grooming items (especially toothbrushes or razors). Obtain hepatitis A and B vaccines. Eat a balanced diet. Do not exceed 3,000 mg of acetaminophen in a 24-hour period or a prescribed drug with more than a 325-mg dose of acetaminophen in it. Review prescribed and over-the-counter medications to know which are combination drugs that contain acetaminophen to prevent excessive dosage. There are more than 600 drugs containing acetaminophen, such as Norco, NyQuil, Percocet, Vicodin, Tylenol with Codeine, or Tylox. Know how to read medicine labels and dosage found in the active ingredient list on the label. Visit www.knowyourdose.org to interactively read a drug label. Avoid alcohol or drink it only in moderation. Do not drink alcohol when taking acetaminophen. Avoid exposure to blood. Use condoms for safer sex. Ensure sanitary conditions and equipment when obtaining a body piercing or tattoo. Do not share intravenous needles.
What are the therapeutic interventions for obesity?
Weight loss (via Healthy balanced diet, calorie restriction, exercise), Support groups, Behavior modification, and Surgical management (Ex. Bariatric surgery)
What is in the temporal and parietal lobes?
Wernicke's area where comprehension of speech occurs (usually only on the left side)
What are some questions to ask during a cultural nutritional assessment?
What types of foods are common in your culture or community? What are your preferred foods? Which foods do you most commonly consume? How and where are your foods chosen and purchased? Who prepares the food in your household? Who purchases the food in your household? How is your food stored for future use? How is your food prepared before being eaten? What foods do you eat or avoid to maintain your health? What foods do you eat or avoid when you are ill?
When is a cure for pancreatic cancer very likely?
When the tumor is located at the head of the pancreas, there is the greatest possibility for cure.
What is Whats up for headaches?
Where is the pain? How does the headache feel? Aggravating or alleviating factors? Timing: When does it typically occur? How long does it last? Ask the patient to rate the severity. Ask about other useful data. Determine the patient's perception of the headache.
Which test would the nurse use as an initial screening test to determine hearing loss? 1. Romberg test 2. Otoscopic examination 3. Caloric test 4. Whisper voice test
Whisper voice test
Which of the following colors would the nurse recognize as an expected finding for the patient's stools immediately after a barium enema? 1. Brown 2. Black 3. Green 4. White
White
What are the diagnostic tests for peritonitis?
White blood cells, Abdominal x-ray or C T scan, and Exploratory surgery
Which of the following blood pressure changes alerts the nurse to increasing intracranial pressure and should be reported immediately? 1. Gradual increase 2. Rapid drop 3. Widening pulse pressure 4. Rapid fluctuations
Widening pulse pressure
Which of the following is the recommended protocol for caring for a severed body part that may be replanted? Select all that apply. 1. Cover it with a warm, dry towel. 2. Wrap it in a clean, moist cloth. 3. Place it directly on dry ice. 4. Wrap it in a dry, sterile dressing. 5. Seal in plastic bag. 6. Place it in ice.
Wrap it in a clean, moist cloth and Seal in plastic bag.
Which of the following actions are controlled by nerves exiting from the cervical portion of the spinal cord? Select all that apply. 1. Blinking 2. Writing 3. Sticking out the tongue 4. Nodding 5. Urinating
Writing and Nodding
What are the diagnostic tests for osteoarthritis?
X-Rays, Magnetic resonance imaging (M R I), and Synovial fluid analysis
What is a barium swallow?
X-ray examination of esophagus, stomach, duodenum, and jejunum using oral barium. Fluoroscope outlines organs. Normal findings: normal organ structures. (abnormal findings indicate Hiatal hernias, motility problems, polyps, strictures, tumors, and ulcers) Pretest: Nothing by mouth (NPO) for 6 hours before test. Encourage no smoking morning of procedure. Posttest: Increase fluids. Laxatives may be ordered. Monitor for constipation.
what is computed tomography colonography?
X-ray examination of interior of colon using CT scanner Normal findings: colon structures normal) (abnormal findings indicate Colorectal cancer, polyps Pretest: Clear liquids only 24 hours before test with water hourly as directed; NPO on day of test. Laxatives as instructed the day before and the morning of test. Posttest: May expel instilled air and feel bloated for several hours.
How is a hiatal hernia diagnosed?
X-ray or Fluoroscopy (an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object.)
What are the diagnostic tests for a spinal cord injury?
X-ray, C T scan, and M R I
What are the diagnostic tests for gastric cancer?
X-ray, Gastroscopy, Gastric fluid analysis, and Serum gastrin
What is the cauda equina?
a bundle of nerve roots that extends from the end of the spinal cord (and is so named because it looks like a horse tail)
What is rheumatoid arthritis?
a chronic, progressive, systemic inflammatory disease that destroys synovial joints and other connective tissues, including major organs****.
What is a ventriculoperitoneal shunt?
a device that drains cerebrospinal fluid into the peritoneal cavity
What is acute compartment syndrome?
a limb-threatening condition in which pressure in limb compartments increases. This causes reduced circulation to the compartment's muscles and nerves.
What is an antagonistic muscle?**
a muscle that opposes the action of another; "the biceps and triceps are antagonistic muscles". muscle, musculus - one of the contractile organs of the body. agonist - a muscle that contracts while another relaxes; "when bending the elbow the biceps are the agonist".
What are migraine headaches?
a neurological disorder involving brain chemicals and neurological pathways
What is the auditory/eustachian tube?
a passageway from the middle ear to the nasopharynx. its purpose is to equalize pressure (unfortunately it can also allow infection to spread from the throat to the middle ear)
What is an Arthrocentesis?
a procedure in which synovial fluid is aspirated from a joint for analysis or to relieve pressure (improves pain and mobility).
What is the pathophysiology of chronic pancreatitis?
a progressive fibro-inflammatory disease in which functioning pancreatic tissue is replaced with fibrotic tissue (aka scar tissue) because of inflammation. (Progressive fibro-inflammatory disease that causes obstructed ducts resulting in Ulceration and tissue death and Exocrine insufficiency)
What is Guillain-Barre syndrome?
a rare neuromuscular disease affecting only 1 in every 100,000 persons. Both men and women in the US are affected equally. Onset is usually between 30-50 years of age. it is an inflammatory disorder characterized by abrupt onset of symmetrical paresis (weakness) that progresses to paralysis. The myelin sheath of the spinal and cranial nerves is destroyed by a diffuse inflammatory reaction. The peripheral nerves are infiltrated by lymphocytes, which leads to edema and inflammation. Segmental demyelination causes atrophy of hte axons, resulting in slowed or blocked nerve conduction. Typically, the demyelination begins in the most distal nerves and ascends in a symmetrical fashion. Remyelination is a much slower process. It occurs in a descending pattern and is accompanied by a resolution of symptoms.
What is biliopancreatic diversion with duodenal switch?
a small tubular pouch is created. Then, most of the small intestine is bypassed, so that, with the connection of a piece of the distal small intestine to the pouch, the food goes directly to the end portion of the small intestine. The end of the bypassed small intestine is reconnected to this end portion of the small intestine so that digestive juices are not lost and can mix with the food.
What is a strain?
a soft tissue injury that occurs when a muscle or tendon is excessively stretched
What is gastric bypass?
a successful weight loss surgery that reduces stomach size and bypasses some of the small intestine, which reduces absorption of calories, causing weight loss
What is a transient ischemic attack (TIA)?
a temporary impairment of cerebral circulation that deprives the brain of glucose and oxygen (along with the blood) but symptoms usually resolve
What is articular cartilage?
a thin layer of hyaline cartilage covers the bone surfaces. IN combination with synovial fluid, the articular cartilage permits friction-free movement
What is a Whipple procedure (pancreatoduodenectomy)?****************************
a very complex surgery, is the most commonly used surgery for exocrine pancreatic cancer. This surgery removes the head and sometimes the body of the pancreas, lymph nodes nearby, the lower portion of the common bile duct, the gallbladder, most of the duodenum, and possibly parts of the stomach nearby. This can be done as an open or laparoscopic surgery. Potential postoperative problems after the Whipple procedure include failure of the suture lines to hold, causing leakage of pancreatic enzymes and bile into the abdomen; pneumonia or atelectasis from shallow breathing because the incision line is directly under the diaphragm; paralytic ileus; gastric retention or ulceration; wound infection; fistula formation; unstable diabetes mellitus; and kidney failure.
Is Presence of Turner sign normal or abnormal for the pancreas?
abnormal
Is Serum amylase more than 500 international unit/L normal or abnormal for the pancreas?
abnormal
How many muscles are in the body?
about 700
How long is the jejunum?
about 8 feet long;
What is brief period of staring a symptom of?
absence seizure
What are some examples of generalized seizures?
absence/petit mal and tonic clonic
What are the mechanism of injury for a traumatic brain injury?
acceleration (a moving object hitting a stationary head (Ex. a person hit in the head with a baseball bat), deceleration (when the head is in motion and strikes a stationary surface (Ex. when a pt trips and falls hitting their head on something), acceleration-deceleration (when the stationary head is hit by a mobile object and the head then strikes a stationary surface), and rotational (can be caused by a direct blow to the head or can occur during a motor vehicle collision in which the vehicle is struck from the side)
What is the cause of traumatic amputation?
accidents (Ex. MVA)
How is feces eliminated?
accomplished by involuntary and voluntary actions. Parasympathetic control initiates the defecation reflex from centers in the sacral region of the spinal cord.
What is the purpose of the myelin sheath?
acts to insulate the axon (conduit/protective layer)
What is quadriplegia?
all four extremities paralyzed
What does decrease in norepinephrine as we age result in?
altered sleep patterns
What is done when a pt gets a cast?
always leave the finger/toes out (to allow for a neurovascular check)
What is Crohn disease (commonly called Crohn's disease)?
an AUTOIMMUNE** inflammatory bowel disease**
What is presbyopia?
an age-related condition in which the eye's lens gradually loses its elasticity. This makes it difficult for the lens to change shape. It is less able to focus light onto the retina to see close objects.
What is a subarachnoid hemorrhage?
an aneurysm involving arteriovenous malformation and head trauma
What is chronic gastritis type A?
an autoimmune gastritis that occurs in the fundus (body of stomach), is often asymptomatic but could lead to pernicious anemia
What is Esophagogastroduodenoscopy (EGD)?
an endoscopic procedure that allows your doctor to examine your esophagus, stomach and duodenum (part of your small intestine).
What is the pathophysiology of labyrinthitis?
an inflammation or infection of the inner ear. It can be caused by either viral or bacterial pathogens. The bacterium or virus enters the inner ear from the middle ear, meninges, or bloodstream. Serous labyrinthitis is a type of acute labyrinthitis that sometimes follows drug intoxication or overindulgence in alcohol. It can also be caused by an allergy.
What is an adjustable gastric band?
an inflatable silicone band is placed around the upper portion of the stomach. This creates a small pouch to limit the amount of food the patient eats. The band is adjustable with a saline solution injected into the band through a port in the skin, making a larger or smaller pouch. The procedure is reversible.
What is Arthroscopy?
an invasive procedure performed under local or light general anesthesia, the patient is treated as a surgical candidate in a same-day surgery setting.
What is a hip replacement called?
an orthoplasty
How are muscles attached to bones?
anchored by tendons
What are some conditions involving oral health care?
angular cheilosis, Dental implants, Dentures, Gingival recession (which can be prevented with Fluoride gel or rinse), Gingivitis (which can be prevented by Flossing daily), Thrush (candida albicans) (can give Nystatin), and Xerostomia (dry mouth) (can give Artificial saliva substitute)
Medications for myasthenia gravis that can increase acetylcholine at the neuromuscular junction are called _________ agents.
anticholinesterase
What is the action of heparin?
anticoagulant
What is teh action of carbamazepine (Tegretol)?
anticonvulsant
What is the action of Clopidogrel (Plavix)?
antiplatelet
Where does oral cancer occur?
anywhere in the mouth
Patients who have difficulty speaking after a stroke are experiencing ________________.
aphasia
Small, white, painful ulcers that appear on the inner cheeks, lips, gums, tongue, palate, and pharynx. _____
aphthous stomatitis
What is aphthous stomatitis (canker sores)?
appears as small, white, painful ulcers on the inner cheeks, lips, tongue, gums, palate, or pharynx. It typically lasts for several days to 2 weeks. (inflammation of the oral cavity)
What condition can be deadly?
appendicitis
What is the appendicular skeleton?
arms/legs, shoulder, pelvic girdles, and synovial joints (aka appendages)
Which cartilage allows for movement?
articular cartilage
How is bilirubin excreted?
as part of bile to be eliminated in feces
Avoid all forms of _________ and medications containing _________.
aspirin; aspirin
Muscles that are not used become wasted, or ____________.
atrophied
What is high blood pressure, bradycardia, and diaphoresis a symptom of?
autonomic dysreflexia
Which of the following parts of a neuron transmits impulses away from the cell body? 1. Dendrite 2. Axon 3. Neurolemma 4. Synapse
axon
What are the stages of diabetic retinopathy?
background retinopathy, preproliferative retinopathy, and proliferative retinopathy.
What is the etiology of meningitis?
bacterial and viral
Term for weight loss surgery from the Greek baros. _____
bariatric
What is the surgical management for obesity?
bariatric surgery, Adjustable gastric banding, Gastric bypass, Gastric plication, Sleeve gastrectomy, and Biliopancreatic diversion with duodenal switch
What is the spinal cord?
basically a bundle of nerve fibers that extends from the base of the brain until about the first lumbar vertebrae
Why is the prognosis for pancreatic cancer often poor?
because most cases are diagnosed after the cancer has already spread. If diagnosed early enough, surgical treatment may provide a cure. The HCP can develop a survivorship care plan for tests and follow-up appointments, healthy lifestyle choices, and things to report to the HCP.
What is the nursing care for disturbed body image r/t preoperative amputation?
begin support services
What is the hamstring group?
biceps femoris, semitendinosus, semimembranosus
The digestive function of the liver is the production of _______ by the hepatocytes.
bile
What is the tendon?
binds bone to muscle
What are the medications for Paget's disease?
bisphosphonates and calcitonin
What can be done to relieve compartment syndrome?
bivalving (they may take it off and put a new one or may not remove it all the way)
After a liver biopsy, nursing care focuses on monitoring for _____.
bleeding
What is the mode of transmission for Hepatitis B?
blood and body fluids
What is the mode of transmission for Hepatitis D?
blood or body fluids
What is caput medusae?
bluish purple swollen vein patter extending out from the navel
What is a transverse fracture?
bone is fractured horizontally.
What are the skeletal system tissues?
bone, cartilage, and fibrous connective tissue (ligaments)
What is metastatic bone disease?
bone-seeking cancers (aka cancers that metastasize to the bone) such as prostate, breast, lung, and thyroid cancer that result in pathological fractures and severe pain (we aim to make it tolerable b/c it is difficult to eliminate)
What are the tarsals?
bones of the ankle
What is the mandible and maxillary?
bottom jaw and upper jaw (respectively)
Gurgling and clicking heard over the abdomen caused by air and fluid movement from peristaltic action that can be classified as normal, hypoactive, hyperactive, or absent _______
bowel sounds
What is acute or chronic pain a nursing diagnosis for?
brain tumor
What is risk for acute or chronic confusion a nursing diagnosis for?
brain tumor
What is risk for injury secondary to disturbed sensory perception a nursing diagnosis for?
brain tumor
What is a fracture?
break in a bone
What is the sternum?
breastbone
What happens while waiting for a C&S?
broad-spectrum antibiotics will be ordered
What are some anticonvulsants to prevent seizures?
carbamazepine (Tegretol)*, lacosamide (Vimpat), ezogabine (Portiga), gabapentin (Neurontin)*, levetiracetam (Keppra)*, lamotrigine (Lamictal), topiramate (Topamax)*, phenytoin (Dilantin)*, phenobarbital (Luminal), and valproic acid (Depakote)*
What is the anatomy of the stomach?
cardia (upper part), fundus (first curve), body and pylorus (near small intestine)
What are the surgical interventions for a stroke?
carotid endarterectomy **(a small incision in the neck and surgical removal of the occlusion from the artery) and balloon angioplasty with a stent
What are axons?
carries nerve signals AWAY from the (cell) body towards the body
What is risk for acute confusion a nursing diagnosis for?
central nervous system infections and traumatic brain injury
What is risk for injury a nursing diagnosis for?
central nervous system infections, seizures, traumatic brain injury, brain tumor, dementia, Parkinson's disease, and Alzheimer's disease
What is self-care deficit (dressing/feeding/toileting) a nursing diagnosis for?
central nervous system infections, traumatic brain injury, and brain tumor
What is impaired physical mobility a nursing diagnosis for?
central nervous system infections, traumatic brain injury, brain tumor, surgery for a herniated disk, spinal cord injury, Parkinson's disease
Is deltoid weakness a symptom of lumbar or cervical spine dysfunction?
cervical
What disks are most commonly herniated?
cervical and lumbar
What are the five sections of the vertebral column?
cervical vertebrae (7), thoracic vertebrae (12), lumbar vertebrae (5), sacrum (5 fused), and coccyx (4 fused)
What are some examples of joints affected by osteoarthritis?
cervical vertebrae, lumbar vertebrae, hip, first carpometacarpal, distal interphalangeal, knee, and first metatarsophalangeal
Consider drinking _________ juice.
cherry
What is the action of Simvastatin (Zocor)?
cholesterol-lowering agent
What is tacrine (Cognex)?
cholinesterase inhibitor
Liver or gallbladder disease may cause pale or _____ -colored stools.
clay
What is the management for a fracture?
closed reduction, open reduction with internal fixation**, and external fixation
Examination of the colon with an endoscope _______
colonoscopy
What happens to the eyes as we age?
color vision fades, glare adaptation difficult, peripheral vision decreases, depth perception decreases, farsightedness is common (and thus reading glasses are needed), the lens become more opaque, and the lens decreases in elasticity (both result in decreased vision)
What is more than two fragments that appear to float?
comminuted
What could be the problem if a pt with a cast suddenly starts complaining of extreme pain?
compartment syndrome
What is an emergency?
compartment syndrome
What is the site of digestion?
completed in the small intestine. (The end products of digestion are absorbed into the blood and lymph.)
What is automatic repetitive movement such as picking or lip smacking a symptom of?
complex partial seizure
What are cones?**
concentrated in the center of the retina (location) are active in bright light and thus are responsible for sharp vison and color vision
What are the types of traumatic brain injury?
concussion, contusion, and hematoma (either subdural which is worse or epidural)
What are interneurons?
connect the incoming sensory pathways with the outgoing motor pathways (only found in the CNS)
What is white matter?
contains bundles of axons (called tracts) that carry impulses from one part of the nervous system to another (appears white due to abundance of myelin)
What is gray matter?
contains mostly the cell bodies of motor neurons and interneurons (it is mostly gray due to its lack of myelin and is H-shaped and divided into two sets of horns the posterior/dorsal horns and the ventral/anterior horns)
What does the occipital lobe do?
contains the visual areas that receive and interpret sight
What is status epilepticus a symptom of?
continuous seizure
What is the function of the accessory nerve?
contraction of neck and shoulder muscles and motor input to larynx (speaking)
What is the purpose of the pyloric sphincter?
contracts when the stomach is churning food and relaxes at intervals to allow small amounts of chyme to pass into the duodenum.
Permanent muscle contractions are called ________________.
contractures
How treatable is oral cancer?
curable if detected early
What are the therapeutic measures for osteomyelitis?**
curative therapy (Debridement, reconstruction, antibiotic), Palliative therapy (Chronic suppressive antibiotic therapy), and if Nonresponsive then Amputation (we try palliative therapy before curative)
The nurse is caring for a patient with a history of acute angle-closure glaucoma. The nurse is preparing to administer the patient's medications. Which medications should the nurse question before administration? Select all that apply. 1. cefazolin (Kefzol) 2. cyclopentolate (Cyclogyl) 3. hydroxyzine (Vistaril) 4. ranitidine (Zantac) 5. morphine 6. warfarin (Coumadin)
cyclopentolate (Cyclogyl) and hydroxyzine (Vistaril)
Abnormal extension posturing when eliciting best motor response is called ________________ posturing.
decerebrate
Abnormal flexion posturing when eliciting best motor response is called ________________ posturing.
decorticate
What are fissures?
deep grooves/sulci
What is the pathophysiology of Huntington's disease?
degeneration of parts of the brain
What is Huntington's disease?
degenerative disease of the nervous system
What is considered a medical emergency?**
delirium
What can you die from?
delirium tremors (DTs caused by alcohol withdrawal)
What is chronic confusion a nursing diagnosis for?
dementia and Alzheimer's disease
What is imbalanced nutrition a nursing diagnosis for?
dementia and Alzheimer's disease
What is risk for caregiver role strain a nursing diagnosis for?
dementia and Alzheimer's disease
Symptoms of Guillain-Barré syndrome are caused by _____ of axons.
demyelinated
What is polyuria and polydipsia following head injury a symptom of?
diabetes insipidus
Which of the following are modifiable risk factors that should be taught to patients at risk for stroke? SELECT ALL THAT APPLY. A. heredity B. age C. diabetes D. race E. high cholesterol F. obesity
diabetes, high cholesterol, and obesity
What is dysphagia?
difficulty swallowing
What is pancreatic amylase?
digests starch to maltose
What will the lung sounds be like with a pneumothorax?
diminished lung sounds (b/c the lung can't expand)
What is not a concern with total knee replacement (that is a concern with total hip replacement?
dislocation (b/c we are replacing the whole thing)
What is the purpose of thrombolytic therapy?**
dissolves clot (may reverse symptoms but time lost is brain lost)
What is palming a cast?
don't use fingers to put on a cast use the palm only to prevent compressing the limb
What medications are used to treat degenerative disorders/dementia such as Alzheimer's, Parkinson's, and Huntington's?***
donepezil (Aricept), rivastigmine (Exelon), and memantine (Namenda)
What is levodopa/carbidopa (Sinemet)?
dopamine agonist that converts to dopamine in the brain
What are most primary tumors of the pancreas?
ductal adenocarcinomas (They occur in the exocrine (digestive secretion) parts of the pancreas.)
Difficulty speaking because of muscle dysfunction is called ________________.
dysarthria
Flexible or rigid device consisting of a tube and optical system for observing the inside of a hollow organ or cavity _______
endoscope
What is a Mediastinoscopy?
endoscopic examination of mediastinum
What are the therapeutic interventions for status epilepticus?
ensure airway and oxygenation and administer diazepam (Valium) or lorazepam (Ativan) via IV
What is unconscious at accident scene a symptom of?
epidural bleed
The lower _______ sphincter prevents backup of stomach contents into the esophagus.
esophageal
The passageway for food into the stomach from the mouth is the _______.
esophagus
Some diseases are characterized by remissions and ____________.
exacerbations
What is a sprain?
excessive stretching of ligaments from twisting movements during a sports activity, exercise, or fall
What is the joint capsule?
extending from the periosteum of each of the articulating bones is a sheet of connective tissue that encloses the joint cavity
What is the location of the large intestine?
extends from the ileum of the small intestine to the anus
What is the location of the small intestine?
extends from the stomach to the cecum of the colon.
What is the rectus femoris?
extends knee and flexes thigh at hip
What is a total gastrectomy used for?
extensive gastric cancer (anastomosis of esophagus to jejunum)
What is an example of an external fixation?
exterior cage around the leg
Voluntary control of defecation is provided by the _______ anal sphincter.
external
What are the components of the Glasgow Coma Scale?
eye opening, verbal response, and motor response (such as posturing) (eye response, motor response, brainstem reflexes, and respirations)
What are we worried about with a femur fracture?
fatty embolism of blood clot
What is steatorrhea?
fatty stools
What is the mode of transmission for Hepatitis A?
fecal-oral route
What provokes the onset of Herpes simplex type 1 (cold sores)?
fever or stress
What is the sympathetic nervous system also known as?
fight or flight response
What are the s/s of carpal tunnel syndrome?
finger, hand, and/or arm pain and/or numbness
How many lumbar vertebrae are there?
five
What is endolymph?
fluid within the membranous labyrinth
Drink plenty of _________, especially water.
fluids
Device consisting of a fluorescent screen that makes the shadows of objects interposed between the tube and the screen visible _______
fluoroscope
What is the nasal bone?
forms the bridge of the nose
What is the frontal bone?
forms the forehead
A test performed to measure secretions of hydrochloric acid and pepsin in the stomach. _______
gastric analysis
What hormone increases the secretion of gastric juices?
gastrin
Inflammation of the stomach. _____
gastritis
What are the two types of subtotal gastrectomy?
gastroduodenostomy/Billroth one) and gastrojejunostomy/Billroth two
What is the alimentary canal also known as?
gastrointestinal tract
Following surgical removal of part of the stomach, of the remaining portion to the proximal jejunum. _____
gastrojejunostomy
Examination of the stomach and abdominal cavity by use of an endoscope. _______
gastroscopy
Feeding via a tube placed in the stomach _______
gavage
What is a splintered and bent fracture that occurs mainly in children?
greenstick
What are the metacarpal bones?
hand bones
What is the pathophysiology of otosclerosis?
hardening of the ear, results from the formation of new bone along the stapes. With the new bone growth, the stapes becomes immobile. This causes conductive hearing loss. The formation of the new bone growth begins in adolescence or early adulthood and progresses slowly. Hearing loss is most apparent after the fourth decade of life. Otosclerosis is more common in women than in men. The disease usually affects both ears. Although the exact cause of otosclerosis is not known, most patients have a family history of the disease. It is therefore thought to be a hereditary disease.
What data is collected during a physical exam of the gastrointestinal system?
health history (travel, elimination, and medications (CLOSTRIDIUM DIFFICILE), nutritional assessment (will be affected by culture), and family history
What subjective data is collected during an assessment of the hearing?
health history and symptoms
What subjective data is collected during an assessment of vision?
health history and symptoms
What is penumbra?
healthy tissue surrounding an infarct
Condition in which the stomach may protrude above the diaphragm. _____
hiatal hernia
The _______ valve prevents backup of fecal material from the large intestine into the small intestine.
ileocecal
In which would you expect liquid stool, an ileostomy or a colostomy?
ileostomy
What is the bone rebuilding process like with osteoporosis?
imbalanced remodeling process
What is a fracture with more than two fragments driven into each other?
impacted
Immovable accumulation of feces in the bowels _______
impaction
What does deposition of aging pigment lipofuscin in nerve cells and amyloid in blood vessels as we age result in?
impairment in cognition, reasoning, judgment, and orientation
What is aphasia?
inability to speak or understand language
What is the pathophysiology of a cerebrovascular accident/stroke (CVA)?
inadequate blood flow to the brain that leads to infarction of brain tissue that could cause permanent damage and neurological deficits if not reversed (Ex. blindness, misuse of words, paralysis)
What does decreased blood flow to the brain as we age result in?
increased syncope and decreased mental function
What is the pathophysiology of Guillain-Barre syndrome?
inflammation of spinal and cranial nerves with segmental demyelination in an ascending pattern, lymphocyte infiltration, and descending demyelination (and thus it may be reversible)
What is encephalitis?
inflammation of the brain
What is cholecystitis?
inflammation of the gallbladder
What is peritonitis?
inflammation/infection of the peritoneum
What function does the cerebrum control?
information storage
What are the therapeutic interventions for trigeminal neuralgia?
initial therapy includes Anticonvulsants such as phenytoin (Dilantin), gabapentin (Neurontin), or carbamazepine (tegretol) to reduce transmission of painful nerve impulses. If medications are not effective surgery to remove the vessel that is irritating the nerve may be done, Nerve blocks, and Surgery to block pain signals
What is a fracture that extends into articular surface?
interarticular
What is a very dangerous medical emergency?********
intestinal obstruction
What are the two types of hemorrhagic stroke?
intracerebral (aka brain bleed) and subarachnoid
What is deficient knowledge a nursing diagnosis for?
intracranial surgery
What is disturbed body image a nursing diagnosis for?
intracranial surgery
What is risk for ineffective cerebral tissue perfusion a nursing diagnosis for?
intracranial surgery
What is risk for infection a nursing diagnosis for?
intracranial surgery
What are the types of mechanical bowel obstructions?
intussusception and volvulus
What is nystagmus?
involuntary, cyclical, rapid eye movement
What does Crohn's disease affect?
involves any part of the intestine
What is a liver scan?
involves injecting a slightly radioactive medium that is taken up by the liver. An instrument is passed over the liver that records the amount of material taken up by the liver and forms a composite picture of the liver. It may show tumors, masses, and abnormal size and patterns of blood vessels.
How do the cervical vertebrae curve?
inward
What are the therapeutic interventions and nursing care for eye trauma involving a foreign object?
irrigate with normal saline
What is the cause of surgical amputation?
ischemia from peripheral vascular disease or bone tumor, frostbite, congenital problems, or infection (Ex. osteomyelitis)
What is often a cause of amputation?
ischemia that leads to necrosis
What is true of PT for a total knee replacement?
it is VERY painful but necessary (knee will freeze up which is more painful if not done)
What happens to the ears as we age?
it is difficult to filter background noises (which leads to impaired verbal communication) and organ of Corti hair cells damaged (leading to high pitch range loss) both result in F, S, K, Sh sounds lost first
How is an aneurysm with a neck (berry aneurysm) treated?
it is identified and clamped with a metal clip
What is a technique for aneurysm treatment?
it is possible to clamp the artery on either side of the aneurysm, removing the portion of the vessel and the aneurysm for m the circulation
What is true of a transient ischemic attack?
it usually does not cause permanent damage and is a warning sign to seek medical attention
What is true of cancer of the liver?
it usually metastasized from another site (aka this is rarely the site of origin of cancer)
What happens as a result of articular cartilage (cartilage that allows movement) wearing down as we age?
joint stiffness and joint pain
Water and the vitamins produced by the normal flora are absorbed in the _______ intestine.
large
What position is a pt in for a proctosigmoidoscopy?
left-lateral knee to chest
What are the symptoms of a right-sided infarct?
left-sided weakness of paralysis, impaired judgment/safety risk, unilateral neglect more common, and indifferent to disability
What is included in the physical assessment to assess a patient's neurological status?
level of consciousness, mental state examination, pupillary response, muscle function, and cranial nerve function
What is included in a basic neurological assessment?
level of consciousness, vital signs, pupil response to light, extremity strength and movement, and sensation
What are some medications used to treat Parkinson's disease?
levodopa (L-dopa) and levodopa/carbidopa combination (Sinemet) (carbidopa prevents peripheral breakdown of levodopa so more is available in the central nervous system (CNS)
What are the accessory organs of digestion?
liver, gallbladder, and pancreas
What are rods?**
located at the periphery of the retina and are active in dim light and thus responsible for night vision
what are feeding tubes not used for?
long-term
What is a fracture that runs along the axis of the bone?
longitudinal
What should ALWAYS be done for a lumbar puncture?
look at your order closely for tests the dr has ordered. If the dr wants 5 tests bring 7 tubes and label each with its respective test and pt name and date and collector
Is radiating pain to the ankle a symptom of lumbar or cervical spine dysfunction?
lumbar
What is the purpose of synergistic muscles?***
maintain balance and FINE MOTOR CONTROL
What is included in the pupil assessment?
making sure they are equal, round, reactive to light, and reactive to accomodation
What is closed reduction management of a fracture?
manual realignment, elastic wrap/splints, casts, and traction (skin or skeletal) (weights should NEVER be touching the floor. we want room between the weight and the ground) (the most common treatment for simple fractures. Analgesia and/or procedural sedation is given before the procedure. While manually pulling on the bone (limb), the health care provider (HCP) manipulates the bone ends into alignment. An x-ray confirms that the bone ends are aligned before the area is immobilized by a splint or cast.)
How is an aneurysm without a neck treated?
may be wrapped with a sterile plastic or muslin wrap (provides stability to the aneurysm walls which lessens the chance of rupture)
What is a Snellen chart (E chart)?**
measure distance acuity. This chart has lines of letters, labeled for visual acuity, that range in size The largest letters are at the top, with the smallest at the bottom. For test, people stand 20 feet from the chart. They cover one eye and read aloud a line of letters. The lowest line (smallest letters) on the chart that the patient can read accurately designates the visual acuity of that eye. The E chart is used for people with literacy issues. The patient indicates the direction of the E-shaped figure.
What are the primary headaches?
migraine, tension, cluster, and other headaches
What is the nursing care for anorexia?
monitor Intake/output of food and fluids, Monitor vital signs, electrolytes, and electrocardiogram, and Monitor rate of I V infusion or enteral feeding
How can you be vigilant for complications of the renal system in quadriplegic patients?
monitor intake and output, urine appearance, blood urea nitrogen (BUN), and creatinine.
How can you be vigilant for complications of infection in quadriplegic patients?
monitor respiratory status, urine clarity, wound drainage, temperature, and white blood cellcount. DVT: monitor legs for unequal size, redness, and swelling.
How can you be vigilant for complications of autonomic dysreflexia in quadriplegic patients?
monitor vital signs and maintainpatent urine flow and bowel program.
What are water soluble nutrients?
monosaccharides, amino acids, minerals, water-soluble vitamins (which are absorbed into the blood in the capillary networks)
What are the components of the digestive system?
mouth, salivary glands, pharynx, esophagus, liver, stomach, pancreas, large intestine, small intestine, gallbladder, rectum, and anus
What is the function of the oculomotor nerve?
movement of the eyeball and constriction of pupil for bright light or near vision
What do the motor areas of the frontal lobe control?
movement of the opposite side of the body
What is the function of the hypoglossal nerve?
movement of the tongue
What are the muscular system functions?
movement, heat production, and blood return from the legs
What are the skeletal system functions?
movement, protection, and storage of calcium
What does the corneal light reflex test check?
muscle balance
What are many but not all axons of neurons incased in?
myelin sheath
What is nuchal rigidity?
neck pain and stiffness
What do muscles require for contraction?
nerve impulses
How does the message from the parasympathetic nervous system travel?
nerves are longer and further so message takes longer to travel (the organs respond to the message individually not a whole body response)
What should never be done to the ear?
never put anything into it (including q-tips)
What are the s/s of diverticulosis/diverticulitis?
no symptoms, Constipation, possibly diarrhea, Cramping, Bleeding, and Abdominal tenderness
What are the therapeutic interventions for dry macular degeneration?
none
What are the s/s of abdominal hernias?
none and bulging
Involuntary eye movement is called ________________.
nystagmus
What are the types of gastric bleeding?
occult or observable
What is intussusception?
occurs when peristalsis causes the intestine to telescope into itself
What is volvulus?
occurs when the bowel twists, occluding the lumen of the intestine.
What forms the myelin sheath in the central nervous system (CNS)?
oligodendrocytes
What is the gastrointestinal anatomy and physiology?
oral cavity and pharynx, esophagus, stomach, small intestine, and large intestine
What is often neglected in daily care?
oral health care
What is the hearing sense organ?***
organ of corti
What is the action of mannitol (Osmitrol)?
osmotic diuretic
What is part of bone growth and repair?
osteoblasts
What is considered to be bone tissue?
osteocytes
What are the bone tissues?
osteocytes (bone cell), a matrix of calcium salts and protein collagen, and periosteum (aka connective tissue)
What is the most common and most fatal primary malignant tumor?****
osteosarcoma
What are the primary malignant tumors?
osteosarcoma and Ewing sarcoma
How do the sacral and coccyx fused vertebrae curve?
outward
What is paraplegia?
paralyzed lower extremities
What is hemiplegia?
paralyzed on one side of the body
What is ipsilateral hemiplegia?
paralyzed on same side
Is increased salivation a sympathetic or parasympathetic response?
parasympathetic
Is relaxed urethral sphincter a sympathetic or parasympathetic response?
parasympathetic
A patient might say his leg feels like it is asleep to describe ________________.
paresthesia
What is a synergistic muscle?**
perform, or help perform, the same set of joint motion as the agonists . Synergistic muscles aid the agonist muscles in motor control tasks, but they act against excess motion that the agonists may create.
What are tension headaches?
persistent contraction of the scalp and facial, cervical, and upper thoracic muscles
What is presbycusis?***
progressive hearing loss (loss of high frequency sounds)
What are the clotting factors produced by the liver?
prothrombin and fibrinogen, which circulate in the blood until needed for coagulation.
What is a colonoscopy?
provides visualization of the lining of the lower colon to identify abnormalities through a flexible endoscope, which is inserted rectally. (has to be inserted farther)
What may be helpful during a migraine headache?
providing a dark room and rest to reduce stimulation
What is correct hip flexion after a total hip replacement?
pt maintains a 90 degree angle (any more will be hyperflexion which is bad)
What will occur after a pt undergoes a whipple procedure (no matter their state before it)?***************
pt will be diabetic
What are the therapeutic interventions for metastatic bone cancer?
radiation
A liver scan records the amount of _____ material taken up by the liver to form a composite "picture" of the liver.
radioactive
What is difficult for people with macular degeneration?
reading
What are the complications of an aneurysm?
rebleed, hydrocephalus, vasospasm, and others similar to stroke
What are dendrites?
receive signals from other neurons and conduct the information to the cell body (looks like the bare branches of a tree)
What does the parietal lobe do?
receives, perceives, and interprets the somatic senses and taste (gustation)
The part of the colon that contracts in the defecation reflex is the _______.
rectum
What can result from hip/vertebral fractures due to osteoporosis?
reduced quality of life, increased disability, and risk for death (during year after fracture)
What are Emmetropia, Hyperopia, Myopia, Astigmatism, macular degeneration, and Presbyopia considered?
refractive disorders
What are the therapeutic interventions for Paget's disease?
relieve pain, pt education, and promote quality of life
What are the s/s of rheumatoid arthritis?
remissions and exacerbations and varies by individual
What is -ectomy?
remove
What is a sleeve gastrectomy?
removes about 75% of the stomach, leaving a slim narrow tube (gastric sleeve). This reduces the stomach's volume and limits food intake at one time. It decreases the hormone ghrelin produced by the stomach that causes hunger.
What function does the medulla oblongata control?
respiratory center
What is the earliest sign of a fatty emoblism?
respiratory distress
What is the treatment for postpolio syndrome?
rest
What is the parasympathetic nervous system also known as?
rest and digest
What are gyri?
ridges of the brain
What are the nursing diagnoses for eye surgery?
risk for injury, deficient knowledge, and anxiety
The watery secretion that permits taste and swallowing is produced by the _______ glands.
salivary
What hormone stimulates the secretion of bile?
secretin
What is risk for ineffective health management a nursing diagnosis for?
seizures
What are the complications of meningitis?
seizures, cranial nerve damage, and occasional permanent neurological deficits
What is the function of the trigeminal nerve?
sensation in face, scalp, and teeth and contraction of chewing muscles
What is the function of the vestibulocochlear nerve?
sense of hearing and sense of equilibrium
What is the function of the optic nerve?
sense of sight
What is the function of the olfactory nerve?
sense of smell
What is the function of the facial nerve?
sense of taste, contraction of facial muscles, and secretion of saliva
What is the function of the glossopharyngeal nerve?
sense of taste, secretion of saliva, sensory input for cardiac, respiratory, and blood pressure reflexes, and contraction of pharynx/swallowing
What does the temporal lobe contain?
sensory areas for hearing and olfaction (smell)
What is the function of the vagus nerve?
sensory input in cardiac, respiratory, and blood pressure reflexes, sensory and motor input to larynx (speaking), decreased heart rate, contraction of alimentary tube (swallowing/peristalsis), and increased digestive secretions
What are the diagnostic tests for gout?
serum uric acid and joint fluid for uric acid crystals
What occurs with compartment syndrome?
severe swelling of the fascia
What are sulci?
shallow grooves that divide the gyri
What are the s/s of osteomyelitis?**
site pain, redness, warmth, swelling, and fever
What are the muscular system tissues?
skeletal muscle, fibrous connective tissue (tendons), and fasciae (a band or sheet of connective tissue, primarily collagen, beneath the skin that attaches, stabilizes, encloses, and separates muscles and other internal organs)
Which muscles are voluntary muscles?
skeletal muscles
What is the axial skeleton?
skull, hyoid, vertebral column, and rib cage (aka more central bones)
What is bradykinesia?
slow movement
The _______ intestine is the site of action of bile and pancreatic enzymes.
small
The absorption of most of the end products of digestion occurs in the _______ intestine.
small
Where is digestion completed?
small intestine
What is one of the detrimental things for a stroke?
smoking**
What is ineffective role performance a nursing diagnosis for?
spinal cord injury
What is reflex urinary incontinence a nursing diagnosis for?
spinal cord injury
What is risk for autonomic dysreflexia a nursing diagnosis for?
spinal cord injury
What is hypotension and loss of sympathetic function a symptom of?
spinal shock
What are the most common fracture sites due to osteoporosis?
spine, wrist, and hip
Which stage of Alzheimer's disease is forgetfulness the primary symptom of?
stage 1
Which stage of Alzheimer's disease is confusion the primary symptom of?
stage 2
Which stage of Alzheimer's disease is wandering and incontinence the primary symptom of?
stage 3
What are the s/s of absence seizures (petit mal)?**
staring
What should never be done before a culture?
starting antibiotics
Fatty stools _______
steatorrhea
The digestion of protein begins in the _______.
stomach
What does lith mean?
stone
What is choledocholithiasis?
stones in the common bile duct
What is the function of the gallbladder?
stores bile until it is needed in the small intestine The gallbladder concentrates bile by absorbing water.
What are some bone and soft tissue disorders?
strain, sprain, dislocation, bursitis, and rotator cuff injury
Avoid excessive physical or emotional _________.
stress
What is a fracture from repeated stress (e.g., jogging)?
stress
What is stress-induced gastritis?
stress ulcers that result from ischemia damaging the mucous barrier and acid secretions create ulcerations
Where does CSF circulate?
subarachnoid space
What is acute pain a nursing diagnosis for?
surgery for herniated disk
What is impaired urinary elimination a nursing diagnosis for?
surgery for herniated disk
What is craniotomy?
surgical opening in the skull
Is dilated bronchioles a sympathetic or parasympathetic response?
sympathetic
Is dilated pupils a sympathetic or parasympathetic response?
sympathetic
Is increased heart rate a sympathetic or parasympathetic response?
sympathetic
Is relaxed urinary bladder a sympathetic or parasympathetic response?
sympathetic
What can occur with a spinal cord injury?
sympathetic nervous system disruption including Vasodilation, Hypotension, Bradycardia, Hypothermia, and Urine and feces retention (vasodilation, hypotension, and bradycardia is known as spinal shock)
What is included in a health history when assessing a patient's neurological status?
symptoms, medication used, surgical history, family history, lifestyle, and WHAT'S UP
What is the nursing care for deficient knowledge r/t preoperative amputation?
teach preoperative procedures (VERY important that pt understands what you are taking them to surgery for)
What are the accessory organs of the GI tract?
teeth, tongue, salivary glands, liver, gallbladder, and pancreas.
What may relaxation be helpful to treat?
tension headaches
What is tympanometry?
tests the movement of the tympanic membrane (ear drum) and evaluates middle ear function. The test is not done if the ear canal is obstructed or the ear drum is perforated.
What is the thoracic cage (aka rib cage)?
the 12 pairs of ribs and the sternum
What does portal hypertension cause?
the abdominal veins around the umbilicus to become enlarged and visible (called caput medusae) (DEADLY CONDITION)
What is double-barrel stoma (book)?
the bowel is completely dissected. Both ends of the colon are brought to the outside abdominal wall to form two separate stomas. The proximal stoma is the functioning stoma that expels stool. The distal stoma is called a mucous fistula because mucus produced by the bowel passes from it. A double-barrel stoma is often temporary, allowing the bowel to rest during healing after trauma or surgery.
What is the orbital socket?
the cavity or socket of the skull in which the eye and its appendages are situated
What do the cervical nerves innervate?
the chest, head, neck, shoulders, arms, hands, and diaphragm
What is a really easy bone to break?
the clavicle
What is carpal tunnel syndrome?
the compression of the median nerve within the wrist's carpal tunnel when there is swelling in the tunnel
What is the soma (cell body)?
the control center of the neuron (it contains the nucleus)
Who is at risk for stress-induced gastritis?
the critically ill
What is proctosigmoidoscopy?
the examination of the distal sigmoid colon, the rectum, and the anal canal using a flexible endoscope (sigmoidoscope). Ulcerations, punctures, lacerations, tumors, hemorrhoids, polyps, fissures, fistulas, and abscesses can be detected. Malignancies at an early stage can be detected, so an examination for patients age 45 and older is recommended every 5 years until age 75. (can be used in pts who cannot be put to sleep/it does not have to be inserted far)
What do the thoracic nerves innervate?
the intercostal muscles of the ribcage, the abdominal muscles, and the back muscles
What happens when chyme enters the duodenum?
the intestinal mucosa produces the enzymes sucrase, maltase, and lactase, which complete the digestion of disaccharides to monosaccharides; the peptidases, which complete the digestion of proteins to amino acids; and the nucleosidases and phosphatases, completing nucleotide digestion.
What is the tibia?
the larger and stronger of the two bones in the leg, also known as the shinbone
The nurse is caring for a patient who has had an ostomy created, which will produce soft to hard formed effluent. Mark the area where the nurse would observe this stoma.
the left lower side of the abdomen
What do the lumbar nerves innervate?
the lower abdominal wall and parts of the thighs and legs
What is a priority with rib fractures?
the lungs (can develop pneumothorax or hemothorax) (rales, crackles/rhoni, or wheezes can occur)
What is true of nearsightedness/nearby objects?
the more divergent light rays require more refraction and thus the lens/ciliary muscle constricts
What is osteosarcoma?
the most common primary malignant bone tumor. It is the most fatal bone tumor. It typically metastasizes to the lung within 2 years of diagnosis. It usually affects young people between ages 10 and 25. Males are twice as likely to develop it.
What is Ewing sarcoma?
the most malignant bone tumor. In addition to local pain and swelling, low-grade fever, leukocytosis, and anemia are common. The pelvis and legs are most often affected in children and young men.
What does the frontal lobe contain?
the motor areas that generate impulses that bring about voluntary movement
What occurs at the neuromuscular junction?
the nerve impulse arrives at terminal and causes a release of acetylcholine (A C h) across synaptic cleft. this ACh bonds to ACh receptors and causes the Sarcomere to shorten (aka contract)
What does the neuromuscular junction contain?***
the neurotransmitter acetylcholine
What stimulates pupillary constriction?*
the parasympathetic nervous system which narrows the pupil to admit less light
What special care is needed if a pt has skeletal traction or external fixation (where the hardware/ pins can be seen)?
the pins have to be taken care of b/c infection will go straight into the bone (aka osteomyelitis) (pin care will be done with whatever the physician orders this solely depends on what the physician orders. Each pin will have to be done. go from pin out/clean to dirty. pin will likely scab around skin do not scrub but lightly clean regularly)
What is the pt education for bivalving?
the saw will not cut you (it is only meant to cut the cast)
What is true of syringes used with tubing?
the smaller the syringe, the more pressure
What is Dual-energy x-ray absorptiometry (DEXA)?
the standard screening tool to measure bone density. This noninvasive scan is a low-dose x-ray and takes about 5 minutes to perform while the patient lies on a table. This scan identifies low bone density at the hip and spine. It shows response to treatment.
What stimulates pupillary dilation?
the sympathetic nervous system which widens the pupil and admits more light
What is the neuromuscular junction?*****
the termination of motor neuron on muscle fiber (synapse)
What is proliferative retinopathy?
the third stage. It is characterized by the formation of new blood vessels. They grow into the retinal and optic disc area to increase the blood supply to the retina. The newly formed blood vessels are fragile. They often leak blood into the vitreous and retina. In addition, the newer vessels may grow into the vitreous. This causes a traction effect. It pulls the vitreous away from the retina. Then it pulls the retina away from the choroid. This condition is called retinal detachment (discussed later).
What is the auricle (pinna)?
the visible part of the ear that funnels sound into the auditory canal
What are the therapeutic interventions for Amyotrophic Lateral Sclerosis (ALS)/Lou Gehrig disease?
there is no cure and treatment is palliative goals are aimed at maintaining function as long as possible and emotionally supporting the pt and family. Gllycopyrrolate (Robinul) may be administered to decrease saliva production Quinine (Qualaquin) may be used for muscle cramps, Riluzole (Rilutek) slows the progression of the disease and can prolong life by 3-4 months, Edaravone (Radicava) reduces the glutamate in the body, which damages the motor nerves slowing decline in function, Muscle relaxants, Physical, occupational, speech therapies, Pain control, Enteral feedings, Prevention of infection, and Augmentative alternative communication
What will happen if a pt with a cast has compartment syndrome?
they will bivalve it just to make a window to relieve some of the pressure and allow the tissue to expand (you can get compartment syndrome without a cast though the syndrome will likely be painful)
What occurs if a pt breaks their jaw?
they will wire it shut (called fixation) (THE PERSON WILL HAVE WIRE CUTTERS AROUND THEIR NECK TO REMOVE THE WIRE IN CASE THEY BEGIN TO VOMIT PROFUSELY AND TO PREVENT ASPIRATION)
What do the sacral nerves innervate?
thighs, buttocks, skin of the legs and feet, and anal and genital regions
What are spider angiomas?
thin reddish purple vein lines close to the skins surface
What is the tympanic membrane?
this membranous structure separates the outer ear from the middle ear and vibrates freely in response to sound waves
What is the joint cavity?
this small space between the bones allows for freedom of movement. it also contains synovial fluid
What is the action of tissue plasminogen activator (tPA)?
thrombolytic
What are the two types of ischemic stroke?
thrombotic and embolic
What are some diagnostic/laboratory tests for the neurological system?
thyroid, Vitamin B12, Complete Blood count, creatine kinase, erythrocyte sedimentation rate, electrolytes, hormone levels, venereal disease research laboratory, liver function, and renal function
Why are Cholinergic agents (miotics) such as carbachol (Isopto Carbachol) or pilocarpine (Pilocar) given to people with primary open-angle glaucoma?
to constrict the pupil. When the pupil is constricted, the iris pulls away from the drainage canal. This allows the aqueous fluid to flow freely.
What is the purpose of the thoracic cage?
to protect the heart, lungs, liver, and spleen and to expand the chest cavity for inhalation
What is -plasty?
to repair
What is the cause of myasthenic crisis and what are the s/s?
too little medication that results in ptosis, difficulty swallowing, difficulty speaking, dyspnea, and weakness
What is the cause of cholinergic crisis and what are the s/s?
too much medication that results in salivation, lacrimation, urinary incontinence, diarrhea, gastrointestinal cramping, emesis, increased bronchial secretions, sweating, miosis (constriction of pupils), bradycardia, increasing muscle weakness, and dyspnea
What are ligaments?**
tough cords of connective tissue help bind the bones more firmly together (binds bone to bone**)
What is a fracture at a right angle to bone?
transverse
What are the causes of fractures?
trauma or pathological (from disease such as osteoporosis)
What are some causes of acute compartment syndrome?
trauma, Tight splints, casts or dressings
What is disturbed sensory perception a nursing diagnosis for?
traumatic brain injury
What is the treatment for lower gastrointestinal bleeding?
treat the cause
What is done if pancreatic cancer has progressed to distant involvement of other organ structures and lymph nodes?
treatment is directed at easing symptoms and making the patient more comfortable.
What nerve is being assessed when using a cotton ball?
trigeminal
How can you be vigilant for complications of the skin in quadriplegic patients?
turn frequently, use pressure-reduction devices in bed and wheelchair, and monitor skin condition.
How long after a fracture will a fatty embolism typically develop?
typically 3 days/72 hours after INITIAL injury
What can cause gastric bleeding?
ulcer perforation, tumor, or gastric surgery (s/s vary by severity)
What are the types of abdominal hernias?
umbilical, direct inguinal, indirect inguinal, and femoral
The nurse is collecting data on a patient with acute pancreatitis. Mark the area where the nurse would look for the presence of Cullen sign.
umbilicus
What must be done with delirium?
underlying cause must be corrected (Ex. include pain, hypoxia, medications, and illness)
What is the etiology for Parkinson's Disease?
unknown but linked to genetics, certain drugs, and encephalitis
Why is cirrhosis often irreversible?
unless the cause is identified and treated early this is the case
When does gastric juice secretion begin?
upon sight or smell of food
What is the humerus?
upper arm bone
What is the maxilla?
upper jaw
What is the maxillary?
upper jaw, upper teeth
What is nausea?
urge to vomit
What is caloric test?
used by the HCP to test the function of the eighth cranial nerve and assess vestibular reflexes of the inner ear that control balance. The test is not done if the ear canal is obstructed or the ear drum is perforated. Warm (112°F [44.5°C]) or cold (86°F [30°C]) water is instilled into the ear canal. Expected eye movements and nystagmus are noted. Dizziness may also be felt. No nystagmus is seen if the patient has a disease of the labyrinth, such as Ménière disease.
What is Crutchfield tong traction?
used for skeletal traction in the treatment of fractures of the cervical spine. The tong points are inserted in the parietal area of the skull (just in the outer layers of the bone) and the tong is then attached to the pulling device.
What is the cover test used for?
used in conjunction with an abnormal corneal light reflex test to evaluate muscle balance.
What is electronystagmogram?
used to diagnose the causes of unilateral hearing loss of unknown origin, vertigo, or ringing in the ears. The test is contraindicated in patients who have pacemakers.
What is the purpose of the Glasgow Coma Scale?
used to evaluate patients who have a potential for rapid deterioration in consciousness
What is irrigation?
used to flush particles and harmful chemicals from the conjunctiva and cornea.
What is bivalving a cast
used to open a cast to relieve pressure (DOES NOT MEAN THAT CAST WILL BE REMOVED)
What is a total hip replacement?
uses two components: an acetabular cup that is inserted into the pelvic acetabulum and a femoral component that is inserted into the femur to replace the femoral head and neck
What nerve is being assessed when using a tongue blade and cotton swab?
vagus
What are cluster headaches?
vascular disturbance, stress, anxiety, and emotional distress
What is spinal shock?
vasodilation, hypotension, and bradycardia**
What is the preprocedure care for a lumbar puncture/spinal tap?
verify informed consent and assist with positioning
How does the message from the sympathetic nervous system travel?
very quickly and only a short distance away (the whole body responds to these messages)
What nerve is being assessed when using a tuning fork or whisper?
vestibulocochlear
The structures in the small intestine that contain capillaries and lacteals for absorption are the _______.
villi
What function does the occipital lobe control?
vision center
What is hemianopsia?
vision lost in half of visual field
What objective data is collected during an assessment of vision?
visual acuity (using Snellen/E chart), Rosenbaum card, or a LogMAR chart, Visual fields by confrontation, Muscle balance and eye movement (using Six cardinal fields of gaze, Corneal light reflex, and Cover test), Pupillary reflexes, Inspection, Examination of internal eye by health care provider, and Intraocular pressure (Normal range: 10 to 21 millimeters of mercury)
What should be avoided with cochlear implants?
vomiting (pressure from this can push implant out of ear)
What can happen if a pt has severe osteoarthritis in their hip?
we can do a total hip replacement
What is always part of the discharge teaching for a pt who has had a fracture or a dislocation?
what is your home environment? (we need to know about stairs or high bathtubs or such do they have someone at home to help them does the toilet need a raised seat)
What happens when the head moves?
when the head moves, movement of the endolymph will bend the cupula within the ampulla. The bending of the hair cells at its base generates impulses carried by the vestibular branch of the eighth cranial nerve to the cerebellum and brainstem. Then impulses are sent to the cerebral cortex. These impulses are interpreted as directional acceleration or deceleration; this information is used to maintain equilibrium during movement.
What is the whisper voice test?****
whisper number letter in patient ear and ask them to repeat it back. Make sure to cover lips is they cant read them
How is bleeding treated with a Mallory-Weiss tear?
with an injection of epinephrine to constrict the blood vessel.
where does the sympathetic preganglionic neurons begin?
within the spinal cord
What is flaccid?
without muscle tone
Who does trigeminal neuralgia often affect?
women usually between the ages of 50 and 60
What should be done for replantation?
wrap severed body part in clean, slightly moist cloth. place in sealed plastic bag submerged in ice cold water (but do NOT put it in ice) transport to hospital
