M/S PT #5
Following a total hip replacement, the nurse should position the pt by: Elevating both feet on two pillows Maintaining the extremity in slight abduction using an abduction splint/pillow placed between the thighs Keeping the lower extremities adducted by use of an immobilization binder around both legs. Replacing weights alongside the affected extremity to keep the extremity from rotating.
Maintaining the extremity in slight abduction using an abduction splint/pillow placed between the thighs After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the patient in a supine position and keep the affected extremity in slight abduction using an adduction splint or pillows or Buck's extension traction. The patient must not abduct or flex the operated hip because this may produce dislocation.
Which type of headache is suspected when a headaches are unilateral and throbbing, preceded by a prodrome of photophobia, and associated with a family history of this type of headache? Cluster migraine tension-type frontal type
Migraine Migraine headaches are frequently unilateral and usually throbbing. They may be preceded by a prodrome and frequently there is a family history. Cluster headaches are also unilateral with severe bone-crushing pain but there is no prodrome or family history. Frontal-type headache is not a functional type of headache. Tension-type headaches are bilateral with constant, squeezing tightness without prodrome or family history.
The pt has just been diagnosed with Dupuytren's contracture. Which statement by the nurse is most appropriate? This condition is never bilateral in nature The fourth and fifth fingers are most often affected The cause of this condition is aging This condition will improve with time
The fourth and fifth fingers are most often affected
A pt has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the PRIMARY reason why the nurse has found it difficult to evaluate the effectiveness of the drug that the pt has used? The pt experiences spontaneous remissions from time to times The patient requires multiple drugs simultaneously. The patient endures long periods of exacerbation before the illness responds to a particular drug The patient exhibits intolerance to many drugs.
The pt experiences spontaneous remissions from time to times Evaluating drug effectiveness is difficult because a high percentage of patients with MS exhibits unpredictable episodes of remission, exacerbation, and steady progress without apparent cause. Patients with MS do not necessarily have increased intolerance to drugs, nor do they endure long periods of exacerbation before the illness responds to a particular drug. Multiple drug use is not what makes evaluation of drug effectiveness difficult.
The nurse cares for a pt after a total hip replacement due to degenerate joint disease. The nurse should intervene if which of the following is observed? The pt's heels are lysing on the bed with toes pointed upwards The patient moves slowly when getting out of bed. The patient uses an incentive spirometer every 2 hours. The patient is positioned with a pillow between legs.
The pt's heels are lysing on the bed with toes pointed upwards Elderly are prone to pressure sores, keep heels off bed to prevent pressure sores
During the change of shift report a nurse is told that a pt has a occluded left posterior cerebral artery. The nurse will anticipate that the pt may have Dysphasia visual deficits poor judgment confusion
Visual deficits Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
Which pt is at highest risk for spinal cord injury 50 y/o female with osteoporosis 35 y/o male who coaches soccer 20 y/o female with history of substance abuse 18 y/o male with prior arrest for driving while intoxicated (DWI)
18 y/o male with prior arrest for driving while intoxicated (DWI) The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.
Which pt should NOT be prescribed alendronate A pt on a calorie restricted diet A pt on bed rest who must maintain a supine position A pt who is allergic to iodine/shellfish A female pt being treated for high blood pressure with an ACE inhibitor
A pt on bed rest who must maintain a supine position Alendronate can cause significant gastrointestinal side effects, such as esophageal irritation, so it should not be taken if a patient must stay in supine position. ACE inhibitors are not contraindicated with alendronate and there is no iodine allergy relationship. The patient should not eat or drink for 30 minutes after administration and should not lie down.
Which patient below is NOT at risk for osteoporosis? A 30 year old male who drinks alcohol occasionally and has a BMI of 28. A 50 year old female whose last menstrual period was 7 years ago. A 35 year old female who has a history of seizures and takes Dilantin regularly. A 45 year old male patient who has been taking glucocorticoids for the last 6 months.
A 30 year old male who drinks alcohol occasionally and has a BMI of 28. All these patients are at risk for osteoporosis except a 30 year old male who drinks alcohol occasionally and has a BMI of 28. The risk factors include: older age (45+), being a woman, Caucasian or Asian, post-menopause, glucocorticoids therapy, anticonvulsants (Dilantin), REGULAR alcohol usage, smoking, sedentary lifestyle, BMI <19, family history.
A 40 year old pt has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? Insert an oropharyngeal airway to prevent airway obstruction Apply intermittent pneumatic compression stockings encourage pt to cough and deep breath every 4 hours assist to dangle on edge of bed and assess for dizziness
Apply intermittent pneumatic compression stockings The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A female pt who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication, An appropriate nursing intervention to help the pt communicate is to: Have the pt practice her facial and tongue exercises with a mirror Ask questions that the pt can answer yes or no develop a list of words that the pt can read and practice reading prevent embarrassing the pt by answering for her if she does not respond
Ask questions that the pt can answer yes or no Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
A pt in the clinic reports a recent episode of dysphasia and left sided weakness at home that resplved after 2 hours. The nurse will anticipate teaching the pt about Warfarin (Coumadin) Nimodipine (nimotop) Alteplase (TPA) Aspirin (Ecotrin)
Aspirin Following a transient ischemic attack (TIA), patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. TPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
The nurse should include which of the following pt teaching for prevention of rapid progression of osteoporosis? Avoid calcium supplements Avoid taking skim milk Avoid taking protein-rich foods Avoid alcohol
Avoid ing alcohol Avoiding alcohol and cigarette smoking will prevent rapid progression of osteoporosis. Skim milk is indicated among elderly because it is low in fats. Protein foods are necessary for calcium absorption. Calcium supplements help maintain integrity of the bones
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the pt's Temperature Pulse Blood pressure Respirations
Blood pressure Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored and blood pressure is maintained as identified by the healthcare provider and specific to the patient's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
A pt is suspected of having systemic lupus erythematous. The nurse monitors the pt, knowing that which of the following is one of the initial characteristic signs of systemic lupus erythematous? Weight gain Butterfly rash Raccoon eyes Elevated red blood cell count
Butterfly rash The most distinctive sign of lupus is a facial rash that resembles the wings of a butterfly unfolding across both cheeks, occurs in many but not all cases of lupus.
What should a nurse do first when a pt with a head injury begins to have clear drainage from the nose? Collect the drainage Tilt head back Administer an antihistamine for postnasal drip Compress the nares
Collect the drainage The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the patient tissue because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.
A pt with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which activity should the nurse instruct the pt to avoid? Using an abductor while lying on the side Crossing the legs while sitting down Sitting on a raised commode seat Rising straight from a chair to a standing position
Crossing the legs while sitting down Any activity or position that causes flexion, adduction, or internal rotation of >90 degrees should be avoided until the soft tissue surrounding the prosthesis has stabilized, at approximately 6 weeks. Crossing the legs while sitting down causes internal rotation and can lead to dislocation of the femoral head from the hip socket. Sitting on a raised commode seat prevents hip flexion and adduction. Using an abductor splint while side-lying keeps the hip going in abduction, thus preventing adduction and possible dislocation. Rising straight from a chair to standing position is acceptable for this patient because this action avoids hip flexion, adduction, and internal rotation of >90 degrees.
Following a total joint replacement, which complication has the greatest likelihood of occurring? Polyuria Deep vein thrombosis (DVT) Displacement of the new joint Wound evisceration
DVT DVT is a complication of total joint replacement and may occur during hospitalization or develop later when the patient is home. Patients who are obese, or have previous history of a deep vein thrombosis or pulmonary embolism are at a high risk. Immobility produces venous stasis, increasing the patient's chance to develop a venous thromboembolism. Signs of a DVT include unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the healthcare provider for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Displacement of the new joint is unlikely. Wound evisceration is more likely to occur after abdominal surgeries.
A 73 year old pt with a stoke experiences facial drooping on the right side, and right sided arm and leg paralysis. When admitting the pt which clinical manifestation will the nurse expect to find? Impulsive behavior, hyperactive left-sided tendon reflux Difficulty comprehending instructions Right-sided neglect
Difficulty comprehending instructions Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
After knee arthoplasty, the pt has SCD's. What should the nurse do? Stop the SCD to remove dressings, and bathe the leg Discontinue the SCD when pt is ambulatory Elevate the SCD on two pillows Change the setting on the SCD to make the pt more comfortable
Discontinue the SCD when pt is ambulatory After knee arthroplasty, the knee will be extended and immobilized with a firm compression dressing and an adjustable soft extension splint in place. An SCD will be applied. The SCD can be discontinued when the patient is ambulatory, but while the patient is in bed the SCD needs to be maintained to prevent thromboembolism. The SCD should be positioned on the bed, but not on two pillows. Settings for the SCD are prescribed by the orthopedic surgeon. Initial dressing changes are completed by the orthopedic surgeon and changed as needed per order.
What is the expected outcome of thrombolytic drug therapy for a stroke? Increased vascular permeability Vasoconstriction Prevention of hemorrhage Dissolve emboli
Dissolve emboli
An unconscious pt with multiple injuries to the head and neck arrive in the ER. What should the nurse do first? Establish an airway Determine the identity of the pt Check for neck fractures Stop bleeding from open wound
Establish an airway
Which of the following medications is the most common drug used for osteoporosis? Miacalcin Evista Fosamax Forteo
Fosamax Evista is an Estrogen Agonist/Antagonists that mimics estrogen and used for the prevention and treatment of osteoporosis in postmenopausal women. Miacalcin is approved for osteoporosis in women who are at least 5 years postmenopausal when alternative drug therapy is not appropriate Forteo: An anabolic drug given sub-q and can only be given for 2 years, after the drug is stopped the patient is usually started on a bisphosphonate.
The nurse knows that a 60 year old female pt susceptibility to osteoporosis is most likely related to: Lack of calcium Lack of exercise Genetic disposition Hormonal disturbances
Hormonal disturbances After menopause, women lack hormones necessary to absorb and utilize calcium. Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes. Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely related to osteoporosis.
A pt is taking Calcitonin for osteoporosis. The pt should be monitored for? Hypocalcemia Hypercalcemia Hypokalemia Hyperkalemia
Hypocalcemia Calcitonin is made from salmon calcitonin and acts like the hormone calcitonin which is produced naturally by the thyroid gland. It decreases osteoclast activity, which can decrease calcium levels. Therefore, the patient is at risk HYPOcalcemia.
A patient arrives in the emergency room department with an ischemic stroke. Because the healthcare team is considering administering tissue plasminogen activator (TPA) administration, the nurse should FIRST: Ask what medication the pt is taking? Complete a history of health assessment Identify the time of onset of stroke Determine if the pt is scheduled for any surgical procedures
Identify the time of onset of the stroke Studies show that patients who receive TPA treatment within 3 hrs after the onset of a stroke have better outcomes. The time from the onset of a stroke to TPA treatment is critical. A complete health assessment and history is not possible when a patient is receiving emergency care. upcoming surgical procedures may need to be delayed because of the administration of TPA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the patient is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering TPA.
A school nurse is called after a student falls down a flight of stairs. The student is breathing, but unconscious. After calling the ambulance, which is the most appropriate action by the nurse? place the pt on his side to prevent aspiration try to rouse the pt by gently shaking his shoulders immobilize the neck, securing the head protect the pt's neck from any movement
Immobilize the neck, securing the head Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. If the patient vomits, the nurse should utilize the log-roll technique to turn the patient while keeping the head, neck, and spine in alignment. Rousing the patient by shaking could cause damage to the spinal cord.
Which of the following is the priority nursing diagnosis for a pt diagnosed with a spinal cord injury Ineffective airway clearance altered tissue perfusion fluid volume deficit impaired physical mobility
Ineffective airway Clarence Ineffective Airway Clearance is the priority nursing diagnosis for this patient. The nurse utilizes the ABCs (airway, breathing, circulation) to determine priority. With Ineffective Airway Clearance, the patient is at risk for aspiration and therefore, impaired gas exchange. Fluid Volume Deficit is the nurse's next priority (circulation), and then Altered Tissue Perfusion. If the patient does not have enough volume to circulate, then tissue perfusion cannot be adequately addressed. The last priority for this patient is Impaired Physical Mobility.
Which assessment data would the nurse expect in a pt diagnosed with osteomalacia? Lack of estrogen Lack of Vitamin D Elevated blood sugar Decreased bone mass
Lack of Vitamin D Osteomalacia is the loss of bone related to lack of vitamin D which causes bone softening. Vitamin D is needed for calcium absorption in the small intestines. As a result of Vitamin D deficiency, normal bone building is disrupted, and calcification does not occur to harden the bone. Decreased bone mass occurs with osteoporosis. Lack of estrogen (post-menopausal) is associated with osteoporosis. Elevated blood sugar would not be anticipated with osteomalacia.
Following a T2 spinal cord injury, the pt develops paralytic ileus. While this condition is present, the nurse anticipates that the pt will need: Tube feeding Nasogastric suctioning Intravenous fluids Parenteral nutrition
NG suctioning During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur, and NG suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who had difficulty swallowing and not until peristalsis is returned; PN would be used only if the paralytic ileus was unusually prolonged.
A pt who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first: Notify the orthopedic surgeon Stabilize the leg with Bucks traction Apply an ice pack to the affected hip Position the pt towards the opposite side of the hip
Notify the orthopedic surgeon If a prosthesis become dislocated, the nurse should immediately notify the surgeon. This is done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintain circulation. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. If prescribed by the surgeon an ice pack may be applied postreduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may prescribe the patient be turned toward the side of the reduced hip, but that is not the nurse's first response.
Open fracture: skin over bone is disrupted causing an external wound Closed fracture: does not extend through the skin, no visible wound Complete: break is across the entire bone, the bone is divided into 2 Incomplete: fracture does not divide the bone into 2 portions
Open fracture: skin over bone is disrupted causing an external wound Closed fracture: does not extend through the skin, no visible wound Complete: break is across the entire bone, the bone is divided into 2 Incomplete: fracture does not divide the bone into 2 portions
A patient with an open femoral fracture was discharged to home and reports having a fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. The nurse should interpret these findings as the patient may be experiencing:
Osteomyelitis Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria, a virus, fungus. The patient with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.
When assessing a pt for acute compartment syndrome (ACS) all of the following belong to the 6 P's Except: Pressure Position Pallor Parasthesia
Position The 6 P's when assessing for acute compartment syndrome (ACS): Pain Pressure Paralysis Paresthesia Pallor Pulselessness (rare or late stage)
A pt with a spinal cord injury has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. the nurse should use which medical term to adequately describe this in documentation? Hemiplegia Parasthesia Quadriplegia Paraplegia
Quadriplegia Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.
During an acute bout of gouty arthritis, the nurse should expect the pt's affected foot to appear: Cyanotic Mottled Red Pale
Red Red: Gout is systemic disease caused by inflammation due to uric acid deposits in the joints; symptoms include: redness due to joint inflammation, joint is extremely painful; inspect joint only; too painful to touch. Pale: Indicates decreased blood flow. Mottled: area of discoloration Cyanotic: blue, gray, or purple discoloration of the skin; due to decreased oxygen and increased carbon dioxide.
A nurse is caring for a pt who has a C4 spinal cord injury. Which of the following should the nurse recognize the pt as being at the greatest risk for Neurogenic shock Respiratory compromise Stress ulcers Paralytic ileus
Respiratory compromise Using the airway, breathing and circulation priority framework, the greatest risk to the patient with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilator support as needed is the priority intervention.
A chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints: Rheumatoid Arthritis Regional osteoporosis Osteoporosis Osteoarthritis
Rheumatoid Arthritis Rheumatoid Arthritis is a systemic inflammatory autoimmue disease process that affects primarily the synovial joints. Osteoporosis: Chronic disease of bone loss causes decreased density and increases the risk of fractures. Regional Osteoporosis: occurs when a limb is immobilized related to a fracture, injury or paralysis for longer than 8 to 12 weeks.
A patient asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which of the following responses by the nurse is BEST? "Rheumatoid arthritis is a systemic disease and osteoarthritis is not Rheumatoid arthritis is progressive and osteoarthritis is not." Rheumatoid arthritis is often treated surgically and osteoarthritis is not." There is very little clinical difference between rheumatoid arthritis and osteoarthritis
Rheumatoid arthritis is a systemic disease and osteoarthritis is not
A pt is experiencing poor judgment, base don the nurses finding the nurse would expect the findings of: Right hemisphere stroke Left Hemisphere strokes
Right hemisphere stroke
Nurse in charge of shift report are discussing the care of a pt with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which nursing diagnosis do they determine has the highest propriety for the pt? Risk for aspiration related to inability to protect airway risk for impaired skin integrity related to immobility impaired physical mobility related to weakness disturbed sensory perception related to brain injury
Risk for aspiration related to inability to protect airway Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
You're caring for a pt who has a health history of sever osteoporosis. On assessment you note the pt has sever kyphosis of the upper back. Which nursing diagnosis takes priority for this pt's care? Limited mobility Knowledge deficient regarding disease process Risk for skin breakdown Risk for falls
Risk for falls When assessing the options you want to select the option that is a priority for this patient and risk for falls is the priority. The patient is at risk for falls due to severe kyphosis, which is common in severe osteoporosis (also called Dowager's Hump). This deformity of the spine limits mobility and increases the chances of falls In addition, it is important the nurse takes precautions in preventing falls because the patient will most likely experience a fracture due to severe osteoporosis.
In developing a care plan for a pt with an oen reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is Risk for constipation related to prolonged bed rest activity intolerance related to deconditioning risk for impaired skin integrity related to immobility risk for infection related to disruption of skin integrity
Risk for infection related to disruption of skin integrity Rationale: A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.
For a pt with right hemisphere stroke, the nurse should establish an nursing diagnosis of : ineffective coping related to depression and distress about disability impaired physical mobility related to right-sided hemiplegia risk for injury related to denial of deficits and impulsiveness
Risk for injury related to denial of deficits and impulsiveness The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
Alebdronate (Fosamax) is given to a pt with osteoporosis, The nurse advise the pt to: Take medication during lunch Take medication 2 hours before bed time Take with morning meals. Take medication with 8 oz of water after rising in the morning
Taje medication with 8 oz of water after rising in the morning Alendronate needs to be taken with a glass of water after rising in the morning in order to prevent gastrointestinal effects.
A pt in the emergency department with a sudden-onset reight sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the pt is most important to communicate to the HCP? the pt takes a diuretioc because of a history of hypertension the pt BP is 144-90 The pt has atrial fibrillation and takes warfarin (Coumadin) the pt's speech is difficult to understand
The pt has atrial fibrillation and takes warfarin (Coumadin) The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
After teaching a pt about the use of skeletal traction which statement about the purpose of the traction indicated the pt needs additional teaching: To pull weight with boot To provide long-term pull To align injured bones To apply 25 lb of traction
To pull weight with boot A Skeletal traction is NOT used to pull weight with a boot, and the nurse should explain to the patient that skeletal traction involves the insertion of a wire or pin into the bone to maintain a pull of 5 to 45lbs on the area which will align the injured bones by providing a long-term pull to realing the fracture.
Which is an initial sign of Parkinson's disease? Rigidity Akinesia Bradykinesia Tremor
Tremor The first sign of Parkinson's disease is usually tremors. The patient commonly is the first to notice the sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia.
Which of the following nursing actions is appropriate for preventing skin breakdown in a pt who has recently undergone a laminectomy? place pillows under pt to help pt turn provide the pt with an air mattress teach the pt to grasp the side rails to turn Use the log roll to turn the pt to the side
Use log roll to turn the pt to the side A patient who has undergone a laminectomy needs to be turned by log rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.
Following x-rays of an injured wrist. the pt is informed that it is badly sprained. In teaching the pt to care for the injury, the nurse tells the pt to: Wear an elastic compression bandage continuously use pillows to keep the arm elevated about the heart apply a heating pad to reduce muscle spasms gently exercise the joint to prevent muscle shortening
Use pillows to keep the arm elevated above the heart Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury.
A pt who has been hospitalized for 3 days with a hip fracture and Bucks traction has sudden onset shortness of breath and tachypnea. The pt tells the nurse "I feel like I am going to die" which action should the nurse take first? check the pt's legs for swelling or tenderness stay with the pt and offer reassurance administer oxygen at 4L,min by nasal cannula notify the HCP about the pt's symptoms
administer 4 L/min of O2 administer 4 L/O2 by nasal cannula The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for deep vein thrombosis (DVT) are obtained.
A pt with a spinal cord injury is recovering from spinal shock. The nurse realizes that the pt should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? autonomic dysreflexia autonomic crisis autonomic shutdown autonomic failure
autonomic dysreflexia Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.
A nurse is teaching a wellness class and is covering the warning signs of stroke. A pt asks, "What is most important thing for me to remember?" Which is an appropriate response by the nurse? Be alert for sudden weakness or numbness keep a list of your medications call 911 if you notice a gradual onset of paralysis or confusion know your family history
be alert of sudden weakness or numbness Rationale: Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.
a 70 year old female pt with left sided hemiparesis arrives by ambulance to the ED. Which action should the nurse take first? Assess the Glasgow coma scale score monitor the bp check the respiratory rate and effort send the pt for a computed tomography (CT) scan
check respiratory rate and effort The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.
The nurse is teaching regarding risk factors for stroke (CVA). the greatest risk factor is which of the following? hypertension diabetes renal insufficiency heart disease
hypertension Hypertension is the greatest risk factor for stroke, and should be controlled. Diabetes, heart disease, and renal insufficiency can all lead to stroke, however hypertension is the greatest risk.
A pt with a spinal cord injury was given IV decadron (dexamethasone) after arriving in the ED. the pt also has a history of hypoglycemia. during the hospital stay the nurse would expect to see which of the following? Increased episodes of hypoglycemia no change in pt's glycemic parameters both hyper and hypoglycemia possible episodes of hyperglycemia
possible episodes of hyperglycemia A common side effect of corticosteroids is hyperglycemia. Stress as well as the medication could cause this person to have periods of elevated blood sugars.
A pt hospitalized with a known AV malformation begins to complain of a headache and becomes disorientated. Which is the most appropriate action by the nurse? Document the changes and monitor closely recommend to the family members that they start to look for long term care facility prepare the pt for surgery prepare to give aspirin or a "clot buster"
prepare the pt for surgery An AV malformation is a cluster of vessels, usually located in the midline cerebral artery, that, if ruptured, becomes a surgical emergency to cut the blood flow to the vessels or the patient will bleed out into the brain. Symptoms of rupture include headache,, change in level of consciousness,, nausea and vomiting, and neurological deficits symptoms that mimic any brain bleed. Giving medication to affect coagulation will only make the bleeding worse. Recommending long-term care and merely documenting the changes are not appropriate interventions for a medical emergency.
A 58 year old pt with a left brain stroke auddenly bursts into tears when family members visit. The nurse should: Explain to the family that depression is normal following a stroke have the family members leave the pt alone for a few minutes teach the family that emotional outburst are common after strokes use calm voice to ask the pt to stop crying behavior
teach the family that emotional outburst are common after strokes Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
A 56 year old pt arrives in the ED with hemiparesis and dysarthria that started 2 hours previously, and a health record shows a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the pt for Transluminal angioplasty tissue plasminogen activator (TPA) infusion Intravenous heparin administration Surgical endarterectomy
tissue plasminogen activator (TPA) infusion The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke
A pt arrives in the emergency department with ankle swelling and sever pain after twisting the ankle playing soccer. all of the following orders are written by the HCP. which one will the nurse act first? administer naproxen (Naprosyn) 500 mg PO wrap the ankle and apply an ice pack give acetaminophen with codeine (Tylenol #3) take the pt to the radiography department for x-rays
wrap the ankle and apply an ice pack Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.
