Nursing Comprehensive Study Guide
30. The psychiatric technician is going to complete a procedure on a client that is painful. How should the PT prepare the client?
"you might feel discomfort with this procedure. "(explain procedure)
123. a) What are some nursing interventions that must be implemented when a client has a Foley catheter?
(Inspect for kinks, ensure flow, document I & O amount and characteristics of urine q shift). It is important to perform peri care and clean the catheter Q shift with soap and water. Wipe from front to back and clean the catheter down 6 inches. (p.706)
165). To prevent "tracking" of injected medication from the muscle site into the subcutaneous tissues, how much air should be drawn up after the medication dose has been verified?
(http://books.google.com) 0.2 to 0.3 ml of air
164 a). a) What is the maximum amount of solution that can safely be injected into an average thickness subcutaneous site?
(pg. 936 in Basic Nursing Book) 1.0 ml
161). What action is MOST important for the psychiatric technician to take prior to administering digoxin (Lanoxin) to a client?
(source pg. 887 in Basic Nursing Book). Observe closely for toxicity. There is a specific action/assessment to be performed. What is it? Apical pulse; hold if less than 60 bpm
162). The psychiatric technician needs to instruct a client in the proper administration of nitroglycerin (NTG). What are instructions that would be included?
(source wikihow.com) When seated, keep calm, rinse out mouth, place tablet under tongue, and allow tablet to dissolve.
188. What instructions are important to give to a client who is receiving oxygen therapy?
.
101. What are some Body Mechanics Principles to observe when assisting a client to transfer from the bed to a chair?
1. Check to see if the client has an IV, catheter, or other equipment. Make sure you know how to handle any equipment before attempting to move the client. Obtain help from another person if the client is immobile, heavy, or connected to multiple pieces of equipment. Put a transfer belt around the client's waist if he or she is unsteady or heavy. 2. Raise the head of the bed to a semi-sitting position. Lower the bed to its lowest position. Position the wheelchair or chair next to the bed. Lock the wheel brakes of both the bed and the chair. Remove the wheelchairs footrests. 3. Assist the client with putting on robe and appropriate shoes. 4. Assist the client to sit on the side of the bed. 5. Spread the client's feet and brace your knees against the outside of the client's knees. Prepare to raise the client to a standing position. Bend your knees and not your back. 6. Use a rocking motion to assist the client to stand. The client may use his or her hands to help push upwards from the bed. 7. Instruct the client to reach for the arms of the wheelchair while being pivoted. 8. Make sure the client is correctly positioned in the chair and is comfortable. (pg. 645-647)
103. A client who has been in bed for several days is to be ambulated for the first time. How should the PT prepare the client for this event?
1. Get assistance if needed. 2. Position the client as described for dangling - feet hanging over the edge of the bed. 3. Reassure the client that you will provide necessary protection from falling and explain how. 4. Help the client into clothing and appropriate footwear (non-skid) 5. Use transfer belt the first time the client gets out of bed and each time after that if needed. (pg 628) 6. Check the client's pulse before (Pg. 645)
173. How many medications can safely be mixed in one syringe?
2
174. Which syringes should be used when administering insulin
27 gauge ½ inch needle calibrated in units. (pharmacology lecture)
28. Difference between documenting objective and subjective data.
28. Objective Data: measurable and observable information about client health. Subjective Data: client opinion or feeling that is not observable by the care provider. 398
How much?
3-5 mL
b). What is the maximum amount of solution that can be safely injected into a muscle tissue site of average thickness?
3.0 ml depending on the site
61. What is the ratio of compressions to ventilations when performing CPR alone?
30:2 pg. 495
13. Which interventions should be done IMMEDIATELY to relieve the signs and symptoms of hypoglycemia?
4 ounces of any available juice 376
15 What is the generally accepted as the "normal" range for serum blood glucose?
60mg/dl - 110mg/dl. Pharmacology lecture
171). At what degree angle to the skin should the needle be inserted when administering an intramuscular injection?
90 degree angle
140. The physician has ordered a tepid bath to reduce fever in a client that has a temperature of 103 degrees Fahrenheit. For how long approximately should the bath last
A tepid sponge bath may be temporarily soothing, but may not produce a marked temperature drop unless used for an extended time, about 30 minutes. (753)
97. While lying in the dorsal recumbent position, the client's leg externally rotates. In order to prevent this, the Psychiatric Technician will utilize which of the following devices?
A trochanter roll. These rolls keep the leg and feet from rotating outward, causing later deformities. (pg. 621)****
112. The psychiatric technician is assigned to care for a client that is too weak to get out of bed. How should the P.T. change the linen of a bed that is "occupied" by the client?
Adjust the bed to a comfortable working high for you. Wear gloves for this procedure. Lower the side rail on the near side, while keeping the other side rail raised. Lower the head of the bed if the client can tolerate it. Loosen the top bed linens. Assist the client to turn toward the other side of the bed. Loosen bottom bed linens on your side. Fan-fold used linens from the side of the bed toward the middle and wedge them close to the clients back. Place the clean bottom sheet on the bed folded lengthwise, with the center fold as close to the clients back as possible. Push the clean sheet under the used sheet and as far under the client as possible. Raise the side rail on your side. Help the client roll over the folded linen to your side of the bed. Very carefully ease the used bottom linens out of the bed. Grasp the clean linens and gently ease them out flat. Pull them taut and tuck in the bottom sheet. Assist the client back to the center of the bed. Pg.665
b) Which Personal Protective Equipment items should be removed first by the Psychiatric Technician after providing care to a client who is in Reverse or Protective Isolation?
After providing care gloves are to be removed first *****Pg. 483
55. a) Which Personal Protective Equipment items should be removed first by the Psychiatric Technician after providing care to the client who is in Medical Isolation?
After providing care to a patient the most contaminated equipment should be removed first. GLOVES are removed first**** then the gown. Pg. 483
86. What are some factors that would affect the vital signs of an adult?
Age, gender, weight, height, heredity, medications, vigorous exercise & time of day. V.S. are usually higher in the late afternoon (due to more movements occuring during the day). What we learned from exam, TIME OF DAY HAS THE LEAST EFFECT ON VS
146. When caring for a patient following surgery, what are some nursing interventions/teaching that are important to prevent pulmonary complications from developing?
Ambulatory as soon as possible after surgery, complete range of motion exercises every shift and the use of a pneumatic/sequential compression device. (791) (TCDB - Turn, Cough, Deep Breathe)
63. The psych tech is assigned to change the bandage on a leg wound how should the bandage be applied?
Apply bandage firmly but not so tightly that the circulation is restricted. Watch for evidence of tightness; blanching of the skin, loss of sensation and absent pulse. loosen the bandage if necessary. 507
62. Which is the most effective method for controlling external bleeding in an extremity?
Apply direct firm pressure at the site***** <-- MORE IMPORTANT which will control bleeding. Elevate the injured is SECONDARY part. 511
130. How should the P.T. collect a stool specimen?
Ask the client to tell you when he/she feels the urge to have a bowel movement, label the container, when the client in ready give him/her the bedpan if in bed or place a specimen hat turned toward the back of the toilet if the client will be using the toilet. After the client has had the BM, use a tongue blade to transfer a portion of the feces to the labeled container, take a portion of the feces from three different areas of the stool specimen, close the container and place it in a biohazard bag while keeping the outside of the bag clean. (p.735)
11 What is a dangerous complication that may occur if a nasogastric tube feeding is administered too quickly?
Aspiration pneumonia d/t vomiting/regurgitation, which may lead to client morbidity or mortality (379).
131. What instruction is most important for the nurse to include after application of a binder or bandage to a client's extremity?
Assess for pain level and circulation after applying a binder to a client's extremity. (p.742) (When should the nurse be notified? Pt experiences extreme pain*)
137. A client complains of itching while a bandage is in place. What is the first action the psychiatric technician should take?
Assess the area immediately for bleeding, exudates, swelling or changes in skin color. (743)
58. The psychiatric technician is working at a group home that provides care to infants and small children. When checking on the children during nap time, the P.T. determines that one of the children is not responsive. Which action should be taken first?
Assess the person to ensure the airway is open. If the CHILD is not breathing, do a CPR for a minute THEN call EMS!!***. (give breath after 4-5 compressions). The person has to be able to breathe before other first aid procedures are executed. It is also important to ensure the spine is stabilized before making any other further assessments. Pg. 495 The intervention is different for infants and small children. Review CPR guidelines by the AHA. We discussed this during Normal Growth and Development.
189. What is the correct sequence in the procedure for suctioning a client with a tracheostomy?
Assist the conscious pt. to semi or high Fowlers position. Place unconscious pt. on his/her side facing nurse. Place a towel or drape cross clients chest. Put on gown/goggles. Turn on suction at the appropriate level. (What is the setting for an adult in mmHg? 80-120 mmHg) Put on gloves. Prepare suction equipment. Use non-dominant hand to connect the wall or portable suction catheter tubing to the sterile suction catheter. Dip the catheter into the basin with the sterile saline. Use the thumb on your non-dominant hand to occlude the suction. Remove the oxygen delivery system with the non-dominant hand. Use the dominant hand to insert the catheter into trachea 4-5 inches or until pt. coughs. Do not apply suction while inserting the catheter. Occlude the suction port with non-dominant thumb while rotating and removing the catheter. Suction no longer than 10 seconds per interval. Dip catheter into saline solution while applying the suction. Repeat suction procedure, if necessary. Allow 1 minute between suctions. Reapply the oxygen delivery system while waiting. Cleanse cannula before removing gloves. Throw it away if it is the disposable type. Replace the cannula and lock it in place. Cleanse around stoma and under tube faceplate with sterile cotton ball in hydrogen peroxide. Rinse the area with cotton balls dipped in normal saline. Dry the area with dry gauze pad. Change tracheostomy tape if necessary. Place sterile dressing under faceplate. Reattach oxygen delivery system. (pg. 1450).
7 How can the PT assist when delivering the dinner tray to a client whose dominant arm is in a cast elevated on two pillows?
Assist with spreading butter, pouring pitcher of water into cup, slicing steak, etc. (370)
Dorsal Recumbent:
Back lying, legs extended or slightly bent, arm up or down.
A client that has crutches needs instructions on how to get upstairs. The psychiatric technician instructs the client to begin at the bottom of the stairs and do which of the following?
Bear weight on their good leg and crutches. Put weight on the crutch handle and lift the good leg up on the first stair. Put weight on the good leg, and lift the other leg and crutches up to step. Repeat for each.
124. A client is recovering from anesthesia and is experiencing difficulty voiding. Which action taken by the P.T. would be best to stimulate voiding in the client
Before considering inserting a catheter, the P.T. should try other methods first to help the client with voiding. Some of those techniques include instructing the client to press on the bladder (Crede's maneuver) when attempting to void or bending forward to increase pressure on the abdomen to stimulate emptying of the bladder. (VACG: Bladder Care) (Hands in warm water, sounds of running water.....)
a.) When are controlled drugs counted? Oncoming nurse counts the drugs and outgoing nurse records the drugs at what times of day
Beginning and end of every shift
122. What action/s should be taken by the psychiatric technician when a 60 year old client complains that his stool is dark and tarry?
Black stools often indicate a high intestinal or nasogastric hemorrhage. Notify doctor immediately. pg.700 (Be prepared to Hemoccult/Guaic test)
5 Which foods should be omitted when doing meal planning with a client with a diagnosis of gastric ulcer?
Bland diets has often been prescribed for those with ulcers, esophagitis. GERD, or heartburn, gastritis, hiatal hernia, or other disorders of the gastrointestinal tract. Alcohol, Caffeine/Decaf, Red and black pepper, Chili powder, Fried foods and foods high in fat, peppermint and spearmint oils should be avoiding at on the bland diet. (374)
70. When assessing a client with a suspected head injury which of the following signs indicates that cerebrospinal spinal fluid is leaking?
Blood or fluid draining from the nose or ears with no known injury to the nose bruising behind the ears and under the eyes. 501 What is the color of the fluid? Clear, yellow or pink tinged*
The client in the emergency room was taught the three point crutch gait. The client demonstrated the following sequence in his/her gait.
Both crutches and the weaker limb, then the stronger limb.
89. A client for whom the PT is providing care states that the physician used the term 'bradycardia' to describe her condition. What explanation should the PT give?
Bradycardia is a slower than expected heart rate. Well-conditioned athletes often have a slower rate but often suggests an abnormality. (pg.561)
87. How can the pupillary response of a client be checked BEST during a physical?
By dimming the lights in the room and using a penlight (Lecture/Clinical)
84. How are the respirations of a client counted
By observing the chest and counting the number of times the chest rises in 1 minute. (pg.565)
39. How should the PT remove a mask after leaving an isolation room?
By the string or elastic only*. Dispose immediately after use. If the mask is attached with strings, untie the bottom strings FIRST, then the top strings to prevent the mask from falling onto one's gown (chest) which is contaminated. pg. 472
175. What actions are critically important to take prior to administration of insulin?
Check blood sugar level. (What else is critical to do before giving insulin? Verify dosage with second licensed person). (pharmacology lecture)
69. What is the best first aid to give when a client has been bitten by an animal?
Cleanse the wound with warm soapy water and rinse the area thoroughly. Swab the area with zephiran or alcohol. If a puncture wound is present flush the area with normal saline, do not delay in obtaining Medical Care. 513
23. What are examples of a Subjective Data?
Client said: "My head hurt" "my stomach hurts" 399
18 What is the rationale for keeping a client NPO before surgery for approximately 8 to 10 hours?
Clients are kept NPO before surgery to avoid "Aspiration" - prevent stomach contents from entering lungs due to vomiting that may be brought on by the anesthesia. 954
94. What are some 'collaborative' nursing innervations and principles to remember when providing care to clients who are immobile and confined to bed?
Clients confined to bed need exercise and regular changes in body position to preserve their muscle tone**, normal body functions, and morale. (pg.636)
143. What are some independent nursing interventions that would be appropriate for the P.T. To perform for a client experiencing pain in a particular area of the body?
Comfort measures, physical stimulus, heat and cold application, exercise, distraction and diversion, deep relaxation and guided imagery, support groups, and stress management. (766-767)
23. What are examples of subjective data?
Complaints about pain.
35. A fire is found in a client's room. A co-worker is removing the client. What action should be taken by the psychiatric technician?
Confine the fire by closing all doors AND activate the E.M.S. ACTUAL ANSWER: 1st thing to do is activate fire alarm!
52. Which PPE (Personal Protective Equipment) would the psychiatric technician use when providing care to a client with infectious wound drainage?
Contact Precautions are to be taken to prevent infection. When taking these precautions gloves, gown* (and a mask if splashing of body fluids is expected) pg. 483
159. Terminal illness:
Contact family; Notify supervisor; chaplain, Provide Comfort care, comfort measures.
99. Which are some instructions that the nurse should include in discharge teaching for a client who will be using crutches?
Crutches should be adjusted so the client's weight is borne on the hands. The crutch pads should not touch the axillae, and no weight should be borne on the tops of the crutches. (pg. 631 Fig. 48-13)
180. A client with a diagnosis of Diabetes mellitus is alert and independent in managing ADL. The client complains that her toenails are too long and need to be trimmed. Which actions should be taken by the psych tech?
Cut nails only with a physician's permission. (Who does the cutting of the nails?) Instruct patient in correct method/procedure and monitor. To Cut nails straight across with blunt tipped scissors.. See a podiatrist for treatment of corns, calluses or ingrown toenails. Self-treatment in any form is dangerous and absolutely forbidden. (1307)
187. Which symptoms should the psychiatric technician be ALERT for in a client with a diagnosis of COPD who is receiving oxygen at 2 L/minute via nasal cannula?
Decreased consciousness, decreased respiratory rate, stop breathing. (pg. 1426 + Laura at Vista Cove)
40. The psychiatric technician is performing a procedure when the gloves become ripped. Which actions would be the most appropriate to take?
Discard the gloves, wash hands and change gloves pg. 471
24. Think of a situations that would be considered examples of violating patient confidentiality?
Discussion client information in the hallway. Discussion client information with family member on the phone. (In public places or in the presence of others that are not involved in the care of the client).
121. What action/s should be taken when a client complains of intestinal cramps during the administration of an enema?
Divide the solution into smaller amounts the client will tolerate the procedure better.pg720 (Temporarily stop the flow of solution; instruct client to relax and take deep breaths; then slow the rate of fluid infusion till administration is completed).
22b. A client is admitted to the hospital with complaints of chest pain during exercise. What questions would be a priority for the nurse to ask?
Do you have difficulty breathing? How often do you have this pain and how long it last. 397 ACTUAL ANSWER: How can I help relieve your pain?
22A. A patient is admitted to the hospital with complaints of numbness in her legs alternating with weakness. What questions would be a PRIORITY for the nurse to ask?
Do you need assistance walking? Do you have trouble breathing? What, if anything, relieve the numbness? 397
197. What is the correct procedure for irrigating a colostomy?
Done with a cone tip and bag; the fluid drains into the toilet through an irrigating sleeve. (pg. 1463)
117. To prevent the development of urinary tract infection (UTI) in clients who are immobilized in bed, what are some nursing measures that are recommended?
Drink plenty of liquids especially water. pg699 What about hygiene r/t incontinence etc? Wipe from front to back after BM; right after BM and once per shift perineal care.
147. In order to reduce swelling of the left arm of a client who has had a mastectomy of the left breast, which of the following interventions is best for the P.T. to perform?
Elevate the left arm and apply ice pack to the area swelling has occurred in. Administer pain medication as ordered.
118. What are some instructions that should be given to female clients to lower their risk of developing cystitis?
Encourage to drink 2 to 3 L of liquids each day. Water and juices are best; caffeinated drinks should be avoided.pg. 699 (The instruction needs to be specific to women - cleaning after BR use - clean from front to back, void before AND after sex).
19 You are assigned to a patient with asthma. The doctor wrote the following orders: Vital signs every 2 hours, respiratory treatments every 4 hours as needed, and I&O every shift. Based on this information, when should the nurse perform assessments on this client? 359
Every two hours.
51B. Which patients would need to be placed in Reverse or Protective isolation?
Examples of clients who require Protective Isolation include those who have experienced bone transplants, all organ transplant recipients, burns or chemotherapy, AIDS or immunocompromised patients including babies in the NICU. Many of these patients have a weakened immune system and may not show signs of infection due to a decrease in white blood cells need to create an inflammatory response. pg. 486
108. A coherent client complains of the side rails being in the 'up' position and has tried to crawl over the rails. What is the best approach to take?
Explain to the client and family that the side rails are for the client's protection. (pg. 658) In some cases, having the side rails up can be more dangerous than having them down. For example, an elderly client may continually try to crawl out of bed. The key term in this question is "coherent." What would be reasonable to do when a client is coherent and active? Lower the side rail on one side.
141. The psychiatric technician is assessing a non-verbal client for pain. What is the best indicator that a client is experiencing pain?
Facial grimacing or showing them the Wong-Baker faces pain scale. (760)
38B. How should the hands be positioned?
Finger tips down with the level of the hands below the level of the elbows .
b. Direction of the cleansing motion?
From the center outward.
114. A client has not had a bowel movement for 3 days, except for a small amount of diarrhea. What action should be taken by the psychiatric technician?
Get an order from the MD to check the client for fecal impaction. After three days the stool or feces become harder and more difficult to pass. Diarrhea can be a sign of fecal impaction. Digital removal of impacted stool may be required. Need an order from the MD to remove an impaction. Pg700. Danger of stimulating the Vagus nerve resulting in bradycardia.**
109b.) What equipment is necessary when providing mouth care to an unconscious client?
Gloves, toothette mouth sponge, tongue blade padded with a 4 x 4 gauze sponge, water, towel, water soluble lubricant, suction catheter, and emesis basin.***
46. Which nursing action is the single most effective method of preventing the spread of disease?
Hand washing pg. 480-481
160). Keep controlled drugs separate and locked from other non-controlled drugs. .
Have 2 licensed nurse count the controlled drugs
71. What action should the psych tech take when it is determined that leakage of cerebrospinal fluid is present in a client with a suspected head injury?
Have the person lie flat while RESTRICTING his or her movements; do NOT lower the person's head; keep the person warm and check for signs of increasing intracranial pressure. 501
9 Which action is most important for the psychiatric technician to take when feeding a client through a naso-gastric tube?
Head of bed should be elevated to about 30 degrees to prevent aspiration of stomach contents (379) MOST important is to check placement through auscultation and aspiration.
47. Which disease poses the MOST risk of transmission to health care workers?
Hepatitis B (Blood born pathogens)**** source: google
192. What is BEST for a client who is experiencing dyspnea with rapid shallow respirations?
High Fowlers or Orthopneic. (pg. 619)
185. Which interventions will help prevent the complication of hypoxia during tracheal suctioning?
Hyperoxygenation before*, in between and after suctioning (Video D-339:Trach Suctioning)
65. A client who had climbed up onto the patio roof and jumped off is complaining of pain in the right leg what action should be taken by the psych tech?
If in doubt about the extent of an injury assume that a fracture has occurred in treat the person accordingly until a definite diagnosis is made. Use Isis treatment for a fracture or sprain until medical assistant is available. Do you not have the person stand or walk on a suspected fracture to check for pain doing so is likely to aggravate the injury. Observe for obviously deformed Limbs, cover them with a blanket until you can obtain adequate help if the person must be moved to a safe place the injury should be immobilized. 507
106. The PT is assisting a client to ambulate when the client reports feeling faint and dizzy. What is the correct action for the PT to take?
If walking with a client who feels faint, help him or her to lean against a wall and bend over. If this does not help and no one else is there, gently ease the client to the floor; support the client and stay with them until help arrives. (Nursing Alert pg. 628)
104. What are some precautions for the PT to take when the client who has been in bed for several days is going to take a shower?
Important to STAY close by the client during the shower and assist as needed. Care should be taken to ensure that the client has a good sense of balance. (pg. 627) Also, check for skin breakdown.
102. The psychiatric technician is transferring a client from the bed to the wheelchair. How should the PT position the wheelchair in relation to the bed?
In a 45 degree angle towards the head of the bed. ****(pg. 646)
178. How should the needle and syringe be discarded after medication had been administrated
In a designated sharps container. (pharmacology lecture)
128. A client has been place on a 24-hour urine specimen collection. What instructions should be given to the client and the other members of the nursing team?
Inform everyone involved in the procedure that urine specimen collection is a sterile technique and the container used to collect the specimen should be labeled with the client's name and other pertinent data before beginning. (p.724)
191. Which of the components of the tracheostomy is removed and cleaned several times a day?
Inner Cannula. (pg. 1451)
179. How should the psych tech provide foot care to a client who has peripheral neuropathy related to diabetes mellitus?
Inspect feet daily, wash feet daily, dry feet thoroughly, massage with good quality lotion, never pick at sores or rough spots on skin. (1307)
135. A) What instructions should the psychiatric technician give to a client confined to bed rest to prevent the formation of emboli (blood clots)?
Instruct the client to flex legs and feet as often as possible. Perform leg exercises every 2 hours, complete range of motion every 8 hours and alternate external pressure on each leg. (791)
168). A client has is agitated and the physician orders parenteral administration of a tranquilizer. If the MD wants rapid absorption of medication, into which of the following tissue layers will he order that the medication should be administered?
Intramuscular layer
198. What is the most common and serious problem that develops if the pouch around the urostomy (ileal conduit) does not fit properly?
Irritation. The skin around the stoma will be exposed to continuous urine flow causing excoriation and redness, along with pain. Possible infection.
b). What is the reason for using this muscle site over the others
It has adequate amount of muscle mass and fat
129. What factors should be considered in the procedure for collecting a sputum specimen for culture and sensitivity test?
It is best to obtain a sputum specimen in the morning after the client wakes up and before the client eats, uses mouthwash or brushes the teeth. (p.729) (Discuss in class)
51A. What is the reason for placing a patient in Reverse or Protective Isolation?
It is done in order to prevent a client from being infected by the surrounding people and environment. Protective Isolation prevents pathogens and infectious diseases from coming in contact with a particular client. pg. 486, 1817
42. A client has been placed on "airborne precautions". What actions should be taken?
Keep door closed. Respiratory Precautions: A high filtration particulate respirator (NAS or HEPA filtered N-95 ) Mask & gloves. pg. 483
c. Technique and precautions to take when packing the wound
Keep dressing inside the wound
144. Which of the following positions is BEST to place an unconscious patient in?
Keep the client flat, often in LATERAL position until he or she fully awakens, unless specifically ordered otherwise. OR, Semi-Fowler's at 30 degrees elevation of head of bed. (795)
181. The psych tech assess a sweet, fruity, odor on the breath of a client with a diagnosis of diabetes mellitus. The Pt remembers that this sign indicates that the following condition has developed?
Ketoacidosis (1303)
126. a) What is the normal procedure to obtain a "Clean Catch" urine specimen for culture and sensitivity test?
Label the container to be used before collecting, instruct the client to clean the urethral area thoroughly, instruct the female client to cleanse from front to back ant the male client to cleanse the penis using a circular motion and outward from the urethral meatus, instruct both male and female client to void a small amount of urine into the toilet and to hold and then void in the sterile container provided and finally to void the rest of the urine into the toilet. (p.728)
196. When is a tampon sometimes used when providing care to a client with a colostomy?
Lecture. For occlusion of the colostomy because of diarrhea.
68. What are some interventions to perform when a client is exhibiting signs of myocardial infarction appears anxious?
Loosen any tight clothing. Sit up or elevate the head to ensure easier breathing. 511 AND reassure that help is on the way.
Which diet is best for a client with a diagnosis of cardiovascular disease?
Low fat, low sodium, low calories (376-377) Think of some foods that would be appropriate when answering the question on the exam.
3 What should be included when teaching about dietary restrictions for a client with diagnosis of hypertension?
Low sodium, should consume no more than 1500 mg sodium per day. Encourage foods that are high in Potassium, such as leafy green vegetables, fruit from vines, and root vegetables. (375). Again, think of foods that are lowest in sodium when answering this question.
38C. What should the water temparature be?
Lukewarm pg. 470Source: lecture
Prone:
Lying on abdomen, head to side, arms above head or beside body.
Trendelenburg:
Lying on back, head lower than feet.
Supine:
Lying on the back.
29. The psychiatric technician has recorded nursing care in the wrong client's chart. What action should the P.T. take?
Make a line across it write error and initial
50. What is the purpose of placing a patient in Medical Isolation?
Medical isolation is the separation of people with infectious diseases from others. The purpose for placing certain patients in Medical Isolation is to ensure others are protected from a client's known infectious disease. Isolation allows others to stand clear of any possible routes of transmission. pg. 484, 1806
169). Outer lateral thigh What are the landmarks?
Mid-lateral, mid-anterior thigh, One hands breath above the knee; one hands breath below the greater trochanter with the toes pointing up.
195. When teaching a client with a permanent-end colostomy to perform self-care, what are some measures to take that will facilitate adherence of the colostomy pouch and decrease skin irritation?
Mild soap. Skin barrier paste.
109. a.) How should the PT provide mouth care to an unconscious client?
Move the client into a side lying position, with the head of the bed lowered, as tolerated. The client's head may also be turned to the side (same as the side on which you are standing). While giving oral hygiene, inspect the gums and the mucosa of the mouth. Also inspect the lips for dryness and cracking. Apply petroleum jelly or other ointment as ordered. (670)😂***
21B. How often is NCP updated?
NCP is updated regularly as the client's condition changes. 406
66. Which interventions would be the priority for the PT when providing treatment to a client suspected of being in shock?
Never handle or move injured persons unnecessarily and make every attempt to keep them calm. 493. Treatment of shock is symptomatic aimed at correcting and balances and removing the underlying cause of the shock. The treatment of most types of shock is approximately the same. In a first aid situation: efforts are made to increase the blood supply to the brain in many cases this involves elevating the feet 12 - 18 inches or lowering the head. Bleeding sites are identified if there is bleeding the bleeding is controlled. Cover with a blanket to keep warm. 494
190. A client has difficulty expelling thick, tenacious secretions out of his tracheostomy. What intervention will aid in liquefying these secretions prior to suctioning? How much?
Normal saline. 3-5 mL
85. What are NORMAL values for Temperature, Pulse, and Respirations, and what actions should be taken when Vitals Sign values are abnormal?
Normal temperature remains at approximately 37 c or 98.6F. The normal adult pulse rate is 60 to 80 beats per minute. The normal respiration rate for an adult is 12 to 20 breaths per minute. Document the signs and report to physician. (pg.555-564)
27. What factors are considered when describing a client's neuromuscular status?
Not patient appearance and assess speech affect or motor movement, function & strength
28. Know the difference between documenting objective and subjective data
Objective data is measurable data (ex. Blood pressure, sugar levels, etc.). Subjective data is data that can't be measured such as chest pain, headache, etc.
182. The psych tech is preparing to check the glucose level of a client with diabetes mellitus. After cleaning the client's finger with alcohol, where should the lancet prick the finger?
On the side of the finger aka the lateral aspect of the finger, away from the cuticle and joint. (clinical rotation at RPAC)
125. A client is complaining of abdominal pain and starts to vomit. What action should be taken by the P.T.?
One important thing to do when a client is vomiting would be to position the client in a semi fowler's position or what other position? Or sidelying to prevent aspiration. (Nursing File) (What to give the client when vomiting? Emesis basin; What to do after? Help clean up and replace gown and bed linen)
37. After the laboratory technician obtained a blood sample, the client ripped off the bandage resulting in blood splattering on the wheelchair and floor. What is the correct protocol to follow regarding cleaning a blood spill?
One part of bleach to 10 parts of water.*
90. Which technique would be used to detect the presence of edema during the physical?
Palpate the skin for edema. Press the fingers against suspected edematous areas for 10 seconds; then observe the area for indentations. (pg.596)
110. Shaving with a Straight razor:
Place a warm wet washcloth on the area to be shaved for a few seconds. Apply shaving cream. Hold the skin taut while making strokes. Holding the blade razor at a 45 degree angle** to the skin, move it across the skin in short strokes in the direction the hair grows. (From cheek bone down toward chin; and from neck up towards the chin) Wash the shaven area with a clean, warm, moistened washcloth. Pat the area dry. Pg689
48. What should the psychiatric technician do when a client's Mantoux test (PPD) shows an induration of 12mm after 48 hours?
Place in Isolation and contact MD for chest x-ray or test the sputum source: google
65. A. What action should be taken first when a client collapses while out on a walk in a hundred degrees Fahrenheit weather?
Place the person in a cool Shady place and remove his or her clothing. Wrap the person in cold wet sheets or spray the body with a cold mist of water. Place ice packs on the person's forehead under the armpits and the neck and groin if the person is conscious give sips of cold liquids containing a dilute salt solution tell the person not to drink too quickly to prevent nausea. Prevent shivering; monitor the person's Airway, Breathing and Circulation if necessary begin CPR. 504
88. The psychiatric technician is assigned to monitor oral temperature on ten clients at 0900. One of the clients has just taken an iced drink. What actions is BEST?
Proceed taking the temperature of other clients and return to take his/her temperature last. ****(PubMed.org)
43. Which type of isolation would be ordered for a client that is has received an organ transplant?
Protective (Reverse or Neutropenic ) Isolation* pg.486
163). Which of the following actions should be taken when instilling ear-drops into the ear canal of a pediatric client with a developmental disability?
Pull ear back then downwards then administer drops.
98. A client is having difficulty breathing. Which position should be used to make breathing easier?
Putting clients in the orthopneic position or sitting up will further facilitate breathing. (pg. 621-622)****
92. Prior to moving an immobile client up in bed, in what position should the bed be placed?
Raise the bed to a comfortable working level/height for you. Lower side rails. Lower the head of the bed to a FLAT position and place the pillow against the head of the bed. (pg.622)
16 What is the most likely time for a client to experience an insulin reaction if 10 units of regular insulin had been recieved at 0730? (Review Drug card for this information)
Reaction time is between 8:00 and 9:15. (Basic Injection Skill p.17) Onset is different from Reaction time also called PEAK time. The question is asking for peak time. That is when the insulin is exerting its greatest effect - usually 2-5 hours after administration for Regular Insulin which is fast acting. Therefore, between 9 - 11 am is when the PT needs to monitor the client very carefully for the symptoms described in answer 12. (We need to discuss this in class).
139. The physician ordered a tub soak for a client for 30 minutes at 110 degrees Fahrenheit. Which action should the psychiatric technician take?
Recheck the order with the physician due to the possibility of burning the client. Tub baths are not recommended to be above 105 degrees Fahrenheit. (751)
What kind of diet?
Regular as before the colostomy
157. When checking on s client following surgery, the psychiatric technician notices that the original dressing is soaked with blood. What action should the P.T. take?
Reinforce more dressing and notify the surgeon
64. What is the best intervention to treat a client with hypothermia?
Remove wet clothing. Get the person into warm dry clothing. Cover the person's head hands and feet. A ground cover provides a barrier against moisture and insulates against cold materials under the person. Keep the person awake until medical assistance arrives. Warm beverages also help if the person as alert and can swallow. 502 It is important to do "core re-warming: of the person as long as they are alert and able to swallow.**
31. A client expresses concern over the length of hospitalization and possible loss of employment as a result. How should be psychiatric technician respond?
Respond with empathy and active listening.
21C. What is the determining factor in the revision of a NCP?
Revisions are done to the NCP when there is change in the client conditions OR when the plan is not working. 400
177. What actions should be taken when patients receive multiple injections such as insulin
Rotate the injection sites (pharmacology lecture)
194. What time would be BEST for a client to perform colostomy irrigation?
Same time every day.
1 Which of the following approaches is best to take when the psychiatric technician discovers that a postoperative surgery client who practices Judaism is eating only the fruit and bread on his food tray? Since the nurse cannot change the dietary beliefs of the client, the nurse can help adjust their diet within their belief structures. Kosher eating demands the following:
Separate dishes or pans are used to prepare and to serve meat and dairy foods. Meats must be slaughtered by a ritual method and only the front quarter of the animal may be eaten/ Meat and dairy may not be eaten at the same meal. Food must be prepared ahead of time for the Sabbath which is sundown Friday to sundown Saturday. Pork products, rabbit, shellfish, and scavenger fish are also not allowed. (363)
14. A Client with a diagnosis of Diabetes Mellitus is put on a 1600-calorie ADA diet. What is the goal of her diet teaching?
She will eat three regularly scheduled meals plus snacks. 376
6 Which are some interventions that should be implanted for a client who experiences "gastroesophageal reflux" (GERD) following meals?
Should be encouraged to avoid other foods that may cause them discomfort. Instruct not to lie down for an hour after meals; to maintain ideal weight, eat smaller, more frequently. Discourage smoking and milk based diets (374).
184. A client has been diagnosed with COPD after smoking three packs of cigarettes per day for twenty years. What flow rate should not be exceeded in the administration of oxygen for a client with this diagnosis?
Should not exceed 3 L/minute because many people with COPD retain Carbon dioxide. (1426) DISCUSS IN CLASS
What should be the level of the irrigant bag?
Shoulder height 12-18 inches above of the level of the stoma
10 The psychiatric technician is preparing to administer nutrition (gavage) through a naso-gastric tube. In which position should client be placed?
Sitting position aka Fowler's position and check placement prior to feeding (379).
183. The psych tech is providing care to a client with a diagnosis of peripheral neuropathy related to diabetes mellitus. What interventions should be performed when meeting the needs of the client?
Skin assessments for injuries or break down especially on feet, blood sugar monitoring, and patient education on diabetes and how to take care of themselves at home. (1304-1305)
115. A client is complaining of abdominal pain and has had three episodes of diarrhea in the past 6 hours. Which of the following assessment findings would the P.T. expect to find?
Soft bowel sounds. Pg701 More like Increased and active bowel sounds.**
B. Would the standard treatment for shock apply when a client in shock also has a head injury?
Some people may need to have the head elevated to breathe but in head injury the body is kept level to prevent increased blood flow to the brain thereby causing increased intracranial bleeding and pressure.
60. A 45 year old overweight client who leads a sedentary life style has been diagnosed with Hypercholesteremia. He expresses concern that he has positive family history of heart disease. Which of the following risk factors can or cannot be changed?
Some risk factors that can or cannot be changed are, arrhythmia, cardiomyopathy, and heart failure. Clogged arteries is another risk factor that may or may not be changed. What about family history?** Web Source: http://www.webmd.com/heart-disease/ss/slideshow-visual-guide-to-heart-disease What cannot be changed is the family history****
Which type of diets would be given to clients with a diagnosis of Spastic Quadriplegia who has "dysphagia"?
Speech therapist is often consulted; Diet ranges from thick liquids only to solid and thick liquids. (371). Remember, the prescribed consistency. From test: solid to thick liquid to pudding consistency
63. In which direction is the bandage roll applied?
Spiral from distal to proximal (toward the heart) OR UPWARD
111. A female client who is immobile has long hair that the family has requested should be kept braided. How should the psychiatric technician perform this care?
Start braids toward the front and keep them toward the side. **This helps the braids to be more comfortable when the client lies in bed. Fasten braids with a "scrunchie" or ribbon instead of rubber bands. Rubber bands can pull or break hairs. Pg.675
107. The PT recognizes that meeting safety needs is important to the long term rehabilitation of a client recovering from a cardiovascular accident (stroke). What are some nursing actions/interventions are best to take when assisting the client to ambulate?
Start with short periods of being out of bed. Monitor pulse before and after ambulating. Stand on the weak side and support. (pg. 627 & 645)
176. Which is the preferred route of administration of insulin for a client with a diagnosis 0f diabetes mellitus type 1?
Subcutaneous in the upper arm, upper back, or abdomen (pharmacology lecture)
Fowler's:
Supine with head raised.
Dorsal Lithotomy:
Supine with legs separated, knees acutely flexed, hips at end of examination table and feet in stirrups (usually for a vaginal exam or childbirth).
96. Which of the following actions is BEST to take by the psychiatric technician when performing passive range of motion exercises to a client's joints?
Support above and below all joints during exercises. Cradling joints helps prevent injury and discomfort. (pg.643)
12. The psychiatric technician is assigned to teach a client with a diagnosis of Diabetes Mellitus about recognizing the symptoms of hypoglycemia? Which are the signs and symptoms?
Sweating, shakiness, hunger, fatigue, confusion, seizure and loss of consciousness. 374
67. A client with a history of cardiovascular disease complains of chest pain to the psych tech which symptoms are indicators of myocardial infarction?
Symptoms include shortness of breath difficulty in catching the breath nausea and flu-like symptoms, chills, cold sweats, lightheadedness, faintness, heart palpitations, chest pain perhaps but not necessarily, discomfort in other areas including neck, jaw, back and arms, heartburn and stomach pains, and extreme fatigue. 510
24. Think of situations that would be considered examples of violating patient confidentiality?
Talking about a client to another health care provider in a public space (ex. Elevator).
34. A client is smoking a cigarette in a "No smoking" area. Which action should the P.T. take?
Tell the client this area is not permitted to smoke and needs to extinguish cigarette and stay with the client to ensure* that the cigarette is extinguished.
132. The P.T. is providing care to a client with a bandage. When evaluating the effects of the bandage, what should the P.T. monitor?
The P.T. should monitor circulation, sensation, movement and pain. (p.740)
153. While performing a dressing change, part of the sterile field becomes wet. Which action should the psychiatric technician take?
The PT must start over the procedure again because the field is no longer sterile
91.To prevent injury, when should the Posey jacket NOT be used
The Posey jacket should not be used in bed. (pg.652)
199. Why is it MOST important to attach the ileal drainage pouch to gravity drainage at night?
The adapter connects to a larger container and drains the bag so that the patient doesn't have to get up several times to drain the bag at night. This restricts backflow. Discuss in class.
116. Constipation is a common problem for immobilized patients. What are some factors that would contribute to constipation?
The bowel responds to even the slightest changes in a person's usual eating or exercise habits. Lack of Physical activity, poor diet (low intake of roughage and fiber) and low fluid intake are factors that would contribute to constipation pg 699
133. In what position should the client be placed when preparing to put on anti-embolism stocking (TED hose)
The client should be in a supine position (recumbent) at least for 15 minutes before putting on TED hose. (p. 741)
57. What instruction should be given to a client with a diagnosis of tuberculosis?
The client should be instructed to not to leave the room, to keep the door closed, to refrain from physically making contact with others when possible. If transported from the room the client should be instructed to place a mask on. What to do when coughing or sneezing? Cover mouth with tissue and dispose in bag.**** Pg. 482 - 483
B) What instructions should be given to a client on the use of elastic stockings to prevent the formation of emboli?
The client should not wear the stockings longer than 4-8 hours, they should not sleep in them and if there is any discomfort the client should inform the nurse immediately. (741) (Discuss)
100. How should the PT describe the instructions for walking with crutches using a "swing through gait"?
The client stands on the strong leg, moves both crutches forward the same distance, rests his or her weight on the palms, and swings forward slightly ahead of the crutches. (pg. 631)
113. What information is most important for the P.T. to obtain prior to bathing a client?
The client's comfort and personal preferences. The client's condition* determines which type of bath is the most appropriate. Pg. 678
127. What is the correct procedure to follow when collecting a 24-hour urine specimen?
The collecting container and the bedpan or the urinal should be labeled with the client's name before beginning, instruct the client void for the first time either in the labeled bedpan or urinal or in the toilet if possible, discard that first urine and record the time in the client's chart and on the collection bottle, after the collection period begins measure each specimen of urine voided and pour in the collection bottle placed in ice or being cooled, keep the collection bottle closed and continue the collection for 24 hours from the time the first urine was discarded. (p.734)
138. What is the protocol for the psychiatric technician to follow when administering moist heat application?
The doctor will prescribe where it is to be applied, the type of applications and the schedule of applications. The pack should be as warm as the client can comfortable tolerate, apply it slowly so the client can tell you how it feels. If there is a break in the client's skin, sterile dressings are to be used. (750)
142. A client who is experiencing chronic pain is at risk for developing which secondary condition?
The effects of chronic pain can be destructive to a person's lifestyle and outlook, especially if the cause is unknown. When a person fails to express feelings, suppressed anger may turn inward and cause Depression. (760)
120. What is the maximum safe height at which the container of fluid can be held when administering an enema?
The enema container can be held up to no more than 18 inches (45.7 cm) above the client's anus. Pg.720
b) What instruction should be given to a female client when obtaining a mid-stream urine specimen?
The female client should be instructed to cleanse from front to back and to cleanse each side with a separate wipe or separate area of the wipe**, saving the last wipe or the last area of the wipe for the urethral area itself. Instruct female client to void a small amount of urine into the toilet and to hold and then void in the sterile container provided and finally to void the rest of the urine into the toilet. (p.728)
134. Prior to applying anti-embolism stockings, which action taken by the P.T. is most important?
The most important action would be to use the tape measure to determine the proper stocking size for the client. (p.745)
17 What will be the most likely time for a client to experience an insulin reaction if the client had recieved NPH insulin at 0730? (Review Drug Card for this information)
The reaction time is between 8:30 to 9:30. (Basic Injection Skill p.17) Onset is different from Reaction time also called PEAK time. The question is asking for peak time. That is when the insulin is exerting its greatest effect - usually 6-12 hours after administration for NPH Insulin which is intermediate acting. Therefore, between 2 - 7 pm is when the PT needs to monitor the client very carefully for the symptoms described in answer 12. (We need to discuss this in class).
123c) What is the reason for this method of removing urine from a Foley catheter?
The reason is to obtain a sterile specimen for testing. (p.726)
123b) How should a urine specimen be removed from a Foley catheter?
The specimen should be removed through the catheter port using a 10-20mL syringe with a 20-21 gauge blunt-tipped needle after clamping the tubing** (p.734)
119. What are considered to be the output of a client?
The total adult urine output varies according to the person's fluid intake and kidney efficiency. An adult of average size forms and excretes approximately 500 to 2400 mL of urine every 24 hours.
59. An adult client has been found lying in the hallway and is unresponsive. What interventions should be performed?
This is a CPR question. Refer to AHA guidelines for the intervention for a first responder. Activate EMS, THEN return and do CPR*********** In an emergency situation, the acronym ABCDE is often used to map the order in which one should assess an injured person. A. Airway and Cervical Spine Assess the person to ensure the airway is open. The person has to be able to breath before other first aid procedures are executed. It is also important to ensure the spine is stabilized before making any other further assessments. B. Breathing Assess for breathing. Listen for breathing sounds, watch for chest movement, use ear and check to feel for breathing. It is also vital to maintain the airway, the tongue must be kept from obstructing air flow. Note the color of the gums and nails. Dark or blue colors can be clues to a lack of oxygen. C. Circulation and Bleeding Assess for circulation and bleeding. Palpate the pulse, observe the normality of the pulse, reassess breathing, and consider the possibility of a progressing shock. Press finger on the middle of the injured person's forehead until a the area of the forehead changes color. If it takes more the 2 seconds for the color to return a shock is progressing. D. Disability Conduct an Eye Assessment by following the procedure Perrla + C PE. Pupils Equal R. Round RL React to Light A Accomodation OK C Coordinated Conduct a Neurological Assessment by identifying levels of consiousness. Follow the acronym AVPU for help with this assessment. A. Alert; moves spontaneously: answers questions about name place and date correctly. V. Is verbally responsive P. Responds to Pain stimulation U. Unresponsive E. Expose and Examine Expose and examine the person for any possible injuries. Look for any tag or bracelet that contains any medical information that might be of use. If no injuries are present count pulse and respirations and establish a baseline. Continue in your attempt to contact help. Pg 495- 497
B. During which weather conditions would heat injuries most likely occur?
This usually occurs during a summer heat wave with high temperatures and high humidity AND NO BREEZE. 504
93. What is the MAIN reason that a psychiatric technician performs range of motion exercises on a client who is immobilized in bed due to a neurological impairment?
To avoid joint abnormalities from developing aka contractures. (pg.622)
105. What instructions should the PT give to an elderly client regarding promoting personal hygiene, keeping in mind the age-specific issues for skin integrity etc.
To be observant for any skin breakdown in order to quickly get it treated. Not to take hot baths which are drying to the skin. (pg.676)
145. What are the responsibilities of the P.T. Who is providing care to a client who is receiving antibiotics intravenously?
To check the rate of flow and the time for the next bag. Make sure the needle is in the vein and is not infiltrated. Check the IV site for swelling, warmth, pain, blanching, or redness, report any problems immediately (796)
136. When providing care to a client that is wearing elastic stockings, the psychiatric technician remembers that the stockings should be removed every 8 hours for which reason?
To examine the legs carefully for redness, pitting edema, or skin discoloration. (741)
32. What is approach is helpful to take when a client is irritable and cranky and puts the call light on frequently?
Try to make patient comfortable and assist him for his needs & check on them frequently.
What is the appropriate action as you reach a curb and need to lower the client from the curb when transporting a client in the wheelchair?
Turn around and back the wheelchair down rear wheels first, then return the front to the ground, and finally turn around to the original direction and proceed.
33. The psychiatric technician notices that the electric cord on a client's electric bed is frayed. Which action should be completed first?
Unplug bed*AND transfer the patient to another bed.
110. The psychiatric technician is assigned to shave the face of a male client who is immobile. What is the correct procedure to follow?
Use an electric razor with a detachable head to help prevent the spread of microorganisms. Make sure to read the instructions carefully.
41. A client is admitted to the unit with an infected wound. What is the most appropriate nursing action to take?
Use gloves and gown and use contact precautions pg. 482
95. In observing the principles of proper body mechanics, what should the psychiatric technician do to prevent injury when carrying a heavy item?
Use long, strong muscles of arms and legs. Hold the object so the line of gravity falls within the base of support, keep the back straight and the load close to the body. Ask for help, if necessary. (pg.617)
36. Which method for hand washing should be used after providing are to of a client who is infected?
Using antimicrobial soap or detergent to perform hands antisepsis
167). Which muscle site is recommended for infants and small children?
Vastus Lateralis
193. What are some instructions should also be included when teaching a client postoperative colostomy care
Walk around. Normal activity resumed within 1-3 weeks. (pg. 1465)
38. What is the correct protocol to follow for handwashing?
Wash hands before entering patient room and after providing care.
44. A client has drainage from a wound and is on "contact isolation". Which precaution would be necessary during transportation of this client to another part of the healthcare facility?
Wear PPE as needed. Make sure client wears appropriate PPE, as indicated by his/her condition. Control and contain any of client drainage. Drape wheel chair/stretcher with sheet, disinfect after use. pg.486
53. Which personal protective equipment (PPE) would be needed for a client with Tuberculosis?
When confronting a client who is diagnosed with Tuberculosis Airborne and Special Respiratory precautions are to be taken. When handling patients like these gloves, air-purifying respirator (N-95)**, and gown must be worn. The use of a portable air filter is also needed to maintain precautions. Pg. 482 - 483
54. The psychiatric technician is assigned to transporting a client with a diagnosis of tuberculosis to the X-Ray Department. a) What action should the P.T. take prior to leaving the isolation room regarding him/herself?
When leaving it is always important to remove personal protective equipment and wash hands. AND put mask on.
56. Which of the following precautions would the psychiatric technician take when providing care to a client with an infectious disease such as Hepatitis A?
When providing care to a client with an infectious disease such as Hepatitis A, contact precautions are to be taken. This requires the use of gloves, gown when handling the patient. The client's bed equipment should be cleaned and changed daily. Use disposable utensils and equipment for the client whenever possible. Pg.483
151. When catheterizing a female client, how will the psychiatric technician how that the catheter is inserted into the bladder?
When the psychiatric technician sees urine flowing from the catheter.
54. The psychiatric technician is assigned to transporting a client with a diagnosis of tuberculosis to the X-Ray Department. b) What action should the P.T. take prior to talking the client out of the isolation room?
When transporting the client it is important for the Psych Tech to wear personal protective equipment, and it is also important for the client to wear personal protective equipment as well. Any drainage coming from the client must be controlled. The wheel chair or stretcher should be covered with clean sheet and cleaned after use. Pg 483, 486
20. What are the BEST type of questions to ask when obtaining a nursing history from a client? 367
Why did you come to this facility today?; Are you allergic to any medicine? What is your level of pain now? 397
49. During the admission interview, the psychiatric technician questions the client if she has ever received BCG (vaccine against tuberculosis). What actions should be taken when the client admits receiving this vaccine?
Withhold PPD and contact MD for chest x-ray (May cause a positive skin test. source: google ANSWER, LIKE ABOVE, BUT YOU DONT ISOLATE THEM!!!
21A What is the timeline for the creation of a nursing care plan?
Within 12 to 24 hrs. 407
8 Which test is best for identifying correct placement of a newly inserted naso-gastric tube?
X-ray (PowerPoint) is the "gold standard" for a newly inserted NG tube. After that, auscultation and aspiration are used.
166). What are the three anatomical landmarks that must be identified before administering an intramuscular injection into the ventrogluteal site?
anterior superior iliac spine, the greater trochanter of the femur, and the iliac crest.
26. Which factors are considered when describe the client's level of consciousness?
ask patient simple open-ended questions: Oriented to time, place, person
45. Which PPE (Personal Protective Equipment) would the P.T. use when providing care to a client with a diagnosis of Herpes Simplex-2?
contact precautions - gloves and gown pg. 483 If multiple choice separates the two answer, always pick GLOVES, GLOVES OVER GOWN
38.A How long should the PT scrub hands?
hand washing is 15 seconds with 10 second rinse pg. 470
Sims (left Sims):
left side lying, upper knee flexed, bottom arm behind body.
149. A client is scheduled for surgery and is being informed that an indwelling Foley catheter will be inserted. How can the psychiatric technician best explain?
o Explain to the client with brief details how the procedure will be done and explain what will the catheter do. (Please describe the function of an indwelling catheter - continuously drains urine from the bladder.
155. When preparing to remove a wet-to-dry dressing to debride a wound, what is an important intervention for the psychiatric technician to implement.
o Look up the client's order and see if it is possible to pre-medicate. Look up previous nursing note and gather supplies.
156. What are some nursing interventions to be performed when a client has a Stage III decubitus skin ulcer?
o Make sure the patient does not put any more pressure on the decubitus. Clean and dry the wound and use sterile dressing. See if the client has water and protein in their diet. Document.
148. Two days following surgery to remove a client's appendix, the psychiatric technician notes that the client has abdominal distention, abdominal pain, and diminished bowel sounds. What approach would help to correct this condition?
o Moving the client from side to side, sitting up in bed, or ambulating. Contact & notify the MD for Medications can also be ordered to relieve pain or intestinal gas & to assess for complications.
154. After teaching a client how to change a dressing, the psychiatric technician much document which important information?
o Observe if the client can actually change the dressing.
150. A male client who is uncircumcised is scheduled to be catheterized. Prior to inserting the catheter, what action should the psychiatric technician take?
o Retract the foreskin and do what? Clean with soapy water, then use antiseptic (betadine)....... Replace the foreskin at the end of the procedure. Do not force the foreskin back.
152. Which principle/technique is important to follow when performing urinary catheterization?
o Sterile technique
25. When listing the valuables of a client, the psychiatric technician remarks "You have a very attractive watch." The client responds "Thank you, I've always liked the three diamonds against the yellow gold." What would be the BEST way to describe the watch?
yellow band with 3 clear white stones
76. What does admissions do prior to client arrival to unit?
•A. Enter Client info - Name, age, marital status, next of kin, Healthcare provider and insurance, make facility ID bracelet with record number and get admin docs ready •B. Purpose of Advance Directive - Clients written instruction regarding the type of healthcare desired, given in advance just the case client is unable to decide for self •C. When should A.D. be completed - When admitted, Document that client received information on Advance Directive and provide assistance if needed*** Advance directive is a LEGAL requirement
78. When should discharge planning be done?
•Begins at Admission
72. Neurological Check- Signs and Symptoms of Intracranial Pressure (ICP) increasing?
•Confusion, Disorientation, Agitation •Loss of memory •Change in vision, blurred or double vision •Extreme lethargy* (Keep waking them up or asking questions, to assess) •Numbness, Tingling or weakness in an arm or leg •Persistent, projectile vomiting* •Severe headache* •Speech problems •Seizure
81. Client scheduled to be discharged in an hour what should be in documentation?
•Health Status, direction for at home care, medication or treatment for client to follow (wound care, breathing treatment) where client is going (home or facility), nursing summary (identifying problem and care given) and appointment for post care exam with physician.
77. What responsibility when client arrives in unit?
•Make sure client has completely equipped room, a bed and that they are comfortable. •Inform them of visiting hours and orient them to the room and unit.
73. Actions when a child is having seizure?
•Place client on floor and keep airway clear by placing on the side; cushion head if possible •Protect client safety by making area clear, move chairs, table, toys •Loosen tight clothing •Do not restrain or hold down •Monitor seizure and time
80. Client wants to leave hospital against medical advice, what actions should be taken?
•Provide client with a dated release form to sign; have the signing witnessed; if client doesn't sign, refusal must be documented and sign by two witnesses; report to Team Leader.
74. Actions when a pregnant woman is choking?
•Start Heimlich Maneuver but do on chest instead of abdomen; where should the rescuer's hands be located on the sternum? SAME PLACE AS FOR DOING CPR - LOWER HALF OF THE STERNUM AWAY FOR XIPHOID PROCESS.** •Call for help •Start CPR if choking continues
82. Blood Pressure
•Systolic Blood Pressure - contraction of the heart, pressure of blood against the walls of arteries when heart beats •Systolic BP - identified by the top number of B/P reading •Diastolic Blood Pressure - pressure of the blood against the arterial walls when the heart is at rest between beats •Diastolic BP - identified by the bottom number of B/P reading
79. Prior to surgery, what does given "informed consent" imply?
•That client has had a full explanation, possible complications, alternative procedures and reasons for procedure before its signed and filled in medical record
75. Client having Heimlich Maneuver becomes unconscious what actions to take?
•What is the first action to take? Lower to the floor & open mouth & Inspect for foreign object; if visualized, then sweep with finger to remove. •Start CPR •Call for help •Then continue CPR until EMS arrive
