RNSG 1538 EXAM 3 BLUEPRINT REVIEW
You're providing an in-service to a group of new nurses who will be caring for patients who have Tetralogy of Fallot. Which statement below is INCORRECT concerning how the blood normally flows through the heart? A. Unoxygenated blood enters through the superior and inferior vena cava and travels to the left atrium. B. The pulmonic valve receives blood from the right ventricle and allows blood to flow to the lungs via the pulmonary artery. C. The left atrium allows blood to flow down through the bicuspid valve (mitral) into the left ventricle. D. Oxygenated blood leaves the left ventricle and flows up through the aortic valve and aorta to be pumped to the rest of the body.
A. Unoxygenated blood enters through the superior and inferior vena cava and travels to the left atrium.
What is the nurses best response when a parents asked about why their child is receiving PALIVIZUMAB (SYNAGIS)?
"It is a monoclonal antibody that can prevent severe RSV disease in those who are most susceptible like infants."
Which of the following responses indicates the patient understands the instructions from the physician of a PAP closure?
"The flap closure increases BLOOD FLOW to the body."
Advantages of oral contraceptives
*Regulate and shorten menstrual cycle *Decrease severe cramping and bleeding *Reduce anemia *Reduced ovarian and colorectal cancer risk *Decrease benign breast disease *Reduce risk of endometrial cancer *Improve ance *Minimize perimenopausal symptoms *Decrease incidence of rheumatoid arthritis *Improve PMS symptoms *Protect against loss of bone density
Transposition of the great vessels (TGV) nursing measures
- Administer prostaglandin to maintain the open state of the ductus arteriosus, which will allow the mixing of poorly oxygenated blood with well-oxygenated blood. -Monitor for rapid respirations and cyanosis. -Administer oxygen as needed preoperatively.
Cystic Fibrosis Treatment
- Oral capsules containing pancreatic enzymes to compensate for lack of pancreatic digestive enzymes - Various treatments to preserve as much pulmonary function as possible - Vigorous treatment of pulmonary bacterial infections - Lung transplant may eventually be required if lungs are severely damaged
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication
- deep tendon reflexes 2+
The nurse finds a postpartum patient receiving magnesium sulfate unconscious and not breathing. At which MAGNESIUM LEVEL would you start to see central nervous system (CNS) depression?
-15 mEq/L: possible respiratory depression
Hepatitis B vaccine
-1st dose is given at BIRTH -2nd dose is given at 1-2 months. -3rd dose is given at 6-18 months. *same for children and adolescents age 7-18 yrs
What Evidence-based practice should the nurse implement for antibiotic treatment in children who have UTIs?
-7 to 14 day course of antibiotics is often prescribed, though 2 TO 5 DAY COURSE may be as effective.
What are the clinical manifestations of Tetralogy of Fallot?
-A bluish coloration of the skin caused by blood low in oxygen (cyanosis) -Shortness of breath and rapid breathing, especially during feeding or exercise -Loss of consciousness (fainting) -Clubbing of fingers and toes — an abnormal, rounded shape of the nail bed -Poor weight gain -Tiring easily during play or exercise -Irritability -Prolonged crying -A heart murmur
What is an ANTIDEPRESSANT medication is prescribed for patients with ADHD?
-ATMOXETINE (strattera)
Grief: Tasks of Grieving WORDENS TASKS OF GRIEVING
-Accepting Reality of Loss -Working through the pain and grief -Adjusting to an environment that has changed because of the loss -Emotionally relocating that which has been lost and moving on with life
Ataxic classification of CP
-Affects balance and depth perception -Rare form • Poor coordination • Unsteady gait • Wide-based gait
APGAR
-Appearance (all pink, pink and blue, blue (pale) -Pulse (>100, <100, absent) -Grimace (cough, grimace, no response) -Activity (flexed, flaccid, limp) -Respirations (strong cry, weak cry, absent)
embolic stroke risk factors
-Atrial fibrillation -Left ventricular aneurysm or thrombus -Left atrial thrombus -Recent myocardial infarction - -Endocarditis -Rheumatic valve disease -Mechanical valvular prostheses - -Atrioseptal defects, -Patent foramen ovale -Primiary cardiac tumors.
Tetraology of Fallot (nursing measures)
-Avoid BP measurements and venipunctures in the affected arm after a Blalock-Taussig shunt. Pulse will not be palpable in that arm because of use of the subclavian artery for the shunt. -Monitor for ventricular arrhythmias after corrective repair.
What are some of the common surgical procedure for clients experiencing congenital heart defects like that of TETRALOGY OF FALLOT ?
-BLALOCK-TAUSSIG SHUNT: an end-to-side anatomosis (or connection with a small Gore-Tex tube) of the subclavian artery and the pulmonary arter -Waterston shunt: anastomosis of the ascending aorta and the pulmonary artery -Definitive correction involves patch closure of the ventricular septal defect and repair of the pulmonary valve and right ventricular outflow tract
Transposition of the great vessels (TGV) surgical procedures
-Balloon atrial septotomy is usually done as soon as the diagnosis is made. A balloon-tipped catheter is passed through the atrial septum to enlarge the atrial septum. -Surgical correction involves switching the arteries into their normal anatomic positions.
A nurse is assessing a child with ADHD. What is important for the nurse to consider when assessing the child?
-Break complex tasks into small steps -Ensure child's safety and that of others (stop unsafe behavior, provide close supervision) -Improved role performance (give pos feedback for meeting expectations) -secured daily routines (establish a daily schedule) -client/family education and support (listen to parent's feelings and frustrations)
What physiological changes happen with cardiovascular disease?
-CHANGE IN HEART MUSCLE ELASTICITY -decreased cardiac output -diminished ability to respond to stress -HR and SV do not increase with max demand -slower heart recovery rate -increased BP
Nursing Care and Pain Relief: Amputation
-Changing patient's position or placing a light sandbag on the residual limb to counteract the muscle spasm may improve the patient's comfort level. -Nurse acknowledges pain as real and finds effective treatment. (Opioid analgesics may be effective and beta-blockers may relieve dull, burning discomfort) (-lol meds) -Antiseizure medications control stabbing and cramping pain (-pams meds) -Tricylic antidepressants alleviate pain and help improve mood and coping ability (increase suicide) -When medications are not effective, pulsed radiofrequency therapy may be tried.
A patient that is allergic to protein in dye can't have what test done?
-Computed tomography WITH CONTRAST
An infant displays O2 saturations of 50-90%. To compensate for low blood oxygen level, the kidneys produce WHICH HORMONE to stimulate the bone marrow in order to produce more RBCs?
-ERYTHROPOIETIN
Children with CHD causing chronic cyanosis are likely to demonstrate what?
-FAILURE TO THRIVE, not obesity
A pregnant client's diabetes has been poorly controlled throughout her pregnancy. The nurse should anticipate which neonatal complication?
-Fetal Macrosomia: Fetal macrosomia (birth weight >4,000 grams) -Due to diabetes the infant may be larger than normal (macrosomia
What is the best thing to tell and older patient with constipation?
-INCREASE HYDRATION
Medical management of STATUS EPILEPTICUS includes which medications?
-IV diazepam (valium) -IV lorazepam (ativan)
Arterial Septal Defect (ASD) surgical procedure
-If small, the defect may be sutured closed. Larger defects may require a patch of pericardium or synthetic material. -Ostium secundum ASD may be repaired percutaneously via cardiac catheterization with a Gore Helex septal occluder (other brands are also available).
ventricular septal defect (VSD) surgical procedure
-If surgical closure is required, it should be performed before permanent pulmonary vascular changes develop. -Surgical closure may be in the form of suture closure of the VSD, transcatheter placement of a device in the defect, or Dacron patch closure.
A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately?
-Intervene Immediately with diminished DTR & urine output of 45 mL/hr
ACYANOTIC congenital heart defects
-Left-> right shunt -increased mixed blood flow -decreased pulmonary blood flow Include: ~Atrial-septal defect ~Ventricular-septal defect ~Patent ductus arteriosus ~Pulmonic stenosis ~Coarctation of aorta ~Aortic stenosis
Signs and symptoms of MgSO4 toxicity
-Loss of DTR -Respiratory depression -Cardiovascular collapse -CNS depression -Hypotension -Flushing -Sweating
What are some common STIMULANT medications to treat ADHD?
-METHYLPHENIDATE (ritalin) -AMPHETAMINE (adderall) -VYVANSE (lisdexamfetamine)
Arterial Septal Defect (ASD) nursing measures
-Monitor for atrial arrhythmias (lifelong) after surgical closure. -With the Gore Helex device, strenuous activity should be avoided for 2 weeks after the procedure
ventricular septal defect (VSD) nursing measures
-Monitor for ventricular dysrhythmias or AV block. -With the clamshell occluding or Amplatzer device, strenuous activity should be avoided for 1 month after the procedure. -PALPATE FOR THRILL
Indomethacin (Indocin)
-NSAID. -Inhibit prostaglandin synthesis resulting in decreased inflammatory responses. -Uses: provide rapid, symptomatic relief of inflammation and pain and to close PDA. -Precautions/Interactions: hypersensitivity to aspirin or other NSAIDs, may increase the risk of MI and stroke.
Newborn Nutrition: Feeding Guidelines; Health promotion and Maintenance
-Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, explain to parents that a newborn will need 2 to 4 oz to feel satisfied at each feeding. Until about age 4 months, most bottle-fed infants need six feedings a day. -Caloric intake- 110-120 cal/kg body weight -Formula contains 20 calories per ounce -Formulas classified based on 3 parameters: Caloric density, Carbs and Saturated fats and Protein Count -Fluid requirements- 100-150ml/kg daily -Recommend bottle feeds be given supplements (Iron)
A nurse reviews the history of a man with erectile dysfunction before teaching him about the use of tadalafil (Cialis). Which of the following medications would be contraindicated with the use of tadalafil (Cialis)?
-Nitroglycerin (nitro - dur) -Do not take if you are taking nitrate medications such as nitroglycerin (e.g., Nitro-Bid) or isosorbide mononitrate (e.g., Imdur).
Infant with bacterial meningitis may exhibit signs of...?
-Opisthotonos position (backward bending, assumed with nervous system complications) -neck pain (in older children) -bulging fontanel (often a late sign) -infant may be consolable when lying still
What is the increase in RBCs called and how does this affect the workload of the heart?
-POLYCYTHEMIA: this can lead to an INCREASE IN BLOOD VOLUME and possibly blood viscosity, thus increasing the workload of the heart. -disorders within this classifications include TETRAOLOGY OF FALLOT and TRICUSPID ATRESIA
When assessing a neonate Which heart defect at 30 weeks has s/s of bounding pulse, tachypnea, tachycardia and crackles, thrill?
-Patent Ductus arteriosus
Types of Grief
-Physiologic—amputation, mastectomy, hysterectomy, loss of mobility -Safety loss—loss of safe environment (domestic violence, child abuse, public violence) -Loss of security and sense of belonging—loss of loved one affects the need to love and feeling of being loved -Loss of self-esteem—any changed in how a person is valued at work or in relationships or by himself can threaten self-esteem -Loss related to self-actualization—external or internal crisis that blocks or inhibits striving toward fulfillment
What are the clinical manifestations of Ventricular Septal Defect (VSD)?
-Poor eating, failure to thrive -Fast breathing or breathlessness -Easy tiring
What are the common laboratory and diagnostic studies ordered for the assessment of RSV bronchiolitis?
-Pulse oximetry: oxygen saturation might be decreased significantly -Chest x-ray: might reveal hyperinflation and patchy areas of atelectasis or infiltration -Blood gases: might show carbon dioxide retention and hypoxemia -Nasal-pharyngeal washings: positive identification of RSV can be made via enzyme-linked immunosorbent assay (ELISA) or immunofluorescent antibody (IFA) testing
CYANOTIC heart disease
-RIGHT to LEFT shunts Increased lung markings 1-Truncus arteriosis 2-Transposition of the great arteries 5-Total anomalous venous return Decreased lung markings 3-Tricuspid atresia / pulmonary atresia 4-Tetrology of Fallot
Tasks of Grieving and Outcomes of Effective Grieving: RANDO'S SIX Rs inherent to grieving
-Recognize—experiencing the loss, and understanding that it is real -React—emotional response to loss -Recollect and re-experience—memories are reviewed and relived -Relinquish—accepting the world has changed and there is no turning back -Readjust—beginning to return to daily life, loss is less overwhelming -Reinvest—accepting changes have occurred, reenter world and form new relationships.
Autism Spectrum Disorders: Medical Management Approaches
-Reduce behavioral symptoms (stereotype behavior) -Pharm Treatment (antipsychotic such as Haldol and Risperdal) -Helps with temper tantrums, aggression, self-injury, hyperactivity -Others (Naltrexone- Ravia), clomipramine (Anafranil), Clonidine (Catapres)
What is a priority for the nurse when caring for a patient with ADHD?
-SAFETY IS ALWAYS THE PRIORITY -provide environment as free of distractions as possible -provide pos feed back for completion of each step -allow breaks
Older adults rely on WHAT for comfort during stressful times?
-SPIRITUAL BELIEFS
Tricyclic antidepressants can cause what?
-Serious risk for suicide by overdose (tricyclic antidepressants can require 4 to 6 weeks before the client experiences optimal therapeutic benefit)
What are the clinical manifestations of Atrial Septal Defect (ASD)?
-Shortness of breath, especially when exercising -Fatigue -Swelling of legs, feet or abdomen -Heart palpitations or skipped beats -Stroke -Heart murmur, a WHOOSHING SOUND that can be heard through a stethoscope
A nurse is preparing a presentation for a local health fair about meningitis and has developed a display that lists the following causes: Streptococcus group B Haemophilus influenzae type B Streptococcus pneumoniae Neisseria meningitidis Which of these would the nurse highlight as the most common cause of meningitis in newborns?
-Streptococcus group B
Mild systemic reaction Anaphylaxis
-Symptoms within 2 hours of exposure -Nasal congestion -Swelling around eyes -Itching of eyes -Tearing -Sneezing -fullness in the moth and throat -PERIPHERAL TINGLING AND A SENSATION OF WARMTH
What behavior would cause a concern to the nurse when the neonate is feeding?
-The 3 "Cs" (coughing, chocking, and cyanosis)
Tetraology of Fallot
-Think DROP(child drops to floor or squats) -narrowing of the pulmonary artery -Defect, septal -Right Ventricular hypertrophy (THICKENING) -Overriding aorta -Pulmonary stenosis -RIGHT TO LEFT SHUNT -CYANOTIC CONGENITAL HEART DEFECT
Arterial Septal Defect (ASD)
-a congenital condition characterized by a failure of the foramen ovale to close at birth, producing an opening in the septum that separates the right and left atria -ACYANOTIC -LEFT to RIGHT shunt
spina bifida
-a congenital defect that occurs during early pregnancy when the spinal canal fails to close completely around the spinal cord to protect it -HIGH RISK FOR DEVELOPING LATEX ALLERGY
macrocephaly
-abnormally large head -head circumference more than 90% of normal
Principles/purpose of immunizations
-activation -active immunity -immunity lasting years to a lifetime
Successful psychosocial aging is reflected in ability of older people to....?
-adapt to physical loss -social loss -emotional loss -to achieve life satisfaction
Ventricular Septal Defect assessment findings
-auscultate the heart, noting a characteristic HOLOSYTOLIC HARSH MURMUR ALONG THE LEFT STERNAL BORDER
Positive Kernigs and Brudzinski sign in what disease? What are they?
-bacterial meningitis -thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (Kerning's) -passive flexion of the neck spontaneous flexion of knees and hips. (Brudzinski)
A 28 week primigravida with pregnancy induced hypertension is being visited by the home health nurse. The nurse has noted a decrease in urination, abdominal discomfort, and a severe persistent headache. What should the nurse have the client do?
-call the Obstetrician
Normal signs of aging include? Select all that apply.
-decrease in the sense of smell -decrease in muscle mass -decline of sexual desire -decrease of sebaceous and sweat gland
A cerebellar tumor is know to have what clinical manifestations?
-dizziness -ataxic or staggering gait with a tendency to fall toward the side of the lesion -marked muscle incoordination
What are common side effects of SINEMET?
-dyskinesia -neuroleptic malignant syndrome (severe rigidity, stupor, and hyperthermia
Signs and symptoms of otitis media
-fever, pain; infant may PULL AT EAR -enlarged lymph nodes -discharge from ear (if drum is ruptured) -upper respiratory symptoms -vomiting, diarrhea -FUSSINESS/IRRITABILITY -LETHARGY
What are the clinical manifestations for Autism Spectrum Disorder? Select all that apply.
-few facial expressions -avoids eyes contact -repeats words or phases over and over
Moderate Systemic Anaphylaxis
-flushing, warmth, anixety, itching,and symptoms of mild anaphylaxs -Happens within first 2 hours after exposure -more serious reactions include: bronchospasm and edema of the airways or larynx w/ dyspnea, cough, and wheezing.
What types of chest physiotherapy is used for older children and adolescents?
-flutter-valve device -Positive expiratory pressure therapy -high frequency chest compression vest
Fat embolism syndrome
-frequently form in fractures of long bones or pelvic bones -Most often occur in adults younger than 40 and men. -More common in patients with multiple fractures -Classic triad of symptoms include: hypoxemia, neurologic compromise, and a petechial rash.
congenital heart defects teachings
-give medications, if ordered, exactly as perscribed -weigh the child at least once a week or as ordered, same time of day w/same amount of clothes -allow the child to engage in activity as directed. Provide time for the child to rest frequently to avoid overexertion -notify physician or NP if child has increased episodes of respiratory distress, cyanosis, or difficulty breathing; fever; increased edema of the hands, feet, or face; decreased urinary output; weight loss or difficulty eating or drinking; increased fatigue; decreased LOA; vomiting or diarrhea
modifiable risk factors of embolic stroke
-hypertension -Atrial fibrillation -dyslipidemia -diabetes (associated with accelerated atherogenesis) -smoking -obesity -sedentary lifestyle -sleep apnea -excessive alcohol consumption -periodontal disease
What nursing interventions should be implemented for a child client having a seizure?
-if child is standing or sitting, ease child to ground -Keep head safe -Monitor time, duration, and activity during seizure -Give oxygen -place child on one side and open airway if possible -remove hazards in the area -remove tight clothing and jewelry around the neck if possible
Nursing interventions for Parkinson's Disease
-improve mobility (daily exercise and stretching) -enhancing self-fare activities (encourage/support patients during ADLs) -Improving bowel eliminations (INCREASE FLUIDS, foods with fiber, follow regular time pattern) -improving nutrition (supplemental feedings, increase calorie intake) -enhancing swallowing (sit up-right during meals) -encouraging the use of assistive devices -support coping abilities -promote home and community-based care (educate about self care)
Why would the nurse administer DIAZEPAM rectally to a child?
-in order to stop prolonged seizures.
What are some adverse effects of AMPHETAMINE (adderall) ?
-insomnia -hallucinations -weight loss
How and when is Palivizumab administered?
-it is given intramuscular once a month throughout the RSV season.
What are important teachings the nurse should educate a client approaching menopause?
-living a HEALTHY LIFESTYLE -menopause is a normal period in a woman's life -nutritious diet and weight control will enhance physical and emotional well-being -exercise for at least 30 min, 3-4 times a week -fatigue and stress worsen hot flashes
nursing management of ischemic stroke
-maintain adequate blood pressure -avoid hypotension to prevent cerebral ischemia and thrombosis -difficulty in swallowing, hoarseness, or other signs of cranial nerve dysfunction must be assessed -focus assessment of cranial nerves VII (facial), X (vagus), XI (spinal accessory), XII (hypoglossal)
What alterations in LOC would the nurse expect in a patient after having hemorrhagic stroke?
-mild drowsiness -slight slurring of speech -sluggish papillary reaction
Therapeutic management of Cystic Fibrosis
-minimizing pulmonary complications -maximizing lung function -preventing infections -facilitating growth
What are the clinical manifestations of PDA?
-murmur (machine hum) -wide pulse pressure -bounding pulses -asymptomatic (possible) -heart failure -tachycardia -low diastolic BP -tachypnea -rales upon auscultation
coarctation of the aorta (CoA)
-narrowing of the descending portion of the aorta, resulting in a limited flow of blood to the lower part of the body -left sided heart failure -ACYANOTIC -LEFT to RIGHT shunt
What are the warning signs of autism? Select all that apply.
-not babbling by 12 months -not point or using gestures by 12 months -no single words by 16 months -no two-word utterances by 24 months. -loosing language or social skills at ANY AGE
Risk for an unfavorable outcome of meningitis include...
-older age -heart rate greater than 120 bpm -low GCS score -cranial nerve palsies -positive gram stain
What medication is prescribed to client's with CF?
-pancreatic enzymes and supplemental fat-soluble vitamins are prescribed to promote adequate digestion and absorption of nutrients and optimize nutritional status
Personality disorder Characteristic
-personality traits become inflexible and maladaptive -impairment of personality -have identity problems (ex. egocentrism/being self-centered) -gaining power or pleasure at expense of others -motivated by personal gratification -relationships are dysfunctional (deceit, coercion, or intimidation) -lack the capacity for empathy, remorse, or concern
Meningitis symptoms
-preceding respiratory illness or sore throat -presence of fever, chills -headache -vomiting -photophobia -stiff neck -rash -irritability -drowsiness -lethargy -muscle rigidity -seizures
A 2-day old neonate is 30 min post-op of a surgical correction for CHD. Which finding would you report to the physician?
-pulse rate of 90
Personality disorder Treatment Challenges
-realistic outcome -mental illness do not seek care and in fact avoid treatment -narcissistic PD can present challenge to the nurse. Nurse should avoid anger and frustration The client will demonstrate nondestructive ways to express feelings and frustration. The client will identify ways to meet his or her own needs that do not infringe on the rights of others The client will achieve or maintain satisfactory role performance (e.g., at work or as a parent).
What are some practices that older patients should include to promote gastrointestinal health?
-regular tooth brushing and flossing -receiving regular dental care -eating small frequent meals -avoid heavy activity after eating -eating a high-fiber, low-fat diet -DRINKING ENOUGH FLUIDS -avoiding the use of laxative and antacids
What adverse effects can be expected when taking ATMOXETINE (strattera)?
-seizures -may cause liver injury -jaundice -upper abdominal tenderness -dark urine -increased live enzymes
Clinical manifestations of Transposition of the great vessels (TGV)?
-significant CYANOSIS WITHOUT a murmur in the newborn period is highly indicative of TGV. -If heart failure is present, note edema, tachypnea, and adventitious lung sounds. -auscultate the heart, noting a loud second heart sound. A murmur may be heard if the ductus remains open or a septal defect is present.
Compartment syndrome
-sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention is not taken. -Deep, throbbing, unrelenting pain, which continues to increase despite administration of opioids and seems out of proportion to the injury. -HALLMARK SIGN: Pain that occurs or intensifies with passive ROM -Maintain extremity AT HEART LEVEL (NOT ABOVE), and open and bivalve the case or opening splint.
What test confirms the diagnoses of CF?
-sweat chloride test
What are some contraindications for thrombolytic therapy?
-symptom onset greater than 3 hours before admission -patient who is anticoagulated (INR above 1.7) -patient who has recently had any type of intracranial pathology (previous stroke, head injury, trauma)
When is it necessary to call EMS for a child having a seizure?
-the child stops breathing -any injury has occurred -seizure last for MORE THAN 5 min -child's first seizure -child is unresponsive to painful stimuli after seizure
If a client is found to have a RSV they are put into isolation. What criteria is needed in order to come out of isolation?
-two negative test
Methylphendiate (Ritalin) is associated with what common adverse effects?
-weight loss -bone marrow suppression -cardiac arrhythmias -anorexia -can result in slowed or absent growth -insomnia
20 Intracranial Regulation: Brain Tumor. Gerontological Considerations.
...The most frequent tumor types in the older adult are anaplastic astrocytoma, glioblastoma, and cerebral metastases from other sites. The incidence of primary brain tumors and the likelihood of malignancy increase with age. Intracranial tumors can produce personality changes, confusion, speech dysfunction, or disturbances of gait. In older adult patients, early signs and symptoms of intracranial tumors can be easily overlooked or incorrectly attributed to cognitive and neurologic changes associated with normal aging. Neurologic signs and symptoms in the older adult must be carefully evaluated, because brain metastases occur in patients with a history of prior cancer. Researchers are investigating patterns of care and clinical outcomes of older adult patients with primary brain tumors
Nursing interventions for appendicitis continued
1. Monitor vital signs for elevated temperature, increased pulse rate, hypotension, and shallow/rapid respirations; assess abdomen for presence of rigidity, distention, and decreased or absent bowel sounds. Report significant findings to health care provider. 1. Any of these indicators can occur with rupture. 2. Assess and document quality, location, and duration of pain; presence of nausea; and patient's positioning. Devise a pain scale with patient, rating discomfort from 0 (no pain) to 10 (worst pain). 2. Signs of worsening appendicitis that can lead to rupture include pain that becomes accentuated; recurrent vomiting; and patient assuming a side-lying or supine position with flexed knees. Pain that worsens and then disappears is a signal that rupture may have occurred. 3. Monitor for ambulation with a limp or pain with hip extension. 3. Retrocecal abscess may irritate the psoas muscle as it traverses the area of posterior RLQ of the abdomen and results in pain with hip extension. 4. Caution patient about the danger of preoperative self-treatment with enemas and laxatives. 4. Enemas and laxatives increase peristalsis, which increases risk of perforation and hence peritonitis and sepsis. Enemas should be avoided until approved by health care provider (usually several weeks after surgery). If constipation occurs postoperatively, health care provider may prescribe laxatives/stool softeners at bedtime after the third day. 5. Teach postoperative incisional care, as well as care of drains if patient is to be discharged with them. 5. Maintaining a clean incision and avoiding contamination of drains help prevent infection in areas in which the skin is no longer intact. 6. Provide instructions for prescribed antibiotics if patient is to be discharged with them 6. Antibiotics prevent or treat systemic infection from a ruptured appendix. 7. Medicate with antiemetics, sedatives, and analgesics as prescribed; evaluate and document patient's response, using the pain scale. 7. These agents reduce nausea and pain. Opioids are avoided until diagnosis is certain because they mask clinical signs and symptoms. 8. Encourage patient to request medication before symptoms become severe. 8. Prolonged stimulation of pain receptors results in increased sensitivity to painful stimuli and will increase the amount of drug required to relieve the discomfort. 9. Keep patient nothing by mouth (NPO) before surgery. 9. Being NPO helps prevent aspiration during anesthesia when gag reflex is compromised. After surgery, nausea and vomiting usually disappear. 10. If prescribed, insert gastric tube. 10. A gastric tube enables decompression in preoperative patients with severe nausea and vomiting. 11. Teach technique for slow, diaphragmatic breathing. 11. This technique reduces stress and helps promote comfort by relaxing tense muscles. 12. Help position patient for optimal comfort 12. Many patients find comfort from a side-lying position with knees bent, whereas others find relief when supine with pillows under knees (avoiding pressure on popliteal area).
Athetoid or Dyskinetic Cerebral Palsy
10 - 20% of all CP -lesion in the basal ganglia -uncontrolled slow writhing movements affecting hands, feet, arms, or legs and sometimes mm. of the face. -Full ROM with difficulty in mid-range -movements may increase during periods of stress and disappear during sleep -Issues with coordinated m. movement needed for speech.
Grade I fracture
A fracture that has a clean wound of less than 1 centimeter.
Grade II fracture
A fracture that has a wound larger than 1 centimeter without extensive soft tissue damage.
Grade III fracture
A highly contaminated fracture with extensive soft tissue damage.
what is hypotensive syndrome?
A hypotensive syndrome often characterized by sweating, nausea, and tachycardia. It occurs in some pregnant women in the supine position when the pregnant uterus obstructs the inferior vena cava reducing venous return and decreasing cardiac output and B/P
The mother of a child diagnosed with attention-deficit syndrome receives a prescription for a central nervous system (CNS) stimulant to treat her child. The mother asks the nurse, "I don't understand why we're giving a stimulant to calm him down?" What is the nurse's best response to this mother? A) "It helps the reticular activating system (RAS), a part of the brain, to be more selective in response to incoming stimuli." B) "It helps energize the child so they use up all of their available energy and then they can focus on quieter stimuli." C) "No one truly understands why it works but it has been demonstrated to be very effective in treating ADHD." D) "The drugs work really well and you will see a tremendous change in your child within a few weeks without any other treatment."
A) "It helps the reticular activating system (RAS), a part of the brain, to be more selective in response to incoming stimuli."
Friends of a teenage male recently killed in a car accident are discussing their sense of loss. Which of the following comments best indicates that the friends are trying to make sense of the loss cognitively? A) "Why did he have to die so young?" B) "He shouldn't have been driving so recklessly." C) "If we had only stayed longer, he would not have been on that road." D) "It took the ambulance too long to get there."
A) "Why did he have to die so young?"
Which individual is at highest risk for committing suicide? A) A 71-year-old male, alcohol user, independent minded B) A 16-year-old female, diabetic, two best friends C) A 47-year-old male, schizophrenic, unemployed D) A 57-year-old female, depression, active in church
A) A 71-year-old male, alcohol user, independent minded
When educating the parents of a cyanotic infant diagnosed with of tetralogy of Fallot, the nurse will include which of the following statements related to the physiological abnormalities? The infant has: Select all that apply. A) A hole in the ventricular septal B) A small, narrow pulmonary outflow channel C) A large, thick, right ventricular wall D) A very small, narrow aorta E) The pulmonary artery arises from the left ventricle
A) A hole in the ventricular septal B) A small, narrowing pulmonary outflow channel C) A large, thick, right ventricular wall
The surgical nurse is admitting a patient from postanesthetic recovery following the patient's below-the-knee amputation. The nurse recognizes the patient's high risk for postoperative hemorrhage and should keep which of the following at the bedside? A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate
A) A tourniquet
Which of the following are critical components in assessment of a person's grief? Select all that apply. A) Adequate perception regarding the loss B) Adequate time to experience the loss C) Adequate support while grieving for the loss D) Adequate opportunities to say goodbye to the person E) Adequate coping behaviors during the process
A) Adequate perception regarding the loss C) Adequate support while grieving for the loss E) Adequate coping behaviors during the process
A woman comes to the clinic because she has been unable to conceive. When reviewing the woman's history, which of the following would the nurse LEAST LIKELY identify as a possible risk factor? A) Age of 25 years B) History of smoking C) Diabetes since age 15 years D) Weight below standard for height and age
A) Age of 25 years
A 15-year-old female is admitted for treatment of anorexia nervosa. Which is characteristic of anorexia nervosa? A) Body weight less than normal for age, height, and overall physical health B) Amenorrhea for at least two cycles C) Absence of hunger feelings D) Erosion of dental enamel
A) Body weight less than normal for age, height, and overall physical health
The nurse is assisting a child with ADHD to complete his ADLs. Which is the best approach for the nurse to use with this child? A) Break tasks into small steps. B) Let the child complete tasks at his own pace. C) Offer rewards when all tasks are completed. D) Set a time limit to complete all tasks.
A) Break tasks into small steps.
After teaching a group of nursing students about variations in newborn head size and appearance, the instructor determines that the teaching was successful when the students identify which of the following as a normal variation? (Select all that apply.) A) Cephalohematoma B) Molding C) Closed fontanels D) Caput succedaneum E) Posterior fontanel diameter 1.5 cm
A) Cephalohematoma B) Molding D) Caput succedaneum
A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which of the following? Select all answers that apply. A) Complaints of stiff neck B) Photophobia C) Absent headache D) Negative Brudzinski sign E) Vomiting
A) Complaints of stiff neck B) photophobia E) Vomiting
The nurse is educating a client and family about managing panic attacks after discharge from treatment. The nurse includes which of the following in the discharge teaching? Select all that apply. A) Continued development of positive coping skills B) Weaning off of medications as necessary C) Lessening the amount of daily responsibilities D) Continued practice of relaxation techniques E) Development of a regular exercise program
A) Continued development of positive coping skills D) Continued practice of relaxation techniques E) Development of a regular exercise program
The nurse is leading a workshop on sexual health for men. The nurse should teach participants that organic causes of erectile dysfunction include what? Select all that apply. A) Diabetes B) Testosterone deficiency C) Anxiety D) Depression E) Parkinsonism
A) Diabetes B) Testosterone deficiency E) Parkinsonsim
A client's recent diagnosis of Parkinson disease has prompted his care provider to promptly begin pharmacologic therapy. The drugs that are selected will likely influence the client's levels of: A) Dopamine B) Acetylcholine C) Serotonin D) Adenosine
A) Dopamine
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day
A) Encouraging the patient to turn from side to side and to assume a prone position -The nurse encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip.
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of ≥ 180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months
A) Evidence of hemorrhagic stroke
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting
A) Facial droop
The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patient's tumor, the nurse should implement measures to prevent what complication? A) Falls B) Audio hallucinations C) Respiratory depression D) Labile BP
A) Falls
A gerontologic nurse practitioner provides primary care for a large number of older adults who are living with various forms of cardiovascular disease. This nurse is well aware that heart disease is the leading cause of death in the aged. What is an age-related physiological change that contributes to this trend? A) Heart muscle and arteries lose their elasticity. B) Systolic blood pressure decreases. C) Resting heart rate decreases with age. D) Atrial-septal defects develop with age.
A) Heart muscle and arteries lose their elasticity. (This results in REDUCED STROKE VOLUME)
The nurse is working with a client who lost her youngest child 2 months ago. When the nurse approaches, the client, the client yells, "I don't want to talk to you. You have no idea what it's like to lose a child!" The nurse bases her response to the client on the understanding of which of the following? A) Hostility is a common behavioral response to grief. B) It is too soon after the loss to empathize with the client. C) Personality traits such as aggressiveness are exaggerated during the grief process. D) The nurse may have nonverbally indicated a judgmental attitude toward the client.
A) Hostility is a common behavioral response to grief.
Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birth weight? D) Is acrocyanosis present?
A) How many hours old is this newborn?
A child with attention deficit hyperactivity disorder is taking methylphenidate (Ritalin) in divided doses. If the child takes the first dose at 8 AM, which behavior might the school nurse expect to see at noon? A) Increased impulsivity or hyperactive behavior B) Lack of appetite for lunch C) Sleepiness or drowsiness D) Social isolation from peers
A) Increased impulsivity or hyperactive behavior
A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? A) Loss of hearing, tinnitus, and vertigo B) Loss of vision, change in mental status, and hyperthermia C) Loss of hearing, increased sodium retention, and hypertension D) Loss of vision, headache, and tachycardia
A) Loss of hearing, tinnitus, and vertigo
An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness
A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes E) Muscle weakness
The physician has ordered rectal diazepam (Valium) for a 2-year-old boy with status epilepticus. Which of the following instructions is essential for the nurse to teach the parents? A) Monitor their child's level of sedation. B) Watch for fever indicating infection. C) Gradually reduce the dosage as seizures stop. D) Monitor for an allergic reaction to the medication.
A) Monitor their child's level of sedation.
The nurse in a community clinic is caring for a 6-month-old boy and his mother. Which of the following is the priority intervention to promote adequate growth? A) Monitoring the child's weight and height B) Encouraging a more frequent feeding schedule C) Assessing the child's current feeding pattern D) Recommending higher-calorie solid foods
A) Monitoring the child's weight and height
After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension? A) Mother had gestational hypertension during pregnancy. B) Client has a twin sister. C) Sister-in-law had gestational hypertension. D) This is the client's second pregnancy
A) Mother had gestational hypertension during pregnancy.
An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department and her arm placed in a cast. At 11 p.m. her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority? A) Notifying the doctor immediately B) Applying ice C) Elevating the arm D) Giving additional pain medication as ordered
A) Notifying the doctor immediately
All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client? A) Observe for signs of fear or agitation B) Maintain reality through frequent contact C) Encourage to participate in the treatment milieu D) Assess community support systems
A) Observe for signs of fear or agitation
The nurse is working with a patient who expects to begin menopause in the next few years. What educational topic should the nurse prioritize when caring for a healthy woman approaching menopause? A) Patient teaching and counseling regarding healthy lifestyles B) Referrals to local support groups C) Nutritional counseling regarding osteoporosis prevention D) Drug therapy options
A) Patient teaching and counseling regarding healthy lifestyles
In a client's seventh month of pregnancy, she reports feeling "dizzy, like I'm going to pass out, when I lie down flat on my back." The nurse integrates which of the following in to the explanation? A) Pressure of the gravid uterus on the vena cava B) A 50% increase in blood volume C) Physiologic anemia due to hemoglobin decrease D) Pressure of the presenting fetal part on the diaphragm
A) Pressure of the gravid uterus on the vena cava
A nurse is preparing a class for a group of women at a family planning clinic about contraceptives. When describing the health benefits of oral contraceptives, which of the following would the nurse most likely include? (Select all that apply.) A) Protection against pelvic inflammatory disease B) Reduced risk for endometrial cancer C) Decreased risk for depression D) Reduced risk for migraine headaches E) Improvement in acne
A) Protection against pelvic inflammatory disease B) Reduced risk for endometrial cancer E) Improvement in acne
When a client is experiencing a panic attack while in the recreation room, what interventions are the nurse's first priorities? Select all that apply. A) Provide a safe environment. B) Request a prescription for an antianxiety agent. C) Offer the client therapy to calm down D) Ensure the client's privacy. E) Engage the client in recreational activities.
A) Provide a safe environment. D) Ensure the client's privacy
A client with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, "This person is my guide and tells me what I must do every day." The nurse would best describe this type of thinking as which of the following? A) Referential delusion B) Grandiose delusion C) Thought insertion D) Personalization
A) Referential delusion
A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply. A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions D) Use of corticosteroids as ordered E) Weight-bearing exercise
A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions E) Weight-bearing exercise
A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius? A) Risk for Infection B) Risk for Ineffective Role Performance C) Risk for Perioperative Positioning Injury D) Risk for Powerlessness
A) Risk for Infection
Of the following personality disorders, which are most likely related to lack of caring about others? Select all that apply. A) Schizotypal personality disorder B) Borderline personality disorder C) Antisocial personality disorder D) Narcissistic personality disorder E) Obsessive-compulsive personality disorder
A) Schizotypal personality disorder C) Antisocial personality disorder D) Narcissistic personality disorder
A generalized seizure is characterized by: A. Severe twitching of all the body's muscles B. A core body temp of greater than 103 degrees C. A blank stare and brief lapse of consciousness D. Unconsciousness for greater than 30 minutes
A) Severe twitching of all the body's muscles
The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which of the following findings would the nurse most likely expect to assess if the child had transposition of the great vessels? A) Significant cyanosis without presence of a murmur B) Abrupt cessation of chest output with an increase in heart rate/filling pressure C) Soft systolic ejection D) Holosystolic murmur
A) Significant cyanosis without presence of a murmur.
When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely? A) Skeletal traction B) Physical therapy C) Orthotics D) Occupational therapy
A) Skeletal traction
A family brings their father to his primary care physician for a checkup. Since their last visit, they note their dad has developed a tremor in his hands and feet. He also rolls his fingers like he has a marble in his hand. The primary physician suspects the onset of Parkinson disease when he notes which of the following abnormalities in the client's gait? A) Slow to start walking and has difficulty when asked to "stop" suddenly B) Difficulty putting weight on soles of feet and tends to walk on tiptoes C) Hyperactive leg motions like he just can't stand still D) Takes large, exaggerated strides and swings arms/hands wildly
A) Slow to start walking and has difficulty when asked to "stop" suddenly
Which are important in the limit-setting technique to deal with manipulative behavior? Select all that apply. A) Stating the behavioral limit B) Identifying the consequences if the limit is exceeded C) Identifying the expected or desired behavior D) Providing choices E) Allowing flexibility
A) Stating the behavioral limit B) Identifying the consequences if the limit is exceeded C) Identifying the expected desired behavior
A nurse is reviewing the diagnostic findings of a preschool age child who is suspected of having CF. Which of the following findings should the nurse identify as an indication of CF? A) Sweat chloride content 85 mEq/L B) Increased serum levels of fat-soluble vitamins C) 72 hr stool analysis sample indicating hard, packed stools D) Chest x-ray negative for atelectasis
A) Sweat chloride content 85 mEq/L
The nurse is assessing a 16-month-old child during a well-baby checkup. Which of the following behaviors would be consistent with autism spectrum disorder? Select all that apply. A) The child displays little eye contact with others. B) The child thrives on changes in routine. C) The child makes few facial expressions toward others. D) The child does not like repetition. E) The child answers questions verbally.
A) The child displays little eye contact with others. C) The child makes few facial expressions toward others. D) The child does not like repetition.
The nurse is establishing outcomes for a grieving client. Which of the following is an appropriate outcome? A) The client will develop a plan for coping with the loss. B) The client will demonstrate self-reliance during the grief process. C) The client will suppress emotions related to the loss. D) The client will verbalize that loss will not adversely affect the quality of life.
A) The client will develop a plan for coping with the loss.
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? A) The effects of brain tumors are often attributed to the cognitive effects of aging. B) Brain tumors in older adults do not normally produce focal effects. C) Older adults typically have numerous benign brain tumors by the eighth decade of life. D) Brain tumors cannot normally be treated in patient over age 75.
A) The effects of brain tumors are often attributed to the cognitive effects of aging.
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this patient? A) The patient should be approached on the side where visual perception is intact. B) Attention to the affected side should be minimized in order to decrease anxiety. C) The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D) The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.
A) The patient should be approached on the side where visual perception is intact.
A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A) The patient should mobilize as soon as she is physically able. B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C) The patient should remain on bed rest until she expresses a desire to mobilize. D) Lack of mobility will greatly increase the patient's risk of stroke recurrence.
A) The patient should mobilize as soon as she is physically able.
A rehabilitation nurse is working with a patient who has had a below-the-knee amputation. The nurse knows the importance of the patient's active participation in selfcare. In order to determine the patient's ability to be an active participant in self-care, the nurse should prioritize assessment of what variable? A) The patient's attitude B) The patient's learning style C) The patient's nutritional status D) The patient's presurgical level of function
A) The patient's attitude
A nurse is admitting a child who has cystic fibrosis. Which of the following medications should the nurse anticipate including in the plan of care? Select all that apply. A) Tobramycin B) Loperamide C) Fat-soluble vitamins D) Albuterol E) Dornase alfa
A) Tobramycin C) Fat-soluble vitamins D) Albuterol E) Dornase alfa
A child was diagnosed with attention-deficit hyperactivity disorder and methylphenidate was prescribed for treatment to be taken once a day in a sustained release form. On future visits what is a priority nursing assessment for this child? A) Weight and height B) Breath sounds and respiratory rate C) Urine output and kidney function D) Electrocardiogram (ECG) and echocardiogram
A) Weight and height
Which of the following statements about the assessment of persons with anxiety and anxiety disorders is most accurate? A) When an elder person has an onset of anxiety for the first time in his or her life, it is possible that the anxiety is associated with another condition. B) Panic attacks are the most common late-life anxiety disorders. C) An elder person with anxiety may be experiencing ruminative thoughts. D) Agoraphobia that occurs in late life may be related to trauma experienced or anticipated.
A) When an elder person has an onset of anxiety for the first time in his or her life, it is possible that the anxiety is associated with another condition.
An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A) Anaphylactic (type 1) B) Cytotoxic (type II) C) Immune complex (type III) D) Delayed-type (type IV)
A) anaphylactic (type 1)
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A) Cardiac and respiratory status B) Seizure activity C) Pain D) Fluid and electrolyte balance
A) cardiac and respiratory status
A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values? A) Increased eosinophils B) Increased neutrophils C) Increased serum albumin D) Decreased blood glucose
A) increased eosinophils
The nurse is caring for a 5-year-old child with a congenital heart anomaly causing chronic cyanosis. When performing the history and physical examination, what is the nurse least likely to assess? A) obesity from overeating B) clubbing of the nail beds C) squatting during play activities D) exercise intolerance
A) obesity from overeating.
The nurse is planning the type of approach that will be most effective in developing a therapeutic relationship with the client. The nurse should use a matter-of-fact approach with clients with which types of personality disorders? Select all that apply. A) Paranoid B) Antisocial C) Schizotypal D) Narcissistic E) Avoidant
A) paranoid B) Antisocial D) Narcissistic
Which disorder is characterized by pervasive mistrust and suspiciousness of others? A) Paranoid personality disorder B) Schizoid personality disorder C) Histrionic personality disorder D) Dependent personality disorder
A) paranoid personality disorder
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patient's safety? A) Place the patient in a side-lying position. B) Pad the patient's bed rails. C) Administer antianxiety medications as ordered. D) Reassure the patient and family members.
A) place the patient in a side-lying position
The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases. B) Have the patient speak to loved ones on the phone daily. C) Help the patient complete his or her sentences. D) Speak in a loud and deliberate voice to the patient.
A) provide a board of commonly used needs and phrases.
A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called A) systematic desensitization. B) flooding. C) cognitive restructuring. D) exposure therapy.
A) systematic desensitization : One behavioral therapy often used to treat phobias is systematic (serial) desensitization, in which the therapist progressively exposes the client to the threatening object in a safe setting until the client's anxiety decreases. Flooding is a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety. Cognitive restructuring involves challenging the client's irrational beliefs. Exposure therapy is similar to flooding.
A family member, who is caring for a 2-year-old with Tetralogy of Fallot, asks you why the child will periodically squat when playing with other children. Your response is: A. "Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." B. "Squatting helps to decrease systemic vascular resistance, which will decrease the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels." C. "Squatting helps to decrease systemic vascular resistance, which will increase the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." D. "Squatting helps to normalize systemic vascular resistance, which will increase the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels."
A. "Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels."
As the nurse you know which statements are TRUE about Tetralogy of Fallot? Select all that apply: A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." C. "Tetralogy of Fallot is treated with only palliative surgery." D. "Many patients with this condition will experience clubbing of the nails."
A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." D. "Many patients with this condition will experience clubbing of the nails."
As the nurse you know which statements below are correct about the ductus arteriosus? Select all that apply: A. "The ductus arteriosus is a structure that should be present in all babies in utero." B. "The ductus arteriosus normally closes about 3 days after birth or sooner." C. "The purpose of the ductus arteriosus is to help carry blood that is entering the left side of the heart to the rest of the body, hence bypassing the lungs." D. "The ductus arteriosus connects the aorta to the pulmonary vein."
A. "The ductus arteriosus is a structure that should be present in all babies in utero." B. "The ductus arteriosus normally closes about 3 days after birth or sooner."
After admitting a child with an atrial septal defect, you start developing a nursing care plan. What nursing diagnoses can you include in the patient's plan of care based on the complications that arise from this condition? Select all that apply: A. Activity Intolerance B. Risk for Infection C. Decrease Cardiac Output D. Excess Fluid Volume E. Risk for Aspiration
A. Activity Intolerance B. Risk for Infection C. Decrease Cardiac Output D. Excess Fluid Volume
An acoustic neuroma is removed from a patient, and the nurse instructs the patient about tumor recurrence. What should the nurse instruct the patient to monitor (select all that apply)? A. Episodes of dizziness B. Lack of coordination C. Worsening of hearing D. Inability to close the eye E. Clear drainage from the nose
A. Episodes of dizziness B. Lack of coordination C. Worsening of hearing
You're providing education to the parents of a child who has a patent ductus arteriosus. The parents want to know the complications of this condition. In your education, you will include which of the following complications of PDA? Select all that apply: A. Heart failure B. Pulmonary hypertension C. Recurrent lung infections D. Clubbing of the fingernails E. Endocarditis F. Pulmonary stenosis
A. Heart failure B. Pulmonary hypertension C. Recurrent lung infections E. Endocarditis
An echocardiogram shows that your patient has an atrial septal defect located at the bottom of the septum near the tricuspid and mitral valves. As the nurse you know this is what type of atrial septal defect (ASD)? A. Ostium Primum B. Ostium Secundum C. Sinus Venosus D. Coronary Sinus
A. Ostium Primum
The nurse should expect to give which medication/s when a client is experiencing a seizure?
ANTICONVULSANT: -Phenytoin (Dilantin) -Phenobarbital (Luminal) BENZODIAZEPINES: -Diazepam (oral, rectal, or parenteral) -Lorazepam (parenteral or oral)
Nursing interventions for appendicitis
Administer IV fluids to prevent dehydration, NO cathartics, NO enemas because they might rupture the appendix - NOTHING by mouth, administer analgesics "judiciously" because they may mask symptoms of rupture - Place patient in Fowler's position to reduce pain, NO HEAT to lower right abdomen, NO palpation - can cause rupture - If sudden loss of pain, indicates perforation, this is an EMERGENCY
Severe systemic Anaphylaxis
All previous symptoms (moderate) but with abrupt onset -Decreasing BP -Pulse weak, thready (rapid or shallow) -Rapid: bronchospasm, laryngeal edema, severe dyspnea, cyanosis Dysphagia, abdominal cramping, vomiting & diarrhea Seizures, respiratory & cardiac arrest
b. What additional newborn instruction might be appropriate at this time?
At this time, it might be appropriate for the nurse to unwrap the newborn and complete a thorough bedside assessment, pointing out any minor deviations to the mother and explaining their significance. This will allay any future anxiety about her newborn and will afford the opportunity to instruct Ms. Scott on various physiologic and behavioral adaptations present in her daughter.
Lorazepam
Ativan
The nurse is teaching the mother of a child diagnosed with attention-deficit hyperactivity disorder how to administer methylphenidate (Ritalin). When would the nurse instruct the mother to administer this drug? A) "Administer at lunch every day." B) "Administer at breakfast every day." C) "Administer at dinner every day." D) "Administer at bedtime."
B) "Administer at breakfast every day."
A group of patients are being screened to see which patients would be the best candidate for a psychotherapeutic drug trial that helps people concentrate longer on activities. Which patient would be best suited for this trial? A) A 28-year-old salesperson who alternates between overactivity and periods of depression B) A 32-year-old hyperactive nursing student who cannot focus long enough to take a test C) A 55-year-old physician who suddenly falls asleep during the day without warning D) A 16-year-old youth who say he can make the light turn on by pointing at it and hears voices
B) A 32-year-old hyperactive nursing student who cannot focus long enough to take a test
You are the nurse planning an educational event for the nurses on a subacute medical unit on the topic of normal, age-related physiological changes. What phenomenon would you include in your teaching plan? A) A decrease in cognition, judgment, and memory B) A decrease in muscle mass and bone density C) The disappearance of sexual desire for both men and women D) An increase in sebaceous and sweat gland function in both men and women
B) A decrease in muscle mass and bone density
A nurse's assessment of a patient's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it "really hurts to stand up." The nurse should plan care based on the belief that the patient has experienced what? A) A first-degree strain B) A second-degree strain C) A first-degree sprain D) A second-degree sprain
B) A second-degree strain -second-degree strain involves tearing of muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function.
A nurse is providing discharge instructions for a child with CF. Which of the following instructions should the nurse include? A) Provide a low calorie, low protein diet B) Administer pancreatic enzymes with meals and snacks C) Implement fluid restriction during times of infection D) Restrict physical activity.
B) Administer pancreatic enzymes with meals and snacks
An occupational health nurse overhears an employee talking to his manager about a 65 year-old coworker. What phenomenon would the nurse identify when hearing the employee state, "He should just retire and make way for some new blood."? A) Intolerance B) Ageism C) Dependence D) Nonspecific prejudice
B) Ageism
A patient who is scheduled for an open prostatectomy is concerned about the potential effects of the surgery on his sexual function. What aspect of prostate surgery should inform the nurse's response? A) Erectile dysfunction is common after prostatectomy as a result of hormonal changes. B) All prostatectomies carry a risk of nerve damage and consequent erectile dysfunction. C) Erectile dysfunction after prostatectomy is expected, but normally resolves within several months. D) Modern surgical techniques have eliminated the risk of erectile dysfunction following prostatectomy.
B) All prostatectomies carry a risk of nerve damage and consequent erectile dysfunction.
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonic/clonic seizures D) Shortness of breath
B) Alteration in level of consciousness (LOC)
A gerontologic nurse is making an effort to address some of the misconceptions about older adults that exist among health care providers. The nurse has made the point that most people aged 75 years remains functionally independent. The nurse should attribute this trend to what factor? A) Early detection of disease and increased advocacy by older adults B) Application of health-promotion and disease-prevention activities C) Changes in the medical treatment of hypertension and hyperlipidemia D) Genetic changes that have resulted in increased resiliency to acute infection
B) Application of health-promotion and disease-prevention activities
A nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following? Select all that apply. A) Massage B) Applying ice C) Compression dressings D) Resting the affected extremity E) Corticosteroids F) Elevating the injured limb
B) Applying ice C) Compression dressings D) Resting the affected extremity F) Elevating the injured limb
The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. Which of the following would the nurse use when documenting these observations? A) Spastic B) Athetoid C) Ataxic D) Mixed
B) Athetoid
A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? A) Ventricular tachycardia B) Atrial fibrillation C) Supraventricular tachycardia D) Bundle branch block
B) Atrial fibrillation
An older adult patient has fallen in her home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the patient's presurgical care, the nurse should be aware of the patient's heightened risk of what complication? A) Osteomyelitis B) Avascular necrosis C) Phantom pain D) Septicemia
B) Avascular necrosis
A person with temperament traits of high harm avoidance would most likely suffer from which personality disorder? A) Schizoid B) Avoidant C) Narcissistic D) Antisocial
B) Avoidant
What is the primary difference between anorexia nervosa and bulimia nervosa? A) Anorexia has a psychological basis, whereas the cause of bulimia is biologic. B) Clients who are anorexic are proud of their control over eating, and clients with bulimia are ashamed of their behavior. C) Bulimia can be life threatening, whereas anorexia is seldom so. D) There is no real difference between these two types of disorders.
B) Clients who are anorexic are proud of their control over eating, and clients with bulimia are ashamed of their behavior.
While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity
B) Confusion
The client with schizophrenia believes the student nurses are there to spy on the clients. The client is suffering from which of the following symptoms? A) Hallucinations B) Delusions C) Anhedonia D) Ideas of reference
B) Delusion Delusions are fixed false beliefs that have no basis in reality. Hallucinations are false sensory perceptions or perceptual experiences that do not exist in reality. Ideas of reference are false impressions that external events have special meaning for the person. Anhedonia is feeling no joy or pleasure from life or any activities or relationships.
Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a "clunk" when Ortolani's maneuver is performed. Which of the following would the nurse suspect? A) Slipping of the periosteal joint B) Developmental hip dysplasia C) Normal newborn variation D) Overriding of the pelvic bone
B) Developmental hip dysplasia
A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A) Respiratory rate of 16 breaths per minute B) Diminished deep tendon reflexes C) Urine output of 45 mL/hour D) Alert level of consciousness
B) Diminished deep tendon reflexes
The case manager is working with an 84-year-old patient newly admitted to a rehabilitation facility. When developing a care plan for this older adult, which factors should the nurse identify as positive attributes that benefit coping in this age group? Select all that apply. A) Decreased risk taking B) Effective adaptation skills C) Avoiding participation in untested roles D) Increased life experience E) Resiliency during change
B) Effective adaptation skills D) Increased life experience E) Resiliency during change
When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? A) Head turned slightly to the right side B) Elevation of the head of the bed C) Position changes every 15 minutes while awake D) Extension of the neck
B) Elevation of the head of the bed
A patient with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the patient to do? A) Elevate the affected extremity to shoulder level when at rest. B) Engage in exercises that strengthen the unaffected muscles. C) Apply topical anesthetics to accessible skin surfaces as needed. D) Avoid using analgesics so that further damage is not masked.
B) Engage in exercises that strengthen the unaffected muscles.
Which one of the following nursing interventions should take priority for a child with ADHD? A) Structured daily routine B) Ensuring the child's safety and that of others C) Simplifying instructions and directions D) Improved role performance
B) Ensuring the child's safety and that of others.
The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patient's room and finds him resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action? A) Inform the surgeon of this finding. B) Explain the risks of flexion contracture to the patient. C) Transfer the patient to a sitting position. D) Encourage the patient to perform active ROM exercises with the residual limb.
B) Explain the risks of flexion contracture to the patient.
The nurse is meeting a client for the first time who has just spontaneously lost her unborn child. After establishing rapport, the priority nursing intervention should focus on which of the following? A) Assessing the client's support system B) Exploring what this loss means for the client C) Discussing helpful ways to cope with the loss D) Assessing what knowledge the client desires about the situation
B) Exploring what this loss means for the client
The nurse is caring for an infant with suspected patent ductus arteriosus. Which of the following assessment findings would the nurse identify as helping to confirm this suspicion? A) Thrill at the base of the heart B) Harsh, continuous, machine-like murmur under the left clavicle C) Faint pulses D) Systolic murmur best heard along the left sternal border
B) Harsh, continuous, machine-like murmur under the left clavicle at the first and second intercostal spaces.
A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? A) Support the patient's full body weight with a waist belt during ambulation. B) Have a colleague follow the patient closely with a wheelchair. C) Avoid mobilizing the patient in the early morning or late evening. D) Ensure that the patient's family members do not participate in mobilization.
B) Have a colleague follow the patient closely with a wheelchair.
A child with ADHD complains to his parents that he does not like the side effects of his medicine, Adderall. The parents ask the nurse for suggestions to reduce the medication's negative side effects. The nurse can best help the parents by offering which advice? A) Give the child his medicine at night. B) Have the child eat a good breakfast and snacks late in the day and at bedtime. C) Limit the number of calories the child eats each day. D) Let the child take daytime naps.
B) Have the child eat a good breakfast and snacks late in the day and at bedtime.
A 69-year-old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis and admits the patient to the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply. A) Blood pressure greater than 140/90 mm Hg B) Heart rate greater than 120 bpm C) Older age D) Low Glasgow Coma Scale E) Lack of previous immunizations
B) Heart rate greater than 120 bpm C) older age D) Low Glasgow Coma Scale
The nurse is conducting a physical examination of a child with a ventricular septal defect. Which finding would the nurse expect to assess? A) Right ventricular heave B) Holosystolic harsh murmur along the left sternal border C) Fixed split-second heart sound D) Systolic ejection murmur
B) Holosystolic harsh murmur along the left sternal border
A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? A) Identify the triggers that precipitated the seizure. B) Implement precautions to ensure the patient's safety. C) Teach the patient's family about the relationship between brain tumors and seizure activity. D) Ensure that the patient is housed in a private room.
B) Implement precautions to ensure the patient's safety.
Older people have many altered reactions to disease that are based on age-related physiological changes. When the nurse observes physical indicators of illness in the older population, that nurse must remember which of the following principles? A) Potential life-threatening problems in the older adult population are not as serious as they are in a middle-aged population. B) Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential life-threatening problems in older adults. C) The same physiological processes that indicate serious health care problems in a younger population indicate mild disease states in the elderly. D) Middle-aged people do not react to disease states the same as a younger population does.
B) Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential life-threatening problems in older adults.
The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately? A) Intravenous phenobarbital (Luminal) B) Intravenous diazepam (Valium) C) Oral lorazepam (Ativan) D) Oral phenytoin (Dilantin)
B) Intravenous diazepam
A young couple just ended their relationship after a 9-month engagement. The one of the individuals is seeking short-term counseling to assist in grieving this loss. Which type of loss best describes what this client is experiencing? A) Safety loss B) Loss of security and sense of belonging C) Loss of self-esteem D) Loss related to self-actualization
B) Loss of security and sense of belonging
A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care? A) Preventing infection B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure
B) Maintaining spinal alignment
The nurse is preparing a teaching plan for the parents of a child who has been diagnosed with a congenital heart defect. Which of the following would the nurse be least likely to include? A) Daily weight assessment B) Maintenance of strict bed rest C) Prevention of infection D) Signs of complications
B) Maintenance of strict bed rest
A patient has sustained a long bone fracture and the nurse is preparing the patient's care plan. Which of the following should the nurse include in the care plan? A) Administer vitamin D and calcium supplements as ordered. B) Monitor temperature and pulses of the affected extremity. C) Perform passive range of motion exercises as tolerated. D) Administer corticosteroids as ordered.
B) Monitor temperature and pulses of the affected extremity.
A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities
B) Neck flexion produces flexion of knees and hips
The nurse is assessing a client with bulimia nervosa. Which of the following symptoms would the nurse expect to find? Select all that apply. A) Cold intolerance B) Normal weight for height C) Dental erosion D) Hypotension E) Metabolic alkalosis
B) Normal weight for height C) Dental erosion E) Metabolic alkalosis
Which of the following are critical components to assess in a grieving person? Select all that apply. A) Genetic risk B) Perception of the loss C) Support system D) Coping behaviors E) Religion
B) Perception of the loss C) Support system D) Coping behaviors
The nurse is assessing a child with a possible fracture. Which of the following would the nurse identify as the most reliable indicator? A) Lack of spontaneous movement B) Point tenderness C) Bruising D) Inability to bear weight
B) Point tenderness
A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? A) Negative Brudzinski's sign B) Positive Kernig's sign C) Hyperpatellar reflex D) Sluggish pupil reaction
B) Positive Kernig's sign
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. A) INR above 1.0 B) Recent intracranial pathology C) Sudden symptom onset D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission
B) Recent intracranial pathology D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission
Just after delivery, a newborn's axillary temperature is 94° F. What action would be most appropriate? A) Assess the newborn's gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower.
B) Rewarm the newborn gradually.
Mrs. Harris is an 83-year-old woman who has returned to the community following knee replacement surgery. The community health nurse recognizes that Mrs. Harris has prescriptions for nine different medications for the treatment of varied health problems. In addition, she has experienced occasional episodes of dizziness and lightheadedness since her discharge. The nurse should identify which of the following nursing diagnoses? A) Risk for infection related to polypharmacy and hypotension B) Risk for falls related to polypharmacy and impaired balance C) Adult failure to thrive related to chronic disease and circulatory disturbance D) Disturbed thought processes related to adverse drug effects and hypotension
B) Risk for falls related to polypharmacy and impaired balance
A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patient's nursing care, the nurse should prioritize what nursing diagnosis? A) Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake B) Risk for Infection Related to Possible Rupture of Appendix C) Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake D) Chronic Pain Related to Appendicitis
B) Risk for infection related to possible rupture of appendix
A nurse is assessing an infant. Which of the following findings are clinical manifestations of acute otitis media? A) Decreased pain in the supine position B) Rolling head side to side C) Loss of appetite D) Increased sensitivity to sound E) Crying
B) Rolling head side to side C) Loss of appetite E) Crying
You are the nurse caring for an elderly patient with cardiovascular disease. The patient comes to the clinic with a suspected respiratory infection and is diagnosed with pneumonia. As the nurse, what do you know about the altered responses of older adults? A) Treatments for older adults need to be more holistic than treatments used in the younger population. B) The altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications. C) The altered responses of older adults define the nursing interactions with the patient. D) Older adults become hypersensitive to antibiotic treatments for infectious disease states.
B) The altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications
A man comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the patient's history, what might the nurse note that contributes to erectile dysfunction? A) The patient has been treated for a UTI twice in the past year. B) The patient has a history of hypertension. C) The patient is 66 years old. D) The patient leads a sedentary lifestyle.
B) The patient has history of hypertension
A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patient's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? A) Whether the tumor utilizes aerobic or anaerobic respiration B) The specific hormones secreted by the tumor C) The patient's pre-existing health status D) Whether the tumor is primary or the result of metastasis
B) The specific hormones secreted by the tumor
After teaching the mother about follow-up immunizations for her daughter, who received the varicella vaccine at age 14 months, the nurse determines that the teaching was successful when the mother states that a follow-up dose should be given at which time? A) When the child is 20 to 36 months of age B) When the child is 4 to 6 years of age C) When the child is 11 to 12 years of age D) When the child is 13 to 15 years of age
B) When the child is 4 to 6 years of age.
A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A) Generalized seizure B) Absence seizure C) Focal seizure D) Unclassified seizure
B) absence seizure
A client who suffers from frequent panic attacks describes the attack as feeling disconnected from himself. The nurse notes in the client's chart that the client reports experiencing A) hallucinations. B) depersonalization. C) derealization. D) denial.
B) depresonalization
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? A) Pruritus B) Dyskinesia C) Lactose intolerance D) Diarrhea
B) dyskinesia
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized? A) Prevent complications of immobility. B) Maintain and improve cerebral tissue perfusion. C) Relieve anxiety and pain. D) Relieve sensory deprivation.
B) maintain and improve cerebral tissue perfusion
You're caring for a 2-day-old infant with a large patent ductus arteriosus. The mother of the infant is anxious and asks you to explain her child's condition to her again. Which statement below BEST describes this condition? A. "The vessel connecting the aorta and pulmonary vein has closed prematurely, which is leading to increased blood flow to the lungs." B. "The vessel connecting the aorta and pulmonary artery has failed to close at birth, which is leading to a left-to-right shunt of blood." C. The vessel connecting the aorta and pulmonary vein has failed to close at birth, which is leading to a right-to-left shunt of blood." D. "The vessel connecting the aorta and pulmonary artery has closed prematurely, which is leading to a left-to-right shunt of blood."
B. "The vessel connecting the aorta and pulmonary artery has failed to close at birth, which is leading to a left-to-right shunt of blood."
You're working on a unit that provides specialized cardiac care to the pediatric population. Which patient below would be the best candidate for Indomethacin from the treatment of patent ductus arteriosus? A. A 25-year-old adult B. A premature infant C. An 8 month old child D. A 12 year old child
B. A premature infant
A newborn baby, who is diagnosed with transposition of the great arteries, is ordered by the physician to be started on an infusion of prostaglandin E (alprostadil). The purpose of this medication is to: A. Prevent the closure of the foramen ovale. B. Allow a continued connection between the aorta and pulmonary artery via the ductus arteriosus. C. Prevent the closure of the ductus venosus. D. Increase the blood flow to the pulmonary vein, which will increase oxygen levels.
B. Allow a continued connection between the aorta and pulmonary artery via the ductus arteriosus.
Select all the signs and symptoms of how a newborn with transposition of the great arteries may present after birth: A. Machinery-like heart murmur B. Cyanosis C. Low oxygen levels D. Bounding pulses in the upper extremities E. Increased respiratory rate F. Increased heart rate G. Knee-to-chest position
B. Cyanosis C. Low oxygen levels E. Increased respiratory rate F. Increased heart rate
True or False: Atrial septal defects are characterized by a hole in the interatrial septum that allows blood to mix in the right and left atria, which are the lower chambers of the heart. A. True B. False
B. False
True or False: Atrial septal defects can lead to a decrease in lung blood flow. A. True B. False
B. False
Select the structure below that allows blood to flow from the right to left atrium in utero and that should close after birth: A. Ductus Arteriosus B. Formen Ovale C. Ductus Venosus D. Ligamentum teres
B. Formen Ovale
A patient is diagnosed with a large atrial septal defect. You're providing information for the patient on the complications related to this condition. What topics will you include in the patient's education? Select all that apply: A. Tet spells B. Heart failure C. Stroke D. Pulmonary Hypertension E. Rheumatic Fever
B. Heart failure C. Stroke D. Pulmonary Hypertension
True or False: In a normal heart without any type of congenital heart defect, the pulmonary vein carries oxygenated blood away from the lungs to the left side of the heart. A. True B. False
B. True
A newborn baby with transposition of the great arteries has an echocardiogram performed to detect if any other defects are present in the heart. As the nurse, you know that what other defects can most commonly occur with TGA? Select all that apply: A. Complete atrioventricular canal defect B. Ventricular septal defect C. Patent ductus arteriosus D. Tricuspid atresia E. Tetralogy of fallot F. Atrial septal defect
B. Ventricular septal defect C. Patent ductus arteriosus F. Atrial septal defect
2. A 4-month-old is diagnosed with Tetralogy of Fallot. You're providing an illustration to the parent to help him understand the pathophysiology of this condition. What defects must be present in the illustration to help the parent understand their child's condition? Select all that apply: A. Aortic stenosis B. Ventricular septal defect C. Coarctation of aorta D. Right ventricular hypertrophy E. Displacement of the aorta F. Pulmonic stenosis G. Patent ductus arteriosus
B. Ventricular septal defect D. Right ventricular hypertrophy E. Displacement of the aorta F. Pulmonic stenosis
You are assessing the heart sounds of a patient with a severe case of Tetralogy of Fallot. You would expect to hear a __________ murmur at the _______ of the sternal border? A. diastolic; right B. systolic; left C. diastolic; left D. systolic; right
B. systolic; left
During the postictal period of a seizure, you would expect the patient to A. demonstrate minor jerking and eye fluttering. B. sleep for several hours. C. be incontinent of urine and feces. D. require ventilator assistance.
B.) Sleep for several hours.
Spontaneous, irregular, and painless contractions are called
Braxton Hicks contractions
The nurse is caring for a 2-month-old infant who has been diagnosed with acute heart failure. The nurse is providing teaching about nutrition. Which of the following statements by the mother indicates a need for further teaching? A) "The baby may need as much as 150 calories/kg/day." B) "Small, frequent feedings are best if tolerated." C) "I need to feed him every hour to make sure he eats enough." D) "Gavage feedings may be required for now."
C) " I need to feed him every hour to make sure he eats enough.
A nurse is providing teaching to the parents of a child who has had a shunt inserted as treatment for hydrocephalus. The parents demonstrate understanding of the teaching when they state which of the following? A) "Having the shunt put in decreases his risk for developmental problems." B) "If he doesn't get an infection in the first week, the risk is greatly reduced." C) "He will need more surgeries to replace the shunt as he grows." D) "The shunt will help to prevent any further complications from his disease."
C) "He will need more surgeries to replace the shunt as he grows."
A couple comes to the clinic for a fertility evaluation. The male partner is to undergo a semen analysis. After teaching the partner about this test, which client statement indicates that the client has understood the instructions? A) "I need to bring the specimen to the lab the day after collecting it." B) "I will place the specimen in a special plastic bag to transport it." C) "I have to abstain from sexual activity for about 1-2 days before the sample." D) "I will withdraw before I ejaculate during sex to collect the specimen."
C) "I have to abstain from sexual activity for about 1-2 days before the sample."
A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond? A) "It's important to drink plenty of fluids while you're taking laxatives." B) "Make sure that you supplement your laxatives with a nutritious diet." C) "Let's explore other options, because laxatives can have side effects and create dependency." D) "You should ideally be using herbal remedies rather than medications to promote bowel function."
C) "Let's explore other options, because laxatives can have side effects and create dependency."
The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful? A) "I'll basically follow the same diet that I was following before I became pregnant." B) "Because I need extra protein, I'll have to increase my intake of milk and meat." C) "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D) "I'll adjust my diet and insulin based on the results of my urine tests for glucose."
C) "Pregnancy affects insulin production, so I'll need to make adjustments in my diet."
A client comes to the physician's office for an annual checkup. During the interview, the nurse learns that the client's husband died unexpectedly of a heart attack 2 months ago. The most appropriate response by the nurse would be, A) "At least you and your husband enjoyed life right until the end." B) "It's better to go quickly like your husband did instead of suffering." C) "The loss of your husband must be very painful for you." D) "You'll feel better after you get over the shock of your husband's death."
C) "The loss of your husband must be very painful for you."
A client is currently experiencing a panic attack. Which of the following is the most appropriate response by the nurse? A) "Just try to relax." B) "There is nothing here to harm you." C) "You are safe. Take a deep breath." D) "What are you feeling right now?"
C) "You are safe. Take a deep breath."
The nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks the nurse where his tumor came from. What would be the nurse's best response? A) "Your tumor originated from somewhere outside the CNS." B) "Your tumor likely started out in one of your glands." C) "Your tumor originated from cells within your brain itself." D) "Your tumor is from nerve tissue somewhere in your body."
C) "Your tumor originated from cells within your brain itself."
A gerontologic nurse is aware of the demographic changes that are occurring in the United States, and this affects the way that the nurse plans and provides care. Which of the following phenomena is currently undergoing the most rapid and profound change? A) More families are having to provide care for their aging members. B) Adult children find themselves participating in chronic disease management. C) A growing number of people live to a very old age. D) Elderly people are having more accidents, increasing the costs of health care.
C) A growing number of people live to a very old age
Kubler-Ross developed a model of five stages to explain what people experience as they grieve and mourn. Which is stage V of Kubler-Ross's stages of grieving? A) Denial B) Bargaining C) Acceptance D) Anger
C) Acceptance
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect? A) Cytotoxic reaction due to contact with the powder in the gloves B) Immune complex reaction due to contact with anesthetic gases C) Anaphylaxis due to a latex allergy D) Delayed reaction due to exposure to cleaning products
C) Anaphylaxis due to a latex allergy
A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient? A) Electrolyte assessment B) Electrocardiogram C) Arterial blood gases D) Abdominal ultrasound
C) Arterial blood gases -Subtle personality changes, restlessness, irritability, or confusion in a patient who has sustained a fracture are indications for immediate arterial blood gas studies due to the possibility of fat embolism syndrome.
The most effective way for the nurse to provide culturally competent care to individuals who are grieving is which of the following? A) Understand the practices associated with a client's culture. B) Suggest developing a new ritual to make mourning meaningful. C) Ask the client what rituals are personally meaningful. D) Contact a spiritual leader from the client's culture to become involved.
C) Ask the client what rituals are personally meaningful.
The client says to the nurse, "I really want to see my first grandchild born before I die. Is that too much to ask?" The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross? A) Acceptance B) Anger C) Bargaining D) Depression
C) Bargaining
A married couple has just received the news that the husband has terminal cancer. The wife tells the nurse, "Maybe if we get another opinion and start treatment right way there is a chance of survival." The nurse documents that the wife is expressing signs of which of Kubler-Ross's stages of grief? A) Denial B) Anger C) Bargaining D) Depression
C) Bargaining (1) Denial is shock and disbelief regarding the loss. (2) Anger may be expressed toward God, relatives, friends, or health-care providers. (3) Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss. (4) Depression results when awareness of the loss becomes acute. (5) Acceptance occurs when the person shows evidence of coming to terms with death.
The nurse understands that before a client with an eating disorder can accept their body image, he or she must first learn effective coping skills. Which statement best describes the relationship between body image and coping skills? A) Coping skills are dependent on a supportive upbringing. B) When body image is positive, the client will develop better coping skills. C) Being able to cope in healthy ways improves the ability to accept a realistic body image. D) Neurotransmitters that are deficient in clients with eating disorders prohibit the development of effective coping skills.
C) Being able to cope in healthy ways improves the ability to accept a realistic body image.
A 48-year-old woman presenting for care is seeking information about hormone therapy (HT) for the treatment of her perimenopausal symptoms. The patient's need for relief from hot flashes and other symptoms will be weighed carefully against the increased risks of what complications of HT? Select all that apply. A) Anaphylaxis B) Osteoporosis C) Breast cancer D) Cardiovascular disease E) Venous thromboembolism
C) Breast Cancer D) Cardiovascular disease E) Venous thromboembolism
A 48-year-old woman presenting for care is seeking information about hormone therapy (HT) for the treatment of her perimenopausal symptoms. The patient's need for relief from hot flashes and other symptoms will be weighed carefully against the increased risks of what complications of HT? Select all that apply. A) Anaphylaxis B) Osteoporosis C) Breast cancer D) Cardiovascular disease E) Venous thromboembolism
C) Breast cancer D) Cardiovascular disease E) Venous thromboembolism
The nurse is teaching a new mother the proper techniques for breastfeeding her newborn. Which of the following is a recommended guideline that should be implemented? A) Wash the hands and breasts thoroughly prior to breastfeeding. B) Stroke the nipple against the baby's chin to stimulate wide opening of the baby's mouth. C) Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola. D) When finished the mother can break the suction by firmly pulling the baby's mouth away from the nipple.
C) Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola.
A nurse is aware of the need to assess patients' risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis? A) Administration of the measles-mumps-rubella (MMR) vaccine B) Rapid administration of intravenous fluids C) Computed tomography with contrast solution D) Administration of nebulized bronchodilators
C) Computed tomography with contrast solution
A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse recognizes that the patient has likely sustained what? A) Sprain B) Strain C) Contusion D) Dislocation
C) Contusion
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication? A) Urinary output of 20 mL per hour B) Respiratory rate of 10 breaths/minute C) Deep tendons reflexes 2+ D) Difficulty in arousing
C) Deep tendons reflexes 2+ -Prevention of disease progression is the focus of treatment during labor. Blood pressure is monitored frequently, and a quiet environment is important to minimize the risk of stimulation and to promote rest. IV magnesium sulfate is infused to prevent any seizure activity, along with antihypertensives if blood pressure values begin to rise. Calcium gluconate is kept at the bedside in case the magnesium level becomes toxic.
A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A) Denial B) Fear C) Depression D) Disassociation
C) Depression
A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? A) Bathe daily and keep the perineal region clean. B) Avoid voiding immediately after sexual intercourse. C) Drink liberal amounts of fluids. D) Void at least every 6 to 8 hours.
C) Drink liberal amounts of fluids.
A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? A) Bathe daily and keep the perineal region clean. B) Avoid voiding immediately after sexual intercourse. C) Drink liberal amounts of fluids. D) Void at least every 6 to 8 hours.
C) Drink liberal amounts of fluids. -Adequate fluid intake is necessary to flush the bacteria from the bladder. Fever management may also be needed.
A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome
C) Fat embolism syndrome
A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A) Unclassified seizure B) Absence seizure C) Generalized seizure D) Focal seizure
C) Generalized seizure
A 20-year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patient's fracture likely be graded? A) Grade I B) Grade II C) Grade III D) Grade IV
C) Grade III
Which would most likely be a type of behavior that would be manifested by a client who has histrionic personality disorder? A) Insisting that others follow the rules of the unit B) Wondering why others are being friendly to her C) Having a tantrum if not getting enough attention D) Getting others to make decisions for her
C) Having tantrum if not getting enough attention
The nurse is assessing for negative symptoms of schizophrenia in a newly admitted client. The nurse would note which behavior as indicative of a negative symptom? A) Difficulty staying on subject when responding to assessment questions B) Belief of owning a transportation device allowing for travel to the center of the Earth C) Hesitant to answer the nurse's questions during the assessment interview D) Mimicking the postural changes made by the nurse during the assessment interview
C) Hesitant to answer the nurse's questions during the assessment interview -A negative symptom of schizophrenia is alogia, or the tendency to speak very little or to convey little substance of meaning (poverty of content). Associative looseness (fragmented or poorly related thoughts and ideas), delusions (fixed false beliefs that have no basis in reality), and echopraxia (imitation of the movements and gestures of another person whom the client is observing) are all positive symptoms.
A patient in her late fifties has expressed to the nurse her desire to explore hormone replacement therapy (HRT). Based on what aspect of the patient's health history is HRT contraindicated? A) History of vaginal dryness B) History of hot flashes and night sweats C) History of vascular thrombosis D) Family history of osteoporosis
C) History of vascular thrombosis
The nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that the effects of neoplasms are caused by the compression and infiltration of normal tissue. The physiologic changes that result can cause what pathophysiologic events? Select all that apply. A) Intracranial hemorrhage B) Infection of cerebrospinal fluid C) Increased ICP D) Focal neurologic signs E) Altered pituitary function
C) Increased ICP D) Focal neurologic signs E) Altered pituitary function
A newborn is diagnosed with patent ductus arteriosus. The nurse anticipates that the physician will most likely order which medication? A) Alprostadil B) Heparin C) Indomethacin D) Spironolactone
C) Indomethacin
A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route? A) Oral B) Subcutaneous injection C) Intramuscular injection D) Intravenous infusion
C) Intramuscular injection -Botulinum toxin is injected into the spastic muscle to balance the muscle forces across joints and to decrease spasticity
Hydrocephalus is suspected in a 4-month-old infant. Which of the following would the nurse expect to assess? A) Sunken fontanels B) Diminished reflexes C) Lower extremity spasticity D) Skull symmetry
C) Lower extremity spasticity
The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of otitis externa? A) Tophi on the pinna and ear lobe B) Dark yellow cerumen in the external auditory canal C) Pain on manipulation of the auricle D) Air bubbles visible in the middle ear
C) Pain on manipulation of the auricle
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? A) Place the patient in the prone position for 30 minutes/day. B) Assist the patient in acutely flexing the thigh to promote movement. C) Place a pillow in the axilla when there is limited external rotation. D) Place patient's hand in pronation.
C) Place a pillow in the axilla when there is limited external rotation
The nurse is helping a new mother prepare for breastfeeding her infant. During which of the following newborn states of consciousness would the nurse recommended attempting the feeding? A) Light sleep B) Drowsiness C) Quiet alert state D) Active alert state
C) Quiet alert state -Crying is a late sign of hunger; earlier signs include making sucking motions, sucking on hands, or putting the fist to the chin. -Quiet alert state: The infant's eyes are wide open and the body is calm.
A 51-year-old woman is experiencing perimenopausal symptoms and expresses confusion around the possible use of hormone therapy (HT). She explains that her mother and aunts used HT and she is unsure why few of her peers have been prescribed this treatment. What should the nurse explain to the patient? A) Large, long-term health studies have revealed that HT is minimally effective. B) HT has been largely replaced by other nonpharmacologic interventions. C) Research has shown that significant health risks are associated with HT. D) HT has been shown to exacerbate symptoms of menopause in a minority of women.
C) Research has shown that significant health risks are associated with HT.
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patient's plan of care. The presence of what chronic health problem would most likely prompt this diagnosis? A) Herpes simplex B) HIV C) Spina bifida D) Hypogammaglobulinemia
C) Spina bifida
Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain? A) Apply intermittent hot compresses to the area of the amputation. B) Avoid activity until the pain subsides. C) Take opioid analgesics as ordered. D) Elevate the level of the amputation site.
C) Take opioid analgesics as ordered.
An 8-year-old boy with a fractured forearm is to have a fiberglass cast applied. Which of the following would the nurse include when teaching the child about the cast? A) The cast will take a day or two to dry completely. B) The edges will be covered with a soft material to prevent irritation. C) The child initially may experience a very warm feeling inside the cast. D) The child will need to keep his arm down at his side for 48 hours.
C) The child initially may experience a very warm feeling inside the cast.
The nurse is assessing a patient who believes that she has recently begun menopause. What principle should inform the nurse's interactions with this patient? A) The nurse should express empathy for the patient's difficult health situation. B) The nurse should begin by assuring the patient that her health will be much better in a few years. C) The nurse must carefully assess the patient's feelings and beliefs surrounding menopause. D) The nurse should encourage the patient to celebrate this life milestone and its accompanying benefits.
C) The nurse must carefully assess the patient's feeling and beliefs surrounding menopause.
The nurse is assessing a patient who believes that she has recently begun menopause. What principle should inform the nurse's interactions with this patient? A) The nurse should express empathy for the patient's difficult health situation. B) The nurse should begin by assuring the patient that her health will be much better in a few years. C) The nurse must carefully assess the patient's feelings and beliefs surrounding menopause. D) The nurse should encourage the patient to celebrate this life milestone and its accompanying benefits.
C) The nurse must carefully assess the patient's feelings and beliefs surrounding menopause.
A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patient's health status? A) For some patients, these recurrent infections constitute an age-related physiologic change. B) The patient would benefit from a temporary mobility restriction to facilitate healing. C) The patient needs to be assessed for nasopharyngeal cancer. D) Blood cultures should be drawn to rule out a systemic infection.
C) The patient needs to be assessed for nasopharyngeal cancer.
A patient who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the patient's vomiting is most consistent with a brain tumor? A) The patient's vomiting is accompanied by epistaxis. B) The patient's vomiting does not relieve his nausea. C) The patient's vomiting is unrelated to food intake. D) The patient's emesis is blood-tinged.
C) The patient's vomiting is unrelated to food intake?
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A) To decrease cerebral edema B) To prevent seizure activity that is common following a TIA C) To remove atherosclerotic plaques blocking cerebral flow D) To determine the cause of the TIA
C) To remove atherosclerotic plaques blocking cerebral flow.
The nurse is presenting an in-service at a children's unit on hyperactivity. The nurse is told that a 6-year-old on the unit is being treated with methylphenidate (Ritalin). The presenting nurse talks about discharge teaching for this patient and the importance of monitoring what? A) Long bone growth B) Visual acuity C) Weight and complete blood count D) Urea and nitrogen levels
C) Weight and complete blood count
A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? A) Sudden electrolyte changes throughout the brain B) A dysrhythmia in the peripheral nervous system C) A dysrhythmia in the nerve cells in one section of the brain D) Sudden disruptions in the blood flow throughout the brain
C) a dysrhythmia in the nerve cells in one section of the brain
The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A) Mild, intermittent seizures can be expected. B) Take ibuprofen for complaints of a serious headache. C) Take anti-hypertensive medication as ordered. D) Drowsiness is normal for the first week after discharge.
C) take anti-hypertensive medication as ordered.
The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patient's plan of care? A) The patient's hip joint should be maintained in a flexed position. B) The patient should be in a supine position unless ambulating. C) The patient should be placed in a prone position for 15 to 30 minutes several times a day. D) The patient should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.
C) the patient should be placed in a prone position for 15 to 30 minutes several times a day.
As the registered nurse you are developing a plan of care for a patient with Tetralogy of Fallot. Select all the appropriate nursing diagnoses below that would be specific to this patient: A. Risk for deficient fluid volume B. Ineffective airway clearance C. Activity Intolerance D. Failure to thrive E. Risk for impaired liver function
C. Activity Intolerance D. Failure to thrive
A patient has high blood pressure and penile erectile dysfunction. He asks the nurse if he could try tadalafil (Cialis) after seeing an advertisement on television. What medications, if taken by the patient, would the nurse recognize as increasing the risk associated with taking tadalafil? A. Beta-blockers (-lol) B. Angiotensin-converting enzyme (ACE) inhibitors (-pril) C. Alpha-adrenergic blockers D. Calcium channel blockers
C. Alpha-adrenergic blockers
You're educating the parents of a patient with transposition of the great arteries about the treatment options. Which treatment option below provides a permanent solution and is performed within the first few weeks of life? A. Prostaglandin E infusion B. Balloon atrial septostomy C. Arterial switch procedure D. Complete repair with a patch
C. Arterial switch procedure
You're working in the NICU providing care to a neonate who has a large patent ductus arteriosus. Which finding during your head-to-toe assessment would require you to immediately notify the physician? A. Loud, harsh continuous murmur B. Abnormal pulse pressure C. Crackles D. Diaphoresis when feeding
C. Crackles
Your newborn patient has a severe case of transposition of the great arteries. The baby does not have any other defects and is therefore experiencing severe cyanosis and needs medical intervention immediately. The newborn is started on prostaglandin E and is scheduled for a balloon atrial septostomy. Select the statement below that best describes this procedure: A. During this procedure the pulmonary artery and aorta are switched along with their coronary arteries. B. This procedure will enlarge a hole in the ventricular septum and provide permanent treatment for this condition. C. During this procedure a hole in the atrial septum is enlarged, which will be temporary. D. The procedure will switch the pulmonary vein and aorta long with their coronary arteries, which will be permanent.
C. During this procedure a hole in the atrial septum is enlarged, which will be temporary.
While feeding a 3-month-old infant, who has Tetralogy of Fallot, you notice the infant's skin begins to have a bluish tint and the breathing rate has increased. Your immediate nursing action is to? A. Continue feeding the infant and place the infant on oxygen. B. Stop feeding the infant and provide suction. C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. D. Assess the infant's heart rate and rhythm.
C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen.
While assessing a newborn's heart sounds you note a loud murmur at the left upper sternal border. You report this to the physician who suspects the infant may have patent ductus arteriosus. The physician asks you to obtain a pulse pressure. If patent ductus arteriosus is present, the pulse pressure would be ___________. A. Narrow B. Fluctuating C. Wide D. Normal
C. Wide
As noted in the previous question, a loud murmur was noted during assessment of a newborn with patent ductus arteriosus. As the nurse you know that what type of murmur is a hallmark sign of this condition? A. harsh, loud systolic murmur B. soft, blowing diastolic murmur C. systolic and diastolic machinery-like murmur D. machinery-like murmur present on only diastole
C. systolic and diastolic machinery-like murmur
A 5-month-old infant with RSV bronchiolitis is in respiratory distress. The baby has copious secretions, increased work of breathing, cyanosis, and a respiratory rate of 78. What is the most appropriate initial nursing intervention? a. Attempt to calm the infant by placing him in his mother's lap and offering him a bottle. b. Alert the physician or nurse practitioner to the situation and ask for an order for a stat chest x-ray. c. Suction secretions, provide 100% oxygen via mask, and anticipate respiratory failure. d. Bring the emergency equipment to the room and begin bag-valve-mask ventilation.
C.) Suction secretions, provide 100% oxygen via mask, and anticipate respiratory failure.
What is the leading cause of death for patients over the age of 65?
Cardiovascular disease
What is the main surgical procedure for select patients with TIAs?
Carotid endarterectomy
A client at 28 weeks gestation calls the antepartum clinic and states that she is experiencing a small amount of bright red vaginal bleeding with no uterine contractions or abdominal pain. What instruction should the nurse provide?
Come to the clinic today for an ultra sound and evaluation.
A woman has just been served divorce papers from her husband. She has no financial resources and little social support. She states, "He's not really leaving. He'll be back." The most appropriate response by the nurse would be which of the following? A) "Has he done this before?" B) "I'll call social services and get you signed up for financial assistance." C) "You have to face reality. Here are the papers." D) "How is this affecting you right now?"
D) "How is this affecting you right now?
A child with attention deficit/hyperactivity disorder is prescribed long-acting methylphenidate. Which of the following would the nurse include when teaching the child and his parents about this drug? A) "Give the drug three times a day: morning, midday, and after school." B) "This drug may cause drowsiness, so be careful when doing things." C) "Some increase in appetite may occur, so watch how much you eat." D) "Take this drug every day in the morning when you wake up."
D) "Take this drug every day in the morning when you wake up."
The mother of a 15-month-old child is questioning the nurse about the need for the hepatitis B vaccination. Which of the following comments provides the most compelling reason for the vaccine? A) "The most common side effect is injection site soreness." B) "This is a recombinant or genetically engineered vaccine." C) "Immunizations are needed to protect the general population." D) "This protects your child from infection that can cause liver disease."
D) "This protects your child from infection that can cause liver disease.
A client who has been grieving the loss of his wife 2 weeks ago says to the nurse, "The best part of my day is when I am back at work. Is that wrong?" The nurse educates that work and other daily activities serve which purpose? A) "You cannot work effectively this soon. You should finish grieving first." B) "Working reminds you of your loss. It may be too early to go back." C) "Working is your way of avoiding grief, which will make it harder for you to move on." D) "Working is letting you take an emotional break from grieving. There's nothing wrong with that."
D) "Working is letting you take an emotional break from grieving. There's nothing wrong with that."
A woman has just delivered a stillborn baby boy. Which of the following would be the most appropriate nursing response? A) "Can I do anything for you?" B) "If something was wrong, it's better this way." C) "Your son is in heaven with God now." D) "Would you like to hold your son?"
D) "Would you like to hold your son?"
The nurse is working with a woman who lost her partner nearly 3 weeks prior. The woman has recently become less emotional and expressed that few things in her life have meaning right now. Which response by the nurse is most appropriate at this time? A) "I am concerned. You are starting to show signs of ineffective grieving." B) "You must feel some anger. It is alright to let that out." C) "Let's look at the things in your life that you still enjoy." D) "You are just starting to accept that this loss is real."
D) "You are just starting to accept that this loss is real."
The parents of an autistic child ask the nurse, "Will my child ever be normal?" Which would be the most appropriate response by the nurse? A) "You seem worried about your child's future." B) "Autistic children can fully recover with the right treatment and education." C) "Your child should outgrow autistic traits by adolescence." D) "Your child will probably always have some autistic traits."
D) "Your child will probably always have some autistic traits."
The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next? A) Contact the physician B) Offer a snack and administer another dose C) Immediately administer another dose D) Administer next dose as ordered in 12 hours
D) Administer next dose as ordered in 12 hours
A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patient's medication regimen? A) The patient is in a "honeymoon period" when adverse effects of levodopa-carbidopa are not yet evident. B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. C) The patient's temporary improvement in status is likely unrelated to levodopa-carbidopa. D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.
D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.
A community health nurse is leading a health education session addressing menopause and other aspects of women's health. What dietary supplements should the nurse recommend to prevent morbidity associated with osteoporotic fractures? A) Vitamin B12 and vitamin C B) Vitamin A and potassium C) Vitamin B6 and phosphorus D) Calcium and vitamin D
D) Calcium and vitamin D
A 15-month-old girl is having her first health visit at a clinic. The mother has no immunization record but says the child was immunized 3 months ago at the local health department. Which of the following is the best action for the nurse to take? A) Ask the mother to bring the records to the next health maintenance visit. B) Start the catch-up schedule since there are no immunization records. C) Keep the child at the facility while the mother returns home for the records. D) Call the local health department and verify the child's immunization status.
D) Call the local health department and verify the child's immunization status.
After being laid off from work, a client becomes increasingly withdrawn and fatigued, spends entire days in bed, is unkempt, and is eating and sleeping poorly. The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross? A) Anger B) Bargaining C) Denial D) Depression
D) Depression
The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which of the following is the most effective anticipatory guidance? A) Encouraging breastfeeding until the sixth month B) Advocating iron supplements with bottle-feeding C) Advising fluid intake per feeding of 5 or 6 ounces D) Discouraging the addition of fruit juice to the diet
D) Discouraging the addition of fruit juice to the diet
A child with cerebral palsy has undergone surgery for placement of a baclofen pump. Which of the following would the nurse include when teaching the parents about caring for their child? A) Waiting 48 hours before allowing the child to take a tub bath B) Not allowing the child to sleep on his side for about 4 weeks C) Calling the physician if the child's temperature is over 100.5°F D) Discouraging the child from stretching or bending forward for 4 weeks
D) Discouraging the child from stretching or bending forward for 4 weeks -Notify the physician or nurse practitioner if the child has a temperature greater than 101.5°F, or if the child has persistent incision pain. •Avoid tub baths for 2 weeks. •Do not allow the child to sleep on the stomach for 4 weeks after pump insertion. •Discourage twisting at the waist, reaching high overhead, stretching, or bending forward or backward for 4 weeks.
A woman has just had a therapeutic abortion to end an unintended pregnancy. Afterward, the woman cries because although she wanted to have children in future years, this pregnancy was not well-timed. Which type of grief is this woman most likely to experience? A) Anticipatory grief B) Absence of grief C) Complicated grief D) Disenfranchised grief
D) Disenfranchised grief -Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned, publicly, or supported socially. -Anticipatory grief occurs when a person experiences imminent loss and begin to grapple with the very real possibility of loss or death in the near future.
The nurse is providing discharge teaching regarding formula preparation for a new mother. Which of the following guidelines would the nurse include in the teaching plan? A) Always wash bottles and nipples in hot soapy water and rinse well; do not wash them in the dishwasher. B) Store tightly covered ready-to-feed formula can after opening in refrigerator for up to 24 hours. C) Warm bottle of formula by placing bottle in a container of hot water, or microwaving formula. D) Do not add cereal to the formula in the bottle or sweeten the formula with honey.
D) Do not add cereal to the formula in the bottle or sweeten the formula with honey.
A parent of a child with autism spectrum disorder asks the nurse if there is anything that can be done to control the child's tantrums. Which option should the nurse inform the parents that may be appropriate? A) Give the child rewards for resisting tantrums. B) Reason with the child why tantrums are not effective. C) Place the child in a time-out when tantrums occur. D) Explore the use of antipsychotic medications to control tantrums.
D) Explore the use of antipsychotic medications to control tantrums.
A woman gives birth to a healthy newborn. As part of the newborn's care, the nurse instills erythromycin/tetracycline ophthalmic ointment as a preventive measure related to which STI? A) Genital herpes B) Hepatitis B C) Syphilis D) Gonorrhea
D) Gonorrhea gonorrhea and/or chlamydial organisms if they are present in the mother's vagina during the birth process, possibly resulting in a severe infection and blindness. Therefore, eye prophylaxis is administered.
An elderly patient has come in to the clinic for her twice-yearly physical. The patient tells the nurse that she is generally enjoying good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest? A) Reduce the amount of stress she currently experiences. B) Increase carbohydrate intake and reduce protein intake. C) Take herbal laxatives, such as senna, each night at bedtime. D) Increase daily intake of water.
D) Increase daily intake of water.
A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following? A) Apply heat for the first 24 to 48 hours after the injury. B) Maintain the ankle in a dependent position. C) Exercise hourly by performing rotation exercises of the ankle. D) Keep an elastic compression bandage on the ankle.
D) Keep an elastic compression bandage on the ankle.
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing.
D) Loosen the patient's restrictive clothing.
A nurse is teaching the parents of a child diagnosed with cystic fibrosis about medication therapy. Which of the following would the nurse instruct the parents to administer orally? A) Recombinant human DNase B) Bronchodilators C) Anti-inflammatory agents D) Pancreatic enzymes
D) Pancreatic Enzymes
A nursing student appears to cooperate with the group but does not complete agreed upon tasks at the appropriate time repeatedly and then display negativity. The nursing student may be showing signs of which personality disorder or behavior? A) Paranoid B) Borderline C) Narcissistic D) Passive-aggressive behavior
D) Passive- aggressive behavior
The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient? A) Prednisone B) Dexamethasone C) Cafergot D) Phenytoin
D) Phenytoin
While assessing a 4-month-old infant, the nurse notes that the baby experiences a hypercyanotic spell. What is the priority nursing action? A) Provide supplemental oxygen by face mask. B) Administer a dose of IV morphine sulfate. C) Begin cardiopulmonary resuscitation. D) Place the infant in a knee-to-chest position
D) Place the infant in a knee-to-chest position
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties? A) Keep the lighting in the patient's room low. B) Place the patient's clock on the affected side. C) Approach the patient on the side where vision is impaired. D) Place the patient's extremities where she can see them.
D) Place the patient's extremities where she can see them.
A patient has been diagnosed with erectile dysfunction; the cause has been determined to be psychogenic. The patient's interdisciplinary plan of care should prioritize which of the following interventions? A) Penile implant B) PDE-5 inhibitors C) Physical therapy D) Psychotherapy
D) Psychotherapy
A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? A) Report this finding to the physician as an indication of decreased metabolism. B) Provide more stimulation to the patient and monitor the patient closely. C) Recognize this as the expected clinical course of a hemorrhagic stroke. D) Report this to the physician as a possible sign of clinical deterioration.
D) Report this to the physician as possible sign of clinical deterioration.
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has the highest priority? A) Hopelessness related to recent divorce B) Ineffective coping related to inadequate stress management C) Spiritual distress related to conflicting thoughts about suicide and sin D) Risk for suicide related to a highly lethal plan
D) Risk for suicide related to a highly lethal plan
A woman with diabetes is considering becoming pregnant. She asks the nurse whether she will be able to take oral hypoglycemics when she is pregnant. The nurse's response is based on the understanding that oral hypoglycemics: A) Can be used as long as they control serum glucose levels B) Can be taken until the degeneration of the placenta occurs C) Are usually suggested primarily for women who develop gestational diabetes D) Show promising results but more studies are needed to confirm their effectiveness
D) Show promising results but more studies are needed to confirm their effectiveness
All of the following are nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client's negative symptoms improve? A) Impaired verbal communication B) Risk for other-directed violence C) Disturbed thought processes D) Social isolation
D) Social isolation
In planning for a client's discharge, the nurse must know that the most serious risk for the client taking a tricyclic antidepressant is which of the following? A) Hypotension B) Narrow-angle glaucoma C) Seizures D) Suicide by overdose
D) Suicide by overdose -Treatment with antidepressants and spring increase in sunlight and energy may give a person with suicidal ideation the energy to act on it.
A 16-year-old boy complains to the school nurse of headaches and a stiff neck. Which of the following signs and symptoms would alert the nurse that the child may have bacterial meningitis? A) Fixed and dilated pupils B) Frequent urination C) Sunset eyes D) Sunlight is "too bright"
D) Sunlight is "too bright"
A client with terminal cancer has been told he has 3 or 4 months to live. Which of the following would indicate to the nurse that further interventions are needed? A) The client says he wants to live life to the fullest. B) The client hopes for a peaceful and dignified death. C) The client is reviewing his life and talking about death. D) The client says he is well and is making future plans.
D) The client says he is well and is making future plans.
The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A) The ability of the patient to follow instructions during the seizure. B) The success or failure of the care team to physically restrain the patient. C) The patient's ability to explain his seizure during the postictal period. D) The patient's activities immediately prior to the seizure.
D) The patient's activities immediately prior to the seizure.
The nurse is caring for a 9-year-old boy with achondroplasia. Which of the following would the nurse expect to assess? A) Narrow passages from the nose to the throat B) Slim stature, hypotonia, and a narrow face C) Craniosynostosis and a small nasopharynx D) Trident hand and persistent otitis media
D) Trident hand and persistent otitis media.
A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first? A) Perform oral suctioning. B) Page the physician. C) Insert a tongue depressor into the patient's mouth. D) Turn the patient on his side.
D) Turn the patient on his side
A nurse is preparing to discharge an emergency department patient who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the patient to do? A) Elevate the arm above the shoulder 3 to 4 times daily. B) Avoid moving the elbow, wrist, and fingers until bone remodeling is complete. C) Engage in active range of motion using the affected arm. D) Use the arm for light activities within the range of motion.
D) Use the arm for light activities within the range of motion.
A 51-year-old woman has come to the OB/GYN clinic for her annual physical. She tells the nurse that she has been experiencing severe hot flashes, but that she is reluctant to begin hormone therapy (HT). What potential solution should the nurse discuss with the patient? A) Sodium restriction B) Adopting a vegan diet C) Massage therapy D) Vitamin supplements
D) Vitamin supplements
The nurse is preparing to administer methylphenidate to the child admitted to the pediatric unit after breaking a leg when jumping off the garage roof at home. Where will the nurse find the medication? A) In the patient's drawer B) In the refrigerator C) At the patient's bedside D) In the controlled substance cabinet
D) in the controlled substance cabinet
A couple came to the emergency department with their 5-month-old son. He was pronounced dead of sudden infant death syndrome (SIDS). In the next day or two, it will be important for this couple to A) accept that they could do nothing to prevent this death. B) delay the grieving process until they are ready to cope. C) minimize their discussion of the death with others. D) plan funeral arrangements for their son.
D) plan funeral arrangements for their son.
The nurse enters the client's room and finds the client anxiously pacing the floor. The client begins shouting at the nurse, "Get out of my room!" The best intervention by the nurse would be to A) approach the client and ask, "What's wrong?" B) call for help and say, "Calm down." C) turn and walk away from the room without saying anything. D) stand at the doorway and say, "You seem upset
D) stand at the doorway and say, "You seem upset
A newborn baby is born with transposition of the great arteries (TGA). You're explaining the condition to the parents. Which statement by the father demonstrates he understood the education provided about this condition? A. "The pulmonary vein and artery are switched, which causes the pulmonary vein to deliver unoxygenated blood to the systemic circulation while the pulmonary artery delivers oxygenated blood back to the lungs." B. "The aorta and pulmonary vein are switched, which causes the aorta to arise from the right ventricle and the pulmonary vein to arise from the left ventricle." C. "The aorta and pulmonary artery are switched, which causes the aorta to arise from the left ventricle and the pulmonary artery to arise from the right ventricle." D. "The aorta and pulmonary artery are switched, which causes the aorta to arise from the right ventricle and the pulmonary artery to arise from the left ventricle."
D. "The aorta and pulmonary artery are switched, which causes the aorta to arise from the right ventricle and the pulmonary artery to arise from the left ventricle.
You're caring for a newborn who has Tetralogy of Fallot with severe cyanosis. You anticipate the newborn will be started on ___________? A: Indomethacin B. Diclofenac C. Celecoxib D. Alprostadil
D. Alprostadil
You're caring for a 2-year-old patient who has a large atrial septal defect that needs repair. This defect is causing complications. These complications are arising from an abnormal shunting of blood throughout the heart. As the nurse, you know that a __________________ shunt is occurring in the heart due to the defect. A. Right-to-left B. Right C. Left D. Left-to-right
D. Left-to-right
You're assessing the heart sounds of a child with an atrial septal defect. You note a heart murmur at the 2nd intercostal space at the left upper sternal border. Heart murmurs noted in patients with an atrial septal defect are called? A. Holosystolic murmurs B. Diastolic murmurs C. Early systolic murmurs D. Midsystolic murmurs
D. Midsystolic murmurs
A newborn with tracheoesophageal fistula is likely to present with which assessment finding? a. Subnormal temperature b. Absent Moro reflex c. Inability to swallow d. Drooling from mouth
D.) Drooling from the mouth.
positive symptoms of schizophrenia
DELUSIONS of reference, delusions of persecution, delusions of grandeur, thought broadcasting, though insertion, HALLUCINATIONS, disorganized thought, disorganized behaviour, catatonia
A 40-year-old multigravida, history of no prenatal care has delivered a baby boy. The infant has floppy tone and a single deep transverse crease on the palm of the hand What is likely to be the problem for this neonate?
DOWN Syndrome
Phenytoin
Dilantin
A statement made by patient is helping?
Don't want to hurt myself so I called you
Complications of amputation
Hemorrhage Infection Skin breakdown Phantom limb pain Joint contracture
Human Development: Menopause: Clinical Manifestations
Hot flashes or flushes of the head and neck • Dryness in the eyes and vagina • Personality changes • Anxiety and/or depression • Loss of libido • Decreased lubrication • Weight gain and water retention • Night sweats • Atrophic changes—loss of elasticity of vaginal tissues • Fatigue • Irritability • Poor self-esteem • Insomnia • Stress incontinence • Heart palpitations
HPV vaccine
Human Papilloma Virus (HPV2, HPV4) -Three doses should be given over a 6 month -interval for females at 11 to 12 years of age (minimum age is 9 years). -The second dose should be administered 2 months after the first dose, and the third dose should be administered 6 months after the first dose. -HPV4 may be given to males starting at age 9 years of age. -young women aged b/w 9 and 26 should consider getting GARDASIL 9, vaccine against HPV
Embolitic stroke risk factors
Hypertension (Controlling hypertension, the major risk factor, is the key to preventing stroke.) • Atrial fibrillation • Dyslipidemia • Diabetes (associated with accelerated atherogenesis) • Smoking • Asymptomatic carotid stenosis • Obesity • Sedentary lifestyle • Sleep apnea • Excessive alcohol consumption • Periodontal disease
Spastic Classification of CP
Hypertonicity and permanent contractures; different types based on which limbs are affected: • Hemiplegia: both extremities on one side • Quadriplegia: all four extremities • Diplegia or paraplegia: lower extremities • Most common form • Poor control of posture, balance, and movement • Exaggeration of deep tendon reflexes • Hypertonicity of affected extremities • Continuation of primitive reflexes • In some children, failure to progress to protective reflexes
When a mother is compressing the Vena Cava she will present with what s/s?
Hypotension, diaphoretic and Light headedness.
18 & 19. Intracranial Regulation: Brain Tumor. Classifications and clinical manifestations.
I. Intracerebral Tumors A. Gliomas—infiltrate any portion of the brain; most common type of brain tumor 1. Astrocytomas (grades I and II) 2. Glioblastoma (astrocytoma grades III and IV) 3. Oligodendroglioma (low and high grades) 4. Ependymoma (grades I to IV) 5. Medulloblastoma II. Tumors Arising From Supporting Structures A. Meningiomas B. Neuromas (acoustic neuroma, schwannoma) C. Pituitary adenomas
Tetralogy of Fallot TREATMENT
If tet spell: -Knee-chest position -Morphine -Vasoconstrictors (propranolol) -Oxygen Surgeries: -Blalock shunt = connecting subclavian artery to pulmonary artery
historonic personality disorder
Impulsive attention seeking excessive emotionality
An African-American mother who delivered her first baby and is on the mother-baby unit, calls the nursery nurse into her room and expresses concern about how her daughter looks. The mother tells the nurse that her baby's head looks like a "banana" and is mushy to the touch, and she has "white spots" all over her nose. In addition, there appear to be "big bluish bruises" all over her baby's buttocks. She wants to know what is wrong with her baby and whether these problems will go away. a. How should the nurse respond to this mother's questions?
In a calm manner, explain to Ms. Scott that all her observations are normal variations and address each one separately: • "Banana-shaped head"—is MOLDING where the newborn had a slight overriding of the skull bones to navigate the bony pelvis and birth canal during the birth process • "Mushy" feel to head—CAPUT SUCCEDANEUM, which is an edematous area of the scalp as a result of sustained pressure of the occiput against the cervix during labor and birth process • "White spots on nose"—MILLIA, which are plugged, distended, small, white sebaceous glands that are present in most newborns and should not be squeezed by the mother • "Blue bruises on buttocks"—MONGOLIAN SPOTS, which are bluish-black areas of pigmentation that are common in African Americans and have no clinical significance, but can be mistaken for bruises
Tetralogy of Fallot (Management of Cyanosis)
In newborns and very young infants with severe CYANOSIS, prostaglandin infusion will maintain patency of the ductus arteriosus, IMPROVING PULMONARY BLOOD FLOW.
The gravid uterus can periodically occlude what structure that can cause episodes of dizziness, lightheadedness, or syncope?
Inferior Vena Cava
UTI patient teaching to prevent recurrence
Know at risk people: -debilitated people -older people -immune compromised -conditions that cause urinary stasis Health promotion activities: -empty regularly and completely -evacuate bowel regularly -wipe from front to back after going -drink 15ml/lb/day -drinking cranberry juice/tab may reduce attachment of pathogens to bladder epithelium -seek treatment asap For hospital acquired UTI: -RN must follow aseptic technique -wash hands before/after procedure or contact with pt -wear gloves -routine/thorough perineal hygiene especially when a bed pan is used
Which of the following symptoms should the nurse teach a group of women using oral contraceptives to report immediately to the physician?
Leg pain and Edema
Phenobarbital
Luminal
Secondary brain tumors
Metastasize from breast or lung tumors Cause effects similar to those of primary brain tumors
ischemic stroke
Most common type of stroke in older people, occurs when the flow of blood to the brain is blocked by the narrowing or blockage of a carotid artery.
Severe Preeclampsia:
NO seizures, Hyperreflexia, Headaches, Oliguria, Blurred Vision, Epigastric or RUQ pain, pulmonary edema, thrombocytopenia, cerebral disturbances, HELLP
Musculoskeletal Injuries: Gerontologic Considerations and Prevention of Complications
Older adults who have low bone density and who tend to fall frequently have high incidence of hip fracture. -Stress and immobility related to trauma predispose older adult to complication (pneumonia, sepsis, VTE, pressure ulcers, and decreased coping ability). -Nurse MUST assess the older patient for chronic conditions that require close monitoring (edema due to heart failure, absence of peripheral pulses from vascular disease, respiratory problems, etc.) -Coughing and deep breathing is encouraged. -Dehydration and poor nutrition may be present. (Contribute to pressure ulcers) -Encourage joint movement except involved joints
c. What reassurance can be given to this new mother regarding her daughter's appearance?
One can assume that this mother's concern is that these various normal deviations might be permanent. The nurse can identify each and provide reassurance about their approximate time of disappearance: • Molding—transient in nature and should disappear within 72 hours • Caput succedaneum—disappears spontaneously within 3 to 4 days • Milia—will clear up spontaneously within the first month • Mongolian spots—will gradually fade during the first or second year
When assessing a neonate. Which heart defect at 30 weeks has signs and symptoms of BOUNDING PULSES, TACHYPNEA, TACHYCARDIA, and CRACKLES/THRILLS?
PATENT DUCTUS ARTERIOSUS
Positive Homan's sign
Pain in the calf upon flexing the knee and arching or cramping upon dorsiflexion of the foot.
Meningococcemia (neisseria meningitidis)
Pink macules and papules, petechiae (purple rash), hemorrhagic petechiae, hemorrhagic bullae, purpura fulminans
What is an airway clearance technique in which the patient exhales against a fixed orfice flow resistor to help move secretions into the larger airway for expectoration via cough or swallowing?
Positive Expiratory Pressure (PEP)
Alprostadil MOA
Prostaglandin E agent - stimulates adenyl cyclase and production of cAMP - causes vasodilation of the ductus arteriosus smooth muscle -indicated for temporary maintenance of ductus arteriosus patency in infants with ductal-dependent congenital heart defects
The client may report that the president is speaking directly to him on a news broadcast of that special message are sent through the newspaper articles. This is an example of...
Referential delusion
Which of the following would have a negative impact on the client's ability to conceive a child?
Reports history of Uterine fibroids.
A nurse needs to obtain a good monitor tracing on a client in labor. The client lies in a supine position. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which action should the nurse perform first?
Reposition the client on her left side, Laying the patient on her left side which will help elevate pressure off of the vena cave helping with perfusion to the fetus and
What is the treatment of choice for ANXIETY in the ELDERLY?
SSRI ANTIDEPRESSANTS
The nurse is conducting an assessment of a 5-year-old client. During the assessment, the nurse notes that the child does not maintain eye contact or speak. The nurse suspects an Autism Spectrum Disorder. Which additional finding would help support the nurse's suspicion?
The child constantly opens and closes the hands. Explanation: Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for autism spectrum disorder.
A 6-year-old client who has been diagnosed with Autism Spectrum Disorder would be expected to display which behavior?
The client spends time alone and shows little interest in making friends. Explanation: Children with autism develop language slowly or not at all. They may use words without attaching meaning to them or communicate with only gestures or noises. They spend time alone and show little interest in making friends. Approximately 80% of people with autism also are classified as intellectually disabled.
Principles of Immunization
The immune system has the ability to recognize materials present in the body as "self" or "nonself." Foreign materials (nonself) are called antigens. When an antigen is recognized by the immune system, the immune system responds by producing antibodies (immunoglobulins) or directing special cells to destroy and remove the antigen.
How do benzodiazepines work in a client experiencing a seizure?
They are minor sedatives that prevents or stops seizures by slowing down the CNS, making abnormal electrical activity unlikely.
Intracranial Regulation
Three things that can affect intracranial regulation. 1) *Perfusion*: the brain is unable to store oxygen or glucose, so a constant flow of blood is necessary so the metabolic needs of the brain can be met. Interruption of blood flow can lead to tissue damage and death. 2) *Neurotransmission*: neurons must be able to communicate. This means that neurotransmitters are needed to help carry messages across the neuronal synapses. 3) *Pathology*: diseases like cancer and even infections can affect brain function leading to impaired intracranial regulation.
unclassified seizures
Type of seizure that cannot be placed into one of the other three categories because of incomplete data.
How is hydrocephalus treated?
VP shunt to elevate pressure and drain off excess fluid).
Diazepam
Valium
A pt is talking out loud and then stops and turns what is the nurse best response?
Who are you talking to?
AOM risk factors
Younger age. Daycare/nursery attendance. Formula feeding (breast-feeding protective). EUSTACHIAN TUBE DYSFUNCTION URTI. Allergies. Chronic sinusitis. Craniofacial abnormalities e.g. cleft palate, Down's Syndrome. Immunosuppression. Active or passive smoking.
ventricular septal defect (VSD)
a hole in the ventricular septum that causes blood to mix between the RV and LV -ACYANOTIC CONGENITAL HEART DEFECT -LEFT TO RIGHT SHUNT -LOUD HARSH MURMUR heard at LEFT STERNAL BORDER
Generalized seizures
a seizure that affects both sides of the brain
Chest physiotherapy (CPT)
a series of maneuvers including percussion, vibration, and postural drainage designed to promote clearance of excessive respiratory secretions.
embolic stroke
a type of ischemic stroke that causes a clot to travel to the brain, mostly from the left side of the heart
Which of the following findings in a newborn would be considered normal? a. Passage of meconium within the first 24 hours b. Respiratory rate of 80 breaths per minute c. Yellow skin tones at 10 hours after birth d. Bleeding from the umbilicus area
a. Passage of meconium within the first 24 hours -The correct response to this question is "A" since meconium is usually passed during the first 24 hours of life in most newborns.
Focal seizure
abnormal electrical activity that occurs in one or more parts of ONE BRAIN HEMISPHERE; partial seizure
active immunity
acquired when a person's own immune system generates the immune response. Active immunity lasts for many years or for a lifetime.
patent ductus arteriosus (PDA)
an abnormal opening between the pulmonary artery and the aorta caused by failure of the fetal ductus arteriosus to close after birth. This results in increased pulmonary blood flow. -can cause left sided heart failure -ACYANOTIC -LEFT to RIGHT shunt
A pregnant client close to term comes into the clinic for an exam. The woman complains about experiencing shortness of breath. The nurse knows that this complaint can be explained as the: a. Fetus is needing more oxygen now that his/her size is larger. b. Fundus of the uterus is high and pushing the diaphragm upwards. c. Woman is experiencing an allergic reaction because of high histamine levels. d. Oxygen partial pressure concentration is lower in the third trimester.
b. Fundus of the uterus is high and pushing the diaphragm upwards
Which of the following conditions would most likely cause a pregnant woman with type 1 diabetes the greatest difficulty during her pregnancy? a. Placenta previa b. Hyperemesis gravidarum c. Abruptio placentae d. Rh incompatibility
b. Hyperemesis gravidarum
When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: a. Initial period of reactivity b. Second period of reactivity c. Decreased responsiveness period d. Sleep period for newborns
b. Second period of reactivity -The behaviors demonstrated by the newborn, such as alertness, stabilized heart and respiratory rates, and passage of meconium are associated with the SECOND period of reactivity. The FIRST period of reactivity starts with a period of quiet alertness followed by an active alertness with frequent bursts of movement and crying. During the decreased responsiveness period, also called the sleep period, the newborn is relatively unresponsive and difficult to waken.
Which of the following would the nurse include when teaching a pregnant woman about the pathophysiologic mechanisms associated with gestational diabetes? a. Pregnancy fosters the development of carbohydrate cravings. b. There is progressive resistance to the effects of insulin. c. Hypoinsulinemia develops early in the first trimester. d. Glucose levels decrease to accommodate fetal growth.
b. There is progressive resistance to the effects of insulin.
The nurse performs a physical examination on a newborn 2 hours after birth. Which of the following findings indicate a need for a pediatric consultation? Select all that apply. a. Respiratory rate of 50 breaths per minute b. Intermittent episodes of apnea, lasting <10 seconds each c. Absent Moro reflex when startled d. Preauricular skin tag noted on left ear e. White raised bumps noted on nose and face f. Yellow blanching of the skin when pressure applied to the nose
c. Absent Moro reflex when startled f. Yellow blanching of the skin when pressure applied to the nose
Which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head? a. Two soft spots palpated between the cranial bones b. A spongy area of edema outlined on the head c. Head circumference 32 cm, chest 34 cm d. Asymmetry of the head with overriding bones
c. Head circumference 32 cm, chest 34 cm -The correct response to this question is "C" because the circumference of the newborn's head should be approximately 2 cm greater than the circumference of the chest at birth.
Sinemet
carbidopa/levodopa -type of dopaminergic medication to treat PARKINSON'S DISEASE
A child with CHD would show S&S of(6)
clubbing, murmur, poor wt gain/feeding, failure to thrive, fatigue & URI's
sweat chloride test
considered suspicious if the level of chloride in collected sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L
Tetralogy of Fallot
consists of four associated defects: -ventricular septal defect -dextroposition of the aorta -obstruction or narrowing of the pulmonary outflow channel -hypertrophy of the right ventricle
At birth, a newborn's assessment reveals the following: heart rate of 140 bpm, loud crying, some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink body with blue extremities. The nurse would document the newborn's Apgar score as: a. 5 points b. 6 points c. 7 points d. 8 points
d. 8 points
Which of the following newborns could be described as breathing normally? a. Newborn A is breathing deeply, with a regular rhythm, at a rate of 20 bpm. b. Newborn B is breathing diaphragmatically with sternal retractions, at a rate of 70 bpm. c. Newborn C is breathing shallowly, with 40-second periods of apnea and cyanosis. d. Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea.
d. Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea.
The epileptic cry occurs when the
diaphragm contracts to force air from lungs through vocal cords
An acoustic neuroma is a lesion on which cranial nerve?
eighth cranial nerve (nerve responsible for hearing and balance)
bradykinesia
extreme slowness in movement
Macrocephaly in infants can arise due to several factors, such as...
familial macrocephaly, hydrocephalus, neoplasms, or trauma. Infants who manifest rapid growth in head circumference after birth and have features of raised intracranial pressure such as tense anterior fontanelle, vomiting, or change in behavior must be evaluated for hydrocephalus.
The nurse is discussing the insulin needs of a primiparous client with diabetes who has been using insulin for the past few years. The nurse is teaching the client that her insulin needs will increase during pregnancy. The nurse knows the teaching is effective based on which response by the client?
hPl with decrease the effectiveness of my insulin -Gestational diabetes can cause Insulin resistance with placental hormones -Human placental lactogen (hPL) and growth hormone (somatotropin) increase in direct correlation with the growth of placental tissue, rising throughout the last 20 weeks of pregnancy and causing insulin resistance.
Fractures at the ends of long bones, where bone is more vascular and cancellous....
heal more quickly than fractures where bone is dense and less vascular (midshaft) -Weight-bearing exercises stimulates healing of stabilized fractures of long bones in lower extremities
cystic fibrosis (CF)
hereditary disorder of the exocrine glands characterized by excess mucus production in the respiratory tract, pancreatic deficiency, and other symptoms
Focal, Generalized, and Unclassified Seizures
involve UNCONTROLLED MOTOR activity
Cerebral palsy
is a disorder caused by abnormal development of, or damage to, the motor areas of the brain, resulting in a neurologic lesion.
Anaphylaxis
is caused by the interaction of a foreign antigen with specific IgE antibodies found on the surface membrane of mast cells and peripheral blood basophils.
Cerebellar Tumor in a Child
is most likely a Medulloblastoma or Pilocytic Astrocytoma, medulloblastomas are always solid and Astrocytoma are solid and cystic.
passive immunity
is produced when the immunoglobulins of one person are transferred to another. This immunity lasts only weeks or months. -can be obtained by injection of exogenous immunoglobulins. -also can be transferred from mothers to infants via colostrum or placenta
immunity
is the ability to destroy and remove a specific antigen from the body. The acquisition of immunity can be active or passive
By 40 weeks, the fetal head begins to descend and engage in the pelvis, this is called....
lightening
Large fontanels
more than 6 cm in the anterior diameter bone to bone or more than a 1-cm diameter in the posterior fontanel; possibly associated with malnutrition, hydrocephaly, congenital hypothyroidism, triso-mies 13, 18, and 21, and various bone disorders such as osteogenesis imperfecta.
What behaviors are common with Autism Spectrum Disorder?
not responding to won name by 1 year -doesn't show interest by pointing to object by 14 months -avoids eye contact -prefers to be alone -delayed speech & language skills -upset by minor changes in routine -unusual reactions to sounds, smells, or other experiences -REPEATS WORDS OR PHRASES OVER AND OVER
Absent seizure
petit mal, its a brief STARRING episode common in children. Does not necessarily mean that they will have another one.
What is meant by the definition AGEISM?
prejudice or discrimination against older people (predominate in our society)
Vest Airway Clearance System
provides high-frequency chest wall oscillations to increase airflow velocity to create repetitive cough-like shear forces and to decrease the viscosity of secretions.
flutter-valve device
provides high-frequency oscillations to the airway as the child exhales into a mouthpiece that contains a steel ball.
eeclampsia
seizures, hyperreflexia, severe headache, generalized edema, RUQ or epigastric pain, visual disturbances, cerebral hemorrhage, renal failure, HELLP
basal body temperature
the lowest temperature the body reached on awakening and PRE ovulation temperatures are suppressed by estrogen and POST ovulation temperatures are influence by progesterone
Symptoms of Parkinson's Disease
tremors, muscle rigidity, bradykinesia, postural instability, affective flattening
By the 20th week of pregnancy, the uterus is typically at or above the level of the mother's:
umbilicus and measures 20 cm A monthly measurement of the height of the top of the uterus in centimeters, which corresponds to the number of gestational weeks, is commonly used to date the pregnancy.
acoustic nueroma
unilateral tinnitus and hearing loss with or without vertigo or balance disturbance (staggering gait), painful sensation on side of face, may grow slow and considerable size before diagnosed, possible involuntary eye movement
Which behavior primary focus in limit setting?
verbal abuse of other patients
What are some contraindications for women going through menopause with hormone therapy? SELECT ALL THAT APPLY.
women with history of: -breast cancer -cardiovascular conditions -venous thrombosis -impaired liver function -uterine cancer -undiagnosed abnormal vaginal bleeding.
Risk factors for infertility in women include...
• Overweight or underweight (can disrupt hormone function) • Hormonal imbalances leading to irregular ovulation • Uterine fibroids • Tubal blockages • Cervical stenosis • Reduced oocyte quality • Chromosomal abnormalities • Congenital anomalies of the uterus • Immune system disorders • Chronic illnesses such as diabetes, thyroid disease, asthma • STIs • Ectopic pregnancy • Age older than 27 • Endometriosis • Turner syndrome • Eating disorders • History of PID • Smoking and alcohol consumption • Multiple miscarriages • Menstrual abnormalities • Exposure to chemotherapeutic agents and Psychosocial effects
Intracranial Regulation: Seizure Interventions
• Remain calm. • If child is standing or sitting, ease child to the ground, if possible. • Time seizure episode. • Tight clothing and jewelry around the neck should be loosened, if possible. • Place child on one side and open airway, if possible. • Do not restrain the child. • Remove hazards in the area. • Do not forcibly open jaw with a tongue blade or fingers. • Document length of seizure and movements noted, also cyanosis or loss of bladder or bowel control and any other characteristics. • Remain with child until fully conscious.
During the initial newborn assessment, look for signs that might indicate a problem, including:
•Nasal flaring •Chest retractions •Grunting on exhalation -small or large for gestational age
