S3 Unit 1 extras
When compared with their non-Hispanic white counterparts, which factors contribute to the health disparities among the older adult Hispanic population? Select all that apply. One, some, or all responses may be correct. 1 Value differences 2 Language barrier 3 Lack of health care facility 4 Inadequate health insurance 5 Poor diet and nutrition
1234
Which nurses are taking actions that contribute to the nursing goal of achieving cultural competence? Select all that apply. One, some, or all responses may be correct. 1 Nurse A examines own beliefs about mental health. 2 Nurse B reads an article about interpreting nonverbal behavior. 3 Nurse C volunteers at a clinic that serves an immigrant population. 4 Nurse D teaches children of immigrants about eating healthy food. 5 Nurse E uses a cultural assessment tool to gather client data.
1235 Cultural competence includes examining own values and beliefs (Nurse A), acquiring knowledge about behavior that is influenced by culture (Nurse B), encounters with people from other cultures (Nurse C), and using skills in caring for those who are different from one's self (Nurse E). Nurse D should have made a culturally relevant dietary assessment that included the parents before teaching children of immigrants about healthy food.
Which statements by the student nurse indicate an understanding of caring for clients of various cultures? Select all that apply. One, some, or all responses may be correct. 1 "The focus is on understanding the traditions, beliefs, and values of the client's culture." 2 "Care would be provided strictly on the basis of the traditions, beliefs, and values of the client's community." 3 "Generalized education and information would be provided to clients belonging to a different community." 4 "The cultural background of the client has no effect on his or her health, wellness, and illness." 5 "I will be aware of my own cultural background and beliefs when attending to clients who belong to different cultures."
15 To provide individualized care to the client, the nurse would focus on the client's traditions, beliefs, and values. The nurse would be aware of his or her own cultural background and beliefs to ensure that stereotypes and prejudices do not get in the way of client care. The nurse would refrain from assuming that every client follows the cultural practices and traditions of his or her community stringently. When educating a client about any illness or procedure, the nurse would understand that the client may have unique cultural perceptions regarding the cause of the illness and treatment and may need specific education and information. The nurse would understand that cultural background has an effect on a client's health care beliefs and that it affects his or her health, wellness, and illness.
what ages have the highest risk for getting meningitis
16-21
Which range of heart rate is acceptable for a preschooler? 1 60 to 100 2 80 to 110 3 75 to 100 4 90 to 140
2
Which statement made by the client is a socioeconomic influence on the client's health beliefs? 1 "I am a vegetarian; I cannot eat meat because it is against my tradition." 2 "I cannot afford expensive medications because I have to take care of my family." 3 "My family members always pray before a meal because it is important to thank God."
2 When a client states that he or she cannot afford expensive medications because he or she has to take care of a big family, this statement is an example of a socioeconomic influence on health beliefs. When a client says that he or she is a vegetarian and cannot eat meat because of this tradition, this statement is an example of the influence of cultural background on health beliefs. When a client says that his or her family members always pray before a meal, this statement is an example of the influence of family practices. When a client says that he or she believes that infant vaccinations are sinful, this statement is an example of spiritual factors influencing health beliefs and practices.
Which parameter would the nurse assess first when evaluating memory impairment in a client with Alzheimer disease? 1 Disorientation of self 2 Recollection of past events 3 Remembrance of recent events 4 Impaired ability to name objects
3 The nurse would assess remembrance of recent events first. A common sign of Alzheimer disease is the loss of memory for recent events. Disorientation of self is not a common early sign of Alzheimer disease; disorientation to time and place is more common. Recollection of past events is less impaired than that of recent events. Impaired ability to name objects is not as common as recent memory loss; impaired ability to name objects occurs later in the disease.
Nihilistic delusion
False feeling that self, others or the world is nonexistent or coming to an end
autonomic dysfunction syndrome
a problem with the autonomic nervous system that controls processes such as digestion, heart rate, the immune system and more
The health care provider suspects a client has tuberculosis and prescribes a purified protein derivative (PPD) test, chest x-ray, and sputum culture. Prioritize implementation of the ordered interventions. 1. Institute airborne precautions. 2. Perform a PPD intradermal skin test. 3. Have a chest x-ray performed. 4. Obtain a sputum specimen. 5. Notify the Department of Health.
airborne chest xray ppd intradermal skin test sputum notify health department
mood symptom of schizophrenia
depression anxiety demoralization suicidal excitability aggitation
myalgia
pain in the muscle
what is the purpose of combination therapy for TB
reduce the length of treatment time not for highly resistant cases
goals of the acute phase for patients with schizophrenia
safety medical stabilization
A client experiencing delusions of being poisoned is admitted to the hospital. The client shows no evidence of dehydration and malnutrition at this time. The nurse creates a plan of care for the client and would include which client need as the priority?
safety and security
gustatory hallucinations
tasting things that are not present "i am not eating this because it tastes like someone posioned it"
what do you do when a patients liver function tests are elevated and taking rivastigme
notify PCP because hepatoxicity is a side effect
what age is most at risk for schizophrenia
young adults
Which ability would the nurse expect of a client in the middle stages of Alzheimer disease to be able to do? 1 Recall events from the past 2 Cope effectively with anxiety 3 Follow a simple schedule without help 4 Remember what was eaten on the previous day
1 The client in the middle stages of Alzheimer disease would recall events from the past. Long-term memory appears to be less disturbed by this disorder and remains intact for a longer period. The ability to cope with anxiety is impaired. These clients need assistance to follow a schedule, regardless of how simple it is. Remembering what was eaten on the previous day requires the use of short-term memory, which is impaired early in the disorder.
The nurse reviews the medical records of four male clients. Which client would the nurse note as having the highest risk for development of clinical manifestations related to prostate cancer? 1 African American 55-year-old 2 White 45-year-old 3 Asian 55-year-old 4 Hispanic 45-year-old
1
A client says, "It sounds like there is a roaring fire in the bathroom!" In reality, the client's roommate has just turned on the shower. Which term describes this experience? 1 Illusion 2 Delusion 3 Dissociation 4 Hallucination
1 An illusion is a misperception of an actual stimulus. A delusion is a fixed false belief that is unrelated to an external stimulus. Dissociation is a disturbance in the integrative functions of the client. A hallucination is a false perception with no actual external stimulus.
The nurse is interacting with a client demonstrating positive, cognitive, and affective symptoms of a relapse of schizophrenia. Which statements reflect that the nurse understands the management of these types of symptoms? Select all that apply. "Do you think about hurting yourself?" 2"I can't let you use that broken mirror; it isn't safe." 3"Are you still hearing voices? What are they telling you?" 4"Can you be more specific about what you would like to eat for breakfast this morning?" 5"It is time to prepare for sleep; please take your toothbrush and toothpaste into the bathroom."
1235 Positive symptoms of schizophrenia include auditory hallucinations, or hearing voices, as well as concrete thinking, which requires simple instructions. Cognitive symptoms involve the presence of poor judgment, which can result in physical injury due to an inability to recognize unsafe situations. Affective symptoms involve the expression of emotion with possible depression and suicidal tendencies being present. Negative symptoms would include poverty of content of speech, which would require effort to get additional specific information from the client.
The nurse managing the care of a client diagnosed with schizophrenia would include which intervention in the client's plan of care after the client is prescribed an antipsychotic medication? Select all that apply. Encourage the client to chew gum. 2Assess the client for possible urinary retention. 3Educate the client to the increased risk of developing hypoglycemia. 4Monitor the client's menu selections to ensure adequate fiber consumption. 5Provide the client with sunglasses when being taken outdoors for recreational walks.
1245 Antipsychotic medication can produce side/adverse effects that include urinary retention, dry mouth, constipation, and photosensitivity. Hyperglycemia is a potential risk with the use of some antipsychotic medications.
Which are the benefits of providing culturally competent care? Select all that apply. One, some, or all responses may be correct. 1 Increased client safety 2 Limits number of visitors 3 Reduced health disparities 4 Increased client satisfaction 5 Ensures adequate interpreters
134 Cultural competence is the ability to understand, appreciate, and work with individuals from cultures other than one's own and involves awareness and acceptance of differences. Cultural competence leads to increased client safety, reduced health disparities, and increased client satisfaction. Cultural competence does not limit the number of visitors that clients receive. Cultural competence does not ensure adequate interpreters; however, there are other means of facilitating communication, such as translation devices, that can be useful.
what are signs of IICP in school age kid 1. slurred speech 2. sun setting eyes 3. distended scalp veins 4. morning n/v 5. increased head circumference
14 the others are for infants
which of these increases the risk for TB 1. alcohol abuse 2. history of CHF 3. recent immigration from spain 4. lack of permamnent residence 5. recent release from a correctional facility
145
Which assessment finding alerts the nurse to suspect increasing intracranial pressure in an infant? 1 Sunken eyes 2 Projectile vomiting 3 Depressed fontanels 4 Narrowing pulse pressure
2
Which factor is associated with culture-bound syndrome? 1 Traits are inherited and genetically linked. 2 Etiology may be mystical or spiritual. 3 Signs and symptoms have no organic cause. 4 Illnesses respond only to culture-bound treatments
2
Which statement of the nurse is true regarding disasters? 1 "Multicasualty and mass casualty disaster events are same." 2 "An internal disaster creates a need for evacuation or relocation." 3 "External disasters, rather than internal disasters, result in death." 4 "Multicasualty events require the collaboration of multiple agencies."
2 An internal disaster is an event that occurs inside a health care facility and endangers the safety of staff or clients. It creates a need for evacuation or relocation. Multicasualty and mass casualty disaster events are not the same. Both external and internal disasters may result in deaths. Multicasualty events are managed by a hospital using local resources.
Which approach would the nurse take for a client with Alzheimer disease who is fearful and anxious about being admitted? 1 Exploring the reasons for the client's concerns 2 Reassuring the client with the presence of same staff members 3 Initiating the program of various planned interactions and activities 4 Explaining the purpose of the unit with why admission was necessary
2 Reassuring the client with the presence of same staff members is the approach the nurse would take. The client needs constant reassurance, because forgetfulness blocks previous explanations; presence of the same staff members serves as a continual reminder. This client will be unable to explain the reasons for concerns because of the dementia. Too many varied activities will increase anxiety in a client with Alzheimer disease. Clients with dementia need simple, structured, routine environments and activities. This client will not remember the explanation from one moment to the next.
Which signs and symptoms are characteristic of Alzheimer dementia? Select all that apply. One, some, or all responses may be correct. 1 Ambivalence 2 Forgetfulness 3 Flight of ideas 4 Loose associations 5 Expressive aphasia
25 Older clients who have dementia often have short-term memory loss. Clients in whom dementia is developing often have difficulty expressing themselves (expressive aphasia) or understanding the spoken word (receptive aphasia). Clients with the diagnosis of schizophrenia or depression are often indecisive and ambivalent. A client who is experiencing a manic episode of bipolar disorder experiences flight of ideas. Loose associations between thoughts are related to schizophrenia.
English-speaking parents of an adopted Spanish-speaking preschooler inform the nurse that the child often stutters while speaking. Upon assessment, the nurse finds that there is no hearing impairment, brain injuries, or developmental disorders in the child. Which would the nurse suspect is the cause of the stuttering? 1 The child is pressured to speak English well. 2 The child is not comfortable with the new environment. 3 The change in language exposure has caused stuttering. 4 The parents do not provide a happy environment for the child.
3
The nurse is managing the care of a client with acute schizophrenic relapse. How does the nurse advocate for the client regarding expected needs during the anticipated stabilization phase? The nurse maintains a stable, predictable milieu. 2The nurse fosters a mutually respectful, supportive nurse-client relationship. 3The nurse includes the client in discussions regarding supervised group-home living arrangements. 4The nurse assesses the understanding of the condition processed by both the client and the family members.
3 Advocating supports the client's right to be involved in treatment decision-making. One of the decisions made in preparation for the stabilization phase of a client recovering from a relapse of schizophrenic symptomology is appropriate housing arrangements. Maintaining a therapeutic milieu and nurse-client relationship are nursing responsibilities that are expected and strived for during all phases of client care. Assessing understanding of the condition would be done periodically throughout the client's period of care.
A child is brought into the emergency department with a diagnosis of early chicken pox (varicella). Of all of the equipment needed, which one is most important for the nurse to have ready at the bedside? 1Gown 2Gloves 3Face masks 4Hand sanitizer
3 Face masks are needed for a client with chicken pox, as airborne precautions are required. A special precautions cart set up for airborne precautions needs to be outside the room, and donning needs to be done before entering. Gowns and gloves are also needed, but masks are most important when caring for a client with chicken pox.
Mini-Cog Test
Assesses dementia by having patients remember and repeat three common objects and draw a clock face indicating a particular time.
Which manifestation is an extrapyramidal side effect of chlorpromazine? Select all that apply. One, some, or all responses may be correct. 1 Drooling 2 Facial tics 3 Shuffling gait 4 Tongue rolling 5 Restless movement
all Extrapyramidal symptoms (EPS) are adverse effects of antipsychotic medications and include drooling, facial tics, shuffling gait, tongue rolling, and restless movements. Parkinsonism symptoms include drooling and a shuffling gait. Tardive dyskinesia can manifest with facial tics and tongue rolling. Akathisia is characterized by restless movements.
what liver problem needs sodium restrictions
ascites
somatic delusions
believes that his body is changing in an unusual way, such as growing a third arm ex - "my heart no longer works, i am dead"
grandeur delusion
believing that one is a very powerful or important person
donepezil toxicity symptoms
bradycardia hypotension blurred vision hyperhidrosis muscle weakness n/v
neurocognitive impairments in schizophrenia are evidenced by
disorganized thinking and disorganized speech not psychosis substance abuse or disorganized personality
Hepatitis diet
high calorie, high protein, moderate fat and protein after nausea subsides
The nurse is performing the confusion assessment method (CAM) on an older client. What general categories are included in this assessment? Select all that apply.
inattention disorganized thinking altered LOC acute onset and fluctuating coarse
A client diagnosed with schizophrenia has a new prescription for risperidone. The nurse would review which baseline laboratory result before administering the first dose of this medication?
liver function studies
The nurse is advised to join a community health center that mainly caters to Latino clients. Which skills would the nurse develop to help reduce health disparities? Select all that apply. One, some, or all responses may be correct. 1 Learning to speak basic medical Spanish 2 Updating clinical supplies at the health care facility 3 Learning about the health literacy rate of the community 4 Incorporating the health beliefs of the community in any nursing care plans
1345 To provide effective health care service to the ethnic group, the nurse would learn to speak basic medical Spanish. This promotes communication and develops trust between the nurse and the clients. Learning about the clients' health literacy can help the nurse identify areas of opportunity for client education and health promotion. Incorporation of beliefs and values in plans of care can make the care more effective. The nurse would learn about the unique values and beliefs of the ethnic group and respect them to deliver equitable health care. Updating the clinical supplies at the health care facility is a basic responsibility of the nurse but will not help reduce health disparity.
Which intervention(s) will the nurse include in a care plan for a client with Alzheimer disease? Select all that apply. One, some, or all responses may be correct. 1 Limit choices. 2 Use all side rails. 3 Toilet every 2 hours. 4 Ask open-ended questions. 5 Encourage participation in self-care
135 Clients with Alzheimer disease need limited choices; having too many choices can increase confusion and frustration. Toileting every 2 hours supports bladder and bowel training and continence. Encouraging participation in self-care supports independence. The use of all side rails or any other form of restraints needs to be avoided in clients with dementia; trying to free themselves from the restraints can lead to injury. Simple "yes or no" questions are best. Open-ended questions can be confusing and overwhelming.
The nurse is providing care to a bilingual preschool-age child. Which expectations would the nurse have regarding the child's language development? Select all that apply. One, some, or all responses may be correct. 1 Disabilities will manifest in both languages. 2 The language spoken in the home will be less developed. 3 The child will only be able to read in one of the languages. 4 Milestones are reached at the same stage for both languages. 5 Bilingual children often act as medical interpreters for their families.
14 When planning care for a bilingual preschool-age child, the nurse would consider that language disabilities will manifest in both languages and that milestones for both languages will be reached during the same time frame. There is no evidence that the language spoken in the home will be less developed. A bilingual child will be able to read in both languages. Bilingual children should not act as medical interpreters for their family members.
A client diagnosed with schizophrenia is demonstrating the classic behaviors associated with a psychotic relapse. How would the nurse best assess the client's current potential to be violent? Arrange for one-on-one observation of the client. 2Ask the client, "What are your voices saying to you?" 3Ask family members whether the client is generally an angry, aggressive person. 4Review the client's medical record to determine when the behaviors began.
2 A classic symptom of psychotic behavior is hallucinations, particularly command hallucinations that direct a person to take a specific action that can be aggressive. Although general personal traits can be a predictor of behavior, a trigger for violence is command hallucinations. The duration of the symptoms is not as predictive of violence as is the presence of aggressive command hallucinations. One-on-one observation may be an appropriate intervention, but that is determined only after a thorough assessment has been conducted.
A client with hepatitis A experiences anorexia, fatigue, and jaundice. The client's spouse and adult children living at home ask whether they should receive gamma globulin. Which response would the nurse make to the client's family? 1 "Gamma globulin is unnecessary, as long as you follow droplet precautions until the client is asymptomatic." 2 "Gamma globulin injections provide passive immunity for hepatitis B, not hepatitis A." 3 "You should call your primary health care provider immediately about obtaining gamma globulin injections." 4 "Your family member's type of hepatitis is no longer communicable, and gamma globulin is not required."
3 Gamma globulin provides passive immunity to hepatitis type A, if administered to the household or sexual contacts within 2 weeks of exposure. Gamma globulin may provide some protection for those exposed to hepatitis A; contact, not droplet, precautions should be followed. Gamma globulin provides passive immunity for hepatitis type A, not type B. Gamma globulin provides some protection; the hepatitis type A virus is found in the stools of infected individuals before the onset of symptoms and during the first few days of illness.
Which parental statement would the nurse interpret as indicating a need for further teaching when educating the Hispanic parents of a preschooler about preventing lead exposure? 1 "We'll use cold water to cook and drink." 2 "We know to not store food in open cans." 3 "We can use orange powders for diarrhea." 4 "We'll start planning healthy midmorning and afternoon snacks."
3 Greta and azarcon (also known as alarcon, coral, luiga, maria luisa, and rueda), traditional Hispanic remedies taken for upset stomach, constipation, diarrhea, and vomiting, are also used for teething babies. Both are fine orange powders with a lead content as high as 90%. Further teaching is required if the family indicates that they will continue treating diarrhea with a home remedy. Food should not be stored in open cans, particularly those that have been imported. Cold water for consumption (drinking, cooking, and especially reconstitution of powdered infant formula) should be used; hot water dissolves lead more quickly than does cold water, yielding a higher level of lead. Frequent healthy snacks are encouraged because lead is absorbed better on an empty stomach.
Which statement regarding an interpreter is correct? 1 Relatives or friends of the client can serve as interpreters. 2 The interpreter would be able to make literal, word-for-word translations. 3 Interpreting not only the language but also the culture is important. 4 As long as the health care provider is caring for the client, the interpreter should be available.
3 The health care facility should be able to provide interpreters to the clients who cannot speak English or do not speak English well enough to meet their communication needs. The interpreter should be able to interpret not only the language but also the culture. Health care facilities should not rely on relatives or friends of the client for interpreting, because they may not be as open as needed during the encounter. Literal translations are not necessary; words in one language can carry many different connotations in another language. The interpreter should be available at all points of contact but not when communication between the client and the health care provider is not occurring.
Which priority factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment? 1 Level of interest in unit activities 2 Orientation to time, place, and person 3 Ability to perform tasks without becoming frustrated 4 Cognitive impairment, which will increase until adjustment to the home is accomplished
3 The nurse would consider ability to perform tasks without becoming frustrated. When the client is unable to perform a task, frustration occurs and results in more disorganized behavior. Clients with disorientation and cognitive impairment may show little interest in unit activities but should be included to the best of their ability. However, this does not address the client's disorganized behaviors. Although orientation is important, the client's disorientation is already documented; more important is the assessment of the client's ability to function. Although cognitive impairment is important, adjusting to the nursing home may never be fully achieved.
Which description of symptoms is consistent with dementia of the Alzheimer type? 1 Symptom onset is fairly rapid. 2 Symptoms will subside periodically. 3 Symptoms are triggered by personal crisis. 4 Symptoms reflect progressive disintegration
4 Dementia, of the Alzheimer type, results from pathological changes of the central nervous system cells, producing deterioration that is long-term and progressive. These changes involve cognitive, functional, and behavioral changes that reflect predictable stages (stage 1, mild; stage 2, moderate; stage 3, severe). The duration of Alzheimer disease is 3 to 20 years, with an average of 10 years. Symptoms of delirium, not dementia, develop rapidly as a result of derangements of cerebral metabolism and neurotransmission. Once neurons are destroyed, remissions are uncommon. Interpersonal events do not precipitate dementias.
Which portion of the brain is involved with auditory hallucinations? 1 Parietal lobe 2 Frontal cortex 3 Occipital lobe 4 Temporal lobe
4 The temporal lobe helps individuals focus on environmental events and integrates smell and hearing. The parietal lobe receives and integrates information about taste and touch. The frontal cortex receives input from all areas of the brain and integrates information about body position, memory, arousal states, and emotions. The occipital lobe is involved in the perception of visual input and depth perception.
Which explanation best describes what is known about the pathophysiology of dementia of the Alzheimer type? 1 There is a genetic predisposition and dysregulation of neurotransmitters. 2 The dementia is transient and secondary to a physical imbalance or disorder. 3 Hypoxia and decreased perfusion of select areas of the brain causes tissue damage. 4 The presence of amyloid plaques is associated with brain tissue destruction.
4 When an older person's brain atrophies, some unusual deposits of iron are scattered on nerve cells. Throughout the brain, areas of deeply staining amyloid, called senile plaques, can be found; these plaques represent the end stage of destruction of brain tissue. Genetic predisposition, dysregulation of neurotransmitters, and social and environmental factors are associated with depression. Delirium is transient and can be caused by many physical disorders, such as electrolyte imbalance, sepsis, or adverse medication effects. Hypoxia and decreased perfusion of selected areas of brain tissue are typical of vascular dementia.
what is the first action when a pediatric patient develops status epilepticus
apply oxygen
what is related to the changes that causes alzheimers
development of twisted neurofibrillary tangles accumulation of high levels of beta-amyloid protein promotion of plaque formation by apolipoprotein E4 neuritic plaques forming outside of the neurons and in the cerebral cortex
when is rivastigme given
early alzheimers
what criteria would be present for a probable diagnosis of alzheimers
genetic mutation evidence of a memory deterioration lack of evidence for a mixed etiological systemic disorder (infection)
most effective way to minimize the risk for getting bacterial meningitis
get the meningococcal vaccine especially for shared residence, traveling to other countries, immunocompromised
ataxia is associated with
lack of muscle coordination early child sign of hydrocephalus
risk for children in getting TB
malnutrition chronic illness close contact with IV drug users immigration urban, low-income living
olfactory hallucinations
smelling odors that are not really present
why does meningitis develop quickly in preadolescence
the fluid around the brain (CSF) has nutrients that support the growth of bacteria (protein and glucose)
Erotomanic delusions
when an individual believes falsely that another person is in love with him or her
