TEST 5 CC
RA labs
Anti-CCP ESR CRP ANA x-ray
Ipatropium (Atrovent)
Anticholinergic Inhibits interaction of acetylcholine Side effects: Anxiety, dizziness, headache, nausea, vomiting, cramps, cough, worsening of symptoms, palpitations (dysrhytmias)
RA medications
Nonbiologic DMARD NSAIDs (ibuprofen and naproxen) COX-2 enzyme blockers Opioid analgesics Cyclosporine Corticosteroids Methotrexate Cyclophosamide Azathioprine Prosorba
To help assess a client's cerebral function, a nurse should ask: a. "Have you noticed a change in your memory?" b. "Have you noticed a change in your muscle strength?" c. "Have you had any problems with coordination?" c. "Have you had any problems with your eyes?"
"Have you noticed a change in your memory?"
A family of a patient with Alzheimer's disease asks the nurse what causes the condition? Which response by the nurse would be most appropriate? a. "This condition is most likely due to a stroke that the patient didn't realize he had." b. "A specific gene is involved in the development of this disorder." c. "Evidence shows that there are changes in nerve cells and brain chemicals." d. "The numerous drugs that he was taking contributed to his current confusion."
"Evidence shows that there are changes in nerve cells and brain chemicals."
Infantile Spasms Medications
Adrenocorticotropic hormone (ACTH), corticosteroids, and vigabratin
Tonic-clonic (Generalized) nursing priorities
Maintain airway, assess and document seizure activity.
Ischemic stroke diagnoses
Medical history Complete physical and neurologic examination Airway patency assessment, including gag or cough reflex Noncontrast CT scan 12-lead ECG and carotid ultrasound CT angiography on MRI and angiography Transcranial doppler Transthoracic or transesophageal echocardiography Xenon-enhanced CT scan Single photon emission CT (SPECT) scan
Absence (petit mal) medication
Ethosuximide, zonisamide
Which neurotransmitter is implicated in depression? a. Atropine b. Serotonin c. Acetylcholine d. Epinenphrine
Serotonin
A nurse is presenting a safety program to a group of older adults at a continuing care retirement community. The nurse emphasizes measures to reduce the risk of falls based on the understanding that which type of fracture is most common? a. Forearm b. Hip c. Femur d. Ankle
Hip
A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted to older adults, what must be used with caution? a. Hot or cold packs b. Analgesics c. Anti-inflammatory medications d. Whirlpool baths
Hot or cold packs
A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to: a. forget to eat. b. not change his position often. c. exhibit acquiescent behavior. d. wander.
wander
Hemorrhagic medications
Phenytonin (Dilantin) to prevent seizures Insulin to treat hyperglycemia Analgesic agents are given for head and neck pain Antihypertensive medications are given to control hypertension (hydralazine, labatalol, and nicardipine) If patient is on Coumadin - fresh frozen plasma and vitamin K
The nurse is attempting to take vital signs of an older adult hospitalized following knee surgery. The client continuously yells, "It's 1999 and you are going to hurt me!" What action should the nurse do first? a. Reorient the patient b. Take the vital signs c. Notify the physician d. Assess for infection
Reorient the patient
Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. The nurse a. Assess the grandmother for adventitious lung sounds b. Informs the family that this is a result of aging c. Administers donepezil (Aricept) every day d. Recommends placement of the grandmother in a nursing home
Assess the grandmother for adventitious lung sounds
Rheumatoid arthritis (RA) patho
Autoimmune reaction. Breaks down collagen causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroys cartilage and erodes the bone.
Status epilepticus nursing assessment
Prolonged seizure or repeated seizures lasting longer than 30 mins with no intercranial recovery. Most common pediatric neurologic emergency; possibly resulting in permanent neurologic sequelae.
A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by a. Placing one food at a time in front of the client during meals b. Cutting the client's food into small pieces c. Serving hot foods at a warm temperature d. Converting liquid foods a gelatin texture
Placing one food at a time in front of the client during meals
A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. The defecit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? a. Risk for aspiration b. Risk for falls c. Risk for impaired skin integrity d. Decreased intracranial adaptive capacity
Risk for aspiration
The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis for risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following? a. Communication difficulties b. Separation from others c. Personality changes d. Impaired memory
d. Impaired memory
SLE (Systemic lupus erytheamosus) patho
Body's immune system inaccurately recognizing one or more components of the cell's nucleus as foreign, seeing it as an antigen.
Partial (focal) seizure medications
Topiramate
A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate? a. Continue taking the vital signs b. Place the client in a secluded room until calm c. Distract the client with a familiar object or music d. Document the inability vital signs due to client's agitation
Distract the client with a familiar object or music
Hemmorhagic diagnoses
CT or MRI scan Cerebral angiography (confirms diagnosis or intracranial aneurysm or AVM) Lumbar puncture (only if CT negative and no evidence of CT) Toxicology screen for patients younger than 40 years
Atrial fibrillation medication
Coumadin (Warfarin) for anticoagulation
Tonic-clonic (Generalized) medications
Primidone
The nurse is caring for an elderly client who is being treated for community-acquired pneumonia. Since the time of admission, the client has been disoriented and agitated to varying degrees. Appropriate referrals were made and the client was subsequently diagnosed with dementia. What nursing diagnosis should the nurse prioritize when planning this client's care? a. Social isolation related to dementia b. Hopelessness related to dementia c. Risk for infection related to dementia d. Acute confusion related to dementia
Acute confusion related to dementia
tPA (tissue plasminogen activator)
Recombinant tPA dosing 0.9 mg/kg within 3 hours of onset of symptoms Transarterial tPA within 6 hours of onset of symptoms Disadvantages: Risk for hemmorhage, dislodgement of clot
Which condition is characterized by a decline in intellectual functioning? a. Depression b. Dementia c. Delirium d. Delusion
Dementia
Damage to the frontal lobe
Learning capacity, memory, or other higher cortical intellectual functions
Complex partial seizures nursing assessment
Mouth movements (chewing, lip smacking), hand movements (picking at clothing, "pill rolling", grasping at objects), rubbing genitalia, eye blinking, head turning, raising of arm, or autonomic symptoms such as vomiting, retching and drooling.
A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse? a. Relocation stress syndrome related to hospitalization b. Defensive coping related to diagnosis of Alzheimer's disease c. Risk for caregiver role strain related to increased client care needs d. Decisional conflict related to lack of relevant treatment information
Risk for caregiver role strain related to increased client care needs
The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. a. The ability to select basic medications for the neurologic dysfunction b.Understanding of the tests used to diagnose neurologic disorders c. Knowledge of nursing interventions related to assessment and diagnostic testing d. Knowledge of the anatomy of the nervous system e. The ability to interpret the results of diagnostic tests
Understanding of the tests used to diagnose neurologic disorders Knowledge of nursing interventions related to assessment and diagnostic testing Knowledge of the anatomy of the nervous system
Which structural and motor change is related to aging and may be assessed in geriatric clients during an examination of neurological function? a. Decreased or absent deep tendon reflexes b. Increased pupillary responses c. Increased autonomic nervous system responses d. Enhanced reaction and movement times
Decreased or absent deep tendon reflexes
An 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The client is oriented to name only. The client's family is very upset because, before having surgery, the client had no cognitive deficits. The client is subsequently diagnosed with postoperative delirium. What should the nurse explain to the client's family? a. This problem is self-limiting and there is nothing to worry about. b. Delirium involves a progressive decline in memory loss and overall cognitive function. c. Delirium of this type is treatable and her cognition will return to previous levels. d. This problem can be resolved by administering antidotes to the anesthetic that was used in surgery.
Delirium of this type is treatable and her cognition will return to previous levels.
Hemmorhagic and Ischemic stroke prevention
Encourage patients to control hypertension Maintain a healthy weight Follow a healthy diet (including a modest alcohol consumption, and exercise daily) Stop smoking
Absence (petit mal) nursing priority
Ensure safety and initiate precaution for patient at-risk for seizures.
What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a. Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the top of the MRI table b. Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table c. Note that no special safety actions need to be taken d. Ensure that no client care equipment containing metal enters the room where the MRI is located
Ensure that no client care equipment containing metal enters the room where the MRI is located
A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to a. Encourage the mother to take responsibility for cooking and cleaning the house b. Ensure that the mother does not have access to car keys or drive an automobile c. Allow the mother to smoke cigarettes outside on the porch without supervision d. Turn off lights at night so that the mother differentiates night and day
Ensure that the mother does not have access to car keys or drive an automobile
Fluticasone (Flonase)
Glucocorticoids Anti-inflammatory and vasoconstrictor properties relax bronchial smooth muscle. Side effects: Fever, headache, pharyngitis, sinusitis, angiodema, churg-strauss syndrome, anaphylaxis, adrenal insufficiency, bronchospasm.
Dexmethasone (Decadron)
Glucocorticoids Decreases inflammation Side effects: Depression, flushing, sweating, seizures, pseudotumor cerebri, hypertension, circulatory collapse, thromboembolism, heart failure, dysrhythmias, nausea, vomiting, and abdominal distention
Beclomethasone (QVAR)
Glucocorticoids Prevents inflammation Side effects: Headache, hoarsenss, candidal infection or oral cavity sore throat
SLE diagnostic
H&P, skin, creatinine, CBC, anti-DNA and anti-sDNA, Anti-sm, Anti-TNF
The nurse is providing client teaching to a client with early stage Alzheimer disease (AD) and her family. The client has been prescribed donepezil hydrochloride. What should the nurse explain to the client and family about this drug? a. It slows the progression of AD b. It cures AD in a small minority of clients c. It removes the client's insight that he or she has AD d. It limits the physical effects of AD and other dementias
It slows the progression of AD
Theophylline (Phyllocontin, Theochron)
Methylxanthines Relaxes smooth muscle of respiratory system by blocking phosphodiesterase which increases cAMP. Increase cAMP alters intracellular calcium ion movements. Side effects: Dizziness, seizures, palpitations, sinus tachycardia, dysrhythmias, nausea, vomiting.
A nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? a. Observing the reaction of pupils to light b. Observing the client's response to painful stimulus c. Using the Romberg test d. Assessing the client's sensitivity to temperature, touch, and pain
Observing the client's response to painful stimulus
A nurse conducts the Romberg test by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and prevents the client form being injured. In which way should the nurse interpret the client's result? a. Positive Romberg test, indicating a problem with LOC b. Negative Romberg test, indicating a problem with body mass c. Negative Romberg test, indicating a problem with vision d. Positive Romberg test, indicating a problem with equilibrium
Positive Romberg test, indicating a problem with equilibrium
A geriatric nurse practitioner is assessing older adults. The nurse practitioner knows that older adults sometimes have difficulty following directions during a neurologic examination or diagnostic procedure. What strategies can the nurse practitioner use to examine older clients? a. Offer incentives such as sweets b. Provide brief instructions, one step at a time c. Spread the examination over 2 or 3 days d. Suggest a nurse or an examiner who is of their age
Provide brief instructions, one step at a time.
Status epilepticus nursing priority
Provide emotional support to the family.
Hemmorhagic stroke clinical manifestations
Sudden severe headache Vomiting Early sudden changes in LOC Possibly focal seizure (due to frequent brain stem involvement) Neurologic defects including motor, sensory, cranial nerve, cognitive, and other similar to ischemic stroke) Loss of consciousness for a variable time Pain and rigidity of neck and spine, characteristic of an intracranial aneurysm rupture of AVM Possibly visual disturbances (visual loss, diplopia, ptosis) Tinnitus, dizziness or hemiparesis Severe bleeding
Infantile Spasms Nursing Assessment
Sudden, forceful, myoclonic contractions involving musculature of the trunk, neck, and extremities. Flexor type, extensor type, and extremities.
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? a. When, if any, was your last narcotic use? b. Do you have any history of forgetfulness? c. Have you been diagnosed with any mental health issues? d. Have you experienced any unusual sensations?
When, if any, was your last narcotic use?
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion to radiopaque dye. Which question is the most important for the nurse to ask? a. "When did you last have something to eat or drink?" b. "When did you last take any medication?" c. "Are you allergic to seafood or iodine?" d. "How much do you weight?"
"Are you allergic to seafood or iodine?"
A nurse is assessing an older adult for depression using the Geriatric Depression Scale. Which question would the nurse ask first? a. "Do you feel your life is empty?" b. "Do you often get bored?" c. "Are you basically satisfied with your life?" d. "Are you in good spirits most of the time?"
"Are you basically satisfied with your life?"
An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate? a. "What concerns you most about Alzheimer disease?" b. "Alzheimer disease can be a great burden on the family. What community resources do you know about?" c. "Once the underlying cause of the confusion is found and treated, your loved one will be better than ever." d. "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion."
"Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion."
A patient with Alzheimer's disease is prescribed donepezil (Aricept). When teaching the patient and family about this drug, which of the following would the nurse include? a. "This drug will help to stop the disease from getting worse." b. "Once it becomes effective, you can stop the drug." c. "The drug helps to control the symptoms of the disease." d. "He'll need to take this drug for the rest of his life."
"The drug helps to control the symptoms of the disease."
The nurse is assessing the client's mental status. Which question will the nurse include in the assessment? a. "Who is the president of the United States?" b. "Can you write your name on this piece of paper?" c. "Can you count backward from 100?" d. "Are you having hallucinations now?"
"Who is the president of the United States?"
Febrile seizures medications
Antipyretics
Febrile seizures nursing priorities
Assess child colour, vital signs, family coping and remove warm clothing.
SLE medications
Blimumad (Benlysta), corticosteroids, antimalarial (-quinolol), Immunosuppressant (alkylating agents and purine analogs), hydralazine, procainamide, isoniazid, chlorpromazine, and antiseizure medications
Complex partial seizures medication
Carbamazepine
RA systemic affects
Cardiovascular (arterial wall stiffness and endothelial dysfunction), nervous system (can compress the adjacent nerve, causing neuropathies and parasthesias).
A health care team is involved in caring with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? a. The nursing staff should rely on the family to assist with care because family members know the client best b. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed. c. As long as the client receives the ordered medication, special care measures aren't necessary. d. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgement.
Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgement.
The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? a. Comatose b. Somnolence c. Stupor d. Normal
Comatose
Tonic-clonic (Generalized) nursing assessment
Consists of three phases: tonic, clonic and postical. This seizure progresses to a clonic phase that lasts 30 to 60 seconds.
The most common affective or mood disorder of old age is a. anxiety disorder b. depression c. schizophrenia d. phobias
depression
A client is actively hallucinating during as assessment. The nurse would be correct in documenting the hallucination as a disturbance in a. thought content b. motor ability c. intellectual function d. emotional status
thought content
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most important? a. "Dementia is a terrible disease of the elderly." b. "The most common cause of dementia in the elderly is Alzheimer's disease." c. "Drug interactions are the most common cause of dementia in the elderly." d. "Depression may manifest as dementia in elderly clients."
"The most common cause of dementia in the elderly is Alzheimer's disease."
A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds: a. "What precipitates the outbursts?" b. "You need to remain calm during the outbursts." c. "Play quiet music that your grandmother may like." d. "Start rubbing her shoulders and her back."
"What precipitates the outbursts?"
Ischemic stroke risk factors
Age (greater than 55 years) Gender (male) Race (African American) Hypertension Atrial fibrillation Hyperlipidemia Obesity Smoking Diabetes Asymptomatic carotid stenosis and valvular heart disease Sickle cell disease Periodontal disease Chronic inflammatory disease (SLE and RA)
Hemmorhagic stroke risk factors
Age (older than 55 years) Cerebral amyloid angiopathy Gender (male) Hypertension Excessive alcohol consumption AVMs (younger patients), intracranial aneurysms, intracranial neoplasms Certain medications (e.g., anticoagulant drugs, amphetamines, illicit drug use) Artherosclerosis
Hemorrhagic medical management
Allow the brain to recover from the initial insult (bleeding), to prevent or minimize the risk of rebleeding, and to prevent or treat complications Bed rest with sedation Management of vasospasm Surgical or medical treatment to prevent rebleeding (shunt) If patient is on Coumadin (Warfarin) patient must be given antidote (FFP and Vitamin K) Sequential compression devices to prevent venous thromboembolism
Nurses and members of other health disciplines at a state's public health division are planning programs for the next 5 years. The group has made the decision to focus on diseases that are experiencing the sharpest increases in their contributions to the overall death rate in the state. This team should plan health promotion and disease prevention activities to address what health problem? a. Stroke b. Cancer c. Respiratory infections d. Alzheimer disease
Alzheimer disease
A client report to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months. She notes that her mother does not respond when the mother's back is turned. The best intervention of the nurse is to a. Ask if the mother could come in for a heating evaluation b. Tell the client it appears the mother has a hearing loss c. Inform the client to ignore the behavior and the mother will stop d. Teach the client techniques for coping with the mother's anger
Ask if the mother could come in for a heating evaluation
Status epilepticus medications
Diazepam
Partial (focal) seizure nursing priorities
Electroencephalogray, continuous seizure activity even despite adequate oxygenation and ventilation.
SLE nursing assessment
Fever, malaise, weight loss, and anorexia. Acute cutaneous lesion consisting of a butterfly shaped rash across the bridge of the nose and cheeks. Oral ulcers, splinter, hemorrhages, alopecia, Raynaud's phenomenon, synovitis, psychosis, cognitive impairment, seizures, peripheral and cranial neuropathies, transerve myelitis, and strokes.
A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease? a. I b. II c. III d. IV
II
A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontienence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should a. Incorporate the client's toileting schedule into the pattern of his wandering b. ask the physician to order sedation to allow the client to rest c. ask the physician to order restraints to prevent wandering d. have the client wear two briefs at a time to ensure absorption of incontinent urine
Incorporate the client's toileting schedule into the pattern of his wandering
Partial (focal) seizure nursing assessment
Jerking of extremities, tingling or numbness, simple visual phenomena, rising epigastric sensation, changes in skin color, BP, heart rate, pupil size, piloerection, dysphagia or asphagia, flashbacks, and hallucinations.
RA Assessment findings
Joint pain and morning stiffness lasting longer than an hour. Systemic joint pain, swelling, warmth, erythema, and lack of function. Palpitations of the joints reveals spongy or boggy tissues. Anemia and symmetrical.
A nurse is working with the family of a patient with Alzheimer's disease to develop an appropriate plan of care. Which of the following would the nurse suggest to foster socialization? a. Promoting frequent lengthy visits from friends b. Encouraging participation in multiple-stepped activities c. Limiting visitors to one or two at a time d. Promoting hobbies involving fine motor skills
Limiting visitors to one or two at a time
Which of the following is an age-related change in the nervous system? a. Loss of neurons in the brain b. More efficient temperature regulation c. Increased myelin d. Increased cerebral blood flow
Loss of neurons in the brain
Ischemic stroke clinical manifestations
Motor loss: disturbance of voluntary motor control, hemeplagia (right or left sided paraylysis), hemiparesis, flaccid paralysis, or decrease in DTR. Communication loss: dysarthria (difficulty speaking), dysphagia (impaired speech) or asphagia (loss of speech), apraxia (inability to perform a previously learned action) Perceptual disturbance and sensory loss: visual perception dysfunctions, slight impairment of touch, difficulty in interrupting visual, tactile, and auditory stimuli, angiosias (loss of the ability to recgonize previously familiar objects) Psychological effects: depression, frustration, resentment, and lack of cooperation
Osteoarthritis patho
Not an autoimmune process. Noninflammatory degenerative disorders of the joints. Most commonly referred to as degenerative joint disease. The articular cartilage breaks down, leading to progressive
An older adult was diagnosed with Alzheimer disease 2 years ago and the disease has progressed at an increasing pace in recent months. The client has lost 7.5 kg (16 pounds) over the past 3 months, leading to a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this client's plan of care? a. Offer the client rewards for finishing all the food on her tray. b. Offer the client bland, low-salt foods to limit offensiveness. c. Offer the client only one food item at a time to promote focused eating. d. Arrange for insertion of a gastrostomy tube and initiate enteral feeding.
Offer the client only one food item at a time to promote focused eating.
Management of increased ICP
Osmotic diuretics, maintaining PaCO2 at 30 to 35 mm Hg, and positioning the patient to avoid hypoxia (elevate the HOB to promote venous drainage and to lower increase ICP).
Absence (petit mal) nursing assessment
Partial impairment of consciousness usually lasting several minutes.
An elderly client recovering from a hip repair becomes disoriented and tries to get out of bed frequently. The client states, "I forget I am in the hospital." The best nursing intervention is to a. Post a sign stating "You are in the hospital" at the client's eye level. b. Raise the upper and lower side rails of the bed. c. Place the client in a Posey chest restraint with ties attached to the bed frame. d. Administer an oral dose of prescribed alprazolam (Xanax).
Post a sign stating "You are in the hospital" at the client's eye level.
Complex partial seizures nursing priority
Protect the patient from injury, cushion the person's head, loosen tight clothing, wear medication bracelet and stay with them until they are recovered.
What is a nurse's role in providing home care for a client with Alzheimer's disease? a. Support client with household errands b. Provide emotional and physical support c. Provide assistance with administering IV fluids d. Contact the Motor Vehicle Department to have driver's license revoked
Provide emotional and physical support
A nurse is providing care to a patient with delirium. Which interventions would be most appropriate to implement? Select all that apply. a. Providing a calm, quiet environment b. Supervising nutritional intake c. Using familiar cues about the environment d. Administering psychoactive drugs e. Keeping the patient awake as much as possible
Providing a calm, quiet environment Supervising nutritional intake Using familiar cues about the environment
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? a. Hyperactive deep tendon reflexes b. Reduction in cerebral blood flow c. Increased cerebral metabolism d. Hypersensitivity to painful stimuli
Reduction in cerebral blood flow
A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? a. Withholding stimulants 24 to 48 hours prior to exam b. Removing all metal-containing objects c. Instructing the patient to void prior to the MRI d. Initiating an IV line for administration of contrast
Removing all metal-containing objects
After a sudden decline in cognition, a 77-year-old man who has been diagnosed with vascular dementia is receiving care in his home. To reduce this man's risk of future infarcts, what action should the nurse most strongly encourage? a. Activity limitation and falls reduction efforts b. Adequate nutrition and fluid intake c. Rigorous control of the client's blood pressure and serum lipid levels d. Use of mobility aids to promote independence.
Rigorous control of the client's blood pressure and serum lipid levels
Febrile seizure nursing priorities
Temp monitoring, pharmacologic and non-pharmacological methods of temp regulation, maintaining child comfort, ensuring hydration, assisting in the treatment of the underlying cause, and family education.
The nurse is caring for a client with late-stage Alzheimer disease. The client's wife states that the client has now become completely dependent and that she feels guilty if she takes any time for herself. What outcomes would be appropriate for the nurse to develop in order to assist the client's wife? a. The caregiver learns to explain to the client why she needs time for herself. b. The caregiver distinguishes essential obligations from those that can be controlled or limited c. The caregiver leaves the client at home alone for short periods of time to encourage independence d. The caregiver prioritizes her own health over that of the client
The caregiver distinguishes essential obligations from those that can be controlled or limited
A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses's assessment and management of this client? a. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic b. Lapses in memory in older adults are considered benign unless they have negative consequences c. Gradual increases in confusion accompany the aging process d. Thorough assessment in necessary because changes in cognition are always considered to be pathologic
Thorough assessment in necessary because changes in cognition are always considered to be pathologic
Which actions by the nurse will assist in promoting an older adult's adherence to medication therapy? Select all that apply. a. Educate the client to keep all medications and bottles for future reference. b. Encourage the client to keep a list of medications and review it frequently for updates. c. Use easy-to-open lids. d. Instruct the client not to take herbal supplements. e. Provide a written medication schedule. f. Encourage the patient to use multiple pharmacies to obtain cheapest prices.
Use easy-to-open lids. Provide a written medication schedule. Encourage the patient to use multiple pharmacies to obtain cheapest prices.
A client at an extended-care facility who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include a. Walking the client in the facility yard during the day b. Allowing the client to take a 2-hour nap in the afternoon c. Providing a glass of warm milk for breakfast d. Having the client sit at the nurse's station during night-time hours
Walking the client in the facility yard during the day
A nurse is reviewing the medications of a client who lives alone and reports having difficulty remembering when to take them. To aid in medication compliance, which of the following measures would the nurse employ? Select all answers that apply. a. Write down the medication schedule for the client. b. Suggest that the client use a multiple-dose medication dispenser. c. Recommend to the client to use one pharmacy for all prescriptions. d. Encourage the client to use containers with safety lids. e. Remind the client to keep empty medication containers to demonstrate use.
Write down the medication schedule for the client. Suggest that the client use a multiple-dose medication dispenser. Recommend to the client to use one pharmacy for all prescriptions.
SLE systemic affects
cardiac: pericarditis, substernal chest pain (aggravated by movement or inspirations), myocarditis, hypertension, cardiac dysrhythmias, and valvular incompetence. renal: nephritis, kidneys control BP so patients may also have hypertension respiratory: pleural effusions and infiltrations (abnormal lung sounds) musculoskeletal: joint swelling, tenderness, and pain on movement. Morning stiffness.
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: a. dysfunction in the cerebrum b. risk for increased intracranial pressure c. dysfunction in the brain stem d. dysfunction in the spinal column
dysfunction in the brain stem
A nurse is planning discharge teaching for an older adult client with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on the client's lower leg. When planning the necessary health education for this client, the nurse should: a. set long-term goals with the client b. provide a list of useful websites to supplement learning c. keep visual cues to a minimum to enhance the client's focus d. keep teaching periods short
keep teaching periods short
The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? a. observing the reaction of pupils to light b. observing the client's response to painful stimulus c. using the Romberg test d. assessing the client's sensitivity to temperature, touch, and pain
observing the client's response to painful stimulus
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: a. stay with the client and encourage him to eat b. help the client fill out his menu c. give the client privacy during meals d. fill out the menu for the client
stay with client and encourage him to eat
