164 EXAM REVIEW Flashcards
The nurse explains that the health-illness continuum is based on:
Variation in degree of health or illness
In performing a pain assessment, the LPN would follow which steps?
Assess location, quality, and intensity on an identified scale
The nurse has assessed that prolonged and unrelieved pain will:
Lower the pain threshold
Everytime the right arm is raised, the patient reports to the nurse that pain is triggered in the right shoulder. To chart this description as a:
Aggrevating factor
Because malignant hyperthermia is a potential postop complication, the nurse should ask:
Has anyone in your family ever had problems with general anesthesia
The nurse attempts to evaluate the presence of pain in a patient who is cognitively impaired by assessing for:
Increasing confusion
The patient scheduled for liver biopsy has given the nurse a list of medications taken at home, the nurse should be concerned about the:
Aspirin
A patient just returned to the surgical unit after varicose vein stripping and ligation. To evaluate pain relief, the best technique for the nurse is to:
Ask the patient to rate the severity of pain on a scale of 1-10
The nurse is alert for sympathetic responses to pain such as:
Increase bp, increased pulse, and increased respiratory rate
To prevent DVT in the postop patient, the nurse plans to ensure the patient:
Ambulates frequently
The sensation of pain defined by the International Association for the Study of Pain as:
Unpleasant sensory and emotional experience
A nurse is assisting in the transfer of a postop patient from the post anesthesia care unit to the surgical nursing unit. To ensure safety of the patient the nurse would:
Put the side rails up after moving the patient from the stretcher to the bed
When the patient with sciatica seats himself in a chair, he gasps and complains of burning and shooting pain in his hip, the nurse assesses that this is________pain:
Neuropathic
The nurse assesses the patient’s limbs and position frequently after regional anesthesia because:
Pain is not perceived although motion is possible
To perform a nursing assessment correctly, the nurse must remember that pain perception involves several CNS processes such as:
Efferent pathways stimulate the spinal cord to recognize the location of pain
The nurse is notified when the patient, newly admitted with liver and gallbladder disease, complains of pain in the right middle back and asks for pain meds. As the basis for the assessment, the nurse uses knowledge of pain to determine that the patient:
Has referred pain sensations. The nurse should follow orders for administering pain medications
Two patients are hospitilized with the same diagnosis. One is 23 years old, with acute recent pain from an injury, and the other is 64 years old with pain of long-standing duration of several years. The difference in anticipated assessment is what?
Older patients with chronic pain usually report lower levels of pain much less severe than they really are
A postop patient is complaining of incisional pain. An order has been given for morphine every 4-6hours PRN. The first assessment by the nurse should be:
Determine when the patient last received pain medication
The postop patient with no previous medical conditions is difficult to arouse when transferred from surgical unit to postanesthesia unit. The nurse monitors the pulse ox and gets a reading of 85%, the nurse’s next action should be:
Arouse the patient, have him cough and encourage deep breathing
Gate-control theory of pain claims that pain is perceived as a stimulation of receptors in the:
Small nerve fibers
During the gathering of data, a patient reveals that he has a weight loss of 17lbs since the death of his spouse 5 weeks earlier. He has no appetite and is not sleeping. According to Maslow, the nurse assesses that the unmet needs are in the category of:
Physiologic
The patient returning from surgery complains of incisional pain that is now rated 7 on 1-10 scale. As a nurse, you know that pain is an example of:
Local adaptation syndrome
The large, heavy older adult patient after a stroke develops a decubitus on the sacrum during the hospital stay. 2 weeks later the patient returns to the hospital with PNA. The distinction between the two are:
Decubitus = Health-care associated infection PNA=community acquired infection
When an individual becomes frightened and experinece increased heart rate and mental activity along with increased blood flow to the skeletal muscles and dilated pupils, the person is experiencing an alarm reaction that helps the body defend against stressors. This alarm reaction is the:
Fight or flight response
The patient on enteral feeding suddenly complains of feeling faint and is sweating. The DBP dropped 20 points. The nurse recognizes dumping syndrome, which is caused by:
Hypertonic fluid entering the jejunum and pulling large amounts of water from the circulating volume
Major advantage in using Maslow’s Hierarchy when planning nursing care is to:
Prioritize patient care
Diagnosis of DKA, the nurse anticipates that the patient will exhibit VS of:
Temp: 97.4 Pulse 100 BPM Respirations 20/min and deep
DI classic symptoms:
Diuresis, tachycardia, and weakness
Sandostatin (Octreotide) for acromegaly will:
Suppress the growth hormone
Addison disease Hydrocortisone will:
Regulate the excretion of K+ and Na+
DKA results in:
Inability of carbs, fats, and protein to be metabolized
T3 and T4 tests for a patient complaining of fatigue, weight gain, muscle aches, pain, and constipation. These lab tests will confirm the DX of hypothyroidism when:
Both tests show decreases
Addisonian crisis can be brought on by:
Infection
Nephrogenic DI:
Does not respond to ADH
Chvostek sign:
Tap the face over the facial nerve, and watch for spasm of facial muscle
CHF has JVD, crackles bilaterally, and dyspnea. Diagnosis with highest priority would be:
Excess fluid volume
Patient’s with arterial insufficiency should be instructed to:
Frequently allow the legs to dangle dependently
Burning aching pain in the legs when walking, symptoms relieved by rest. The nurse would suspect:
Claudication
Vasotec (ACE Inhibitor) what is a positive outcome:
Decreased BP
Age related change making them susceptible to cardiovascular disease:
Stiff peripheral vessels
Stasis dermatitis for a pt with PVD. This indicates the presence of:
Brownish discoloration on lower legs
Older persons adapt more slowly to changes in the peripheral vascular system because of:
Aorta thickening, decreasing cardiac output, stiffening of blood vessels, and slowing heart rate
TPN running 20 ml and is an hour behind schedule. The initial intervention would be:
Document the event and inform the charge nurse
Why can’t a TPN be placed in the arm?
Subclavian artery allows for rapid dilution
While on TPN, include in the care plan
Assess I&O, monitor for hypo/hyperglycemia, assess temp
TPN feeding indicates hyperglycemia when what occurs:
Increase of urine output
Patient with intestinal obstruction has achieved normal hydration when:
Pulse and BP are within patient’s norms, mucous membranes are moist, and fluid I&O are equal
In a patient with hepatitis, a dropping billirubin level indicates:
Liver function is improving
Assess acites on a daily basis by:
Measuring abdominal girth and daily weights
High ammonia level contributes to hepatic encephalopathy. As the level increases the implimentation that should be added to the care plan:
Seizure precautions
Pancreatitis highest priority:
Patient claims satisfaction with pain control
Pancrease should be administered:
Mixed with juice
Another chronic condition R/T pancreatitis:
DM
Lab report showing elevation that is diagnostic for acute pancreatitis is:
Serum Amylase
Permanant colostomy reports some abdominal discomfort and rigidity after 3 days post surgery. The assessment the nurse should report and record is:
VS are Temp 100F, Pulse 92, BP 160/98
Rectal suppositories for stomas:
NO
Monitor bilateral breath sounds and chest movement after a thoracentesis because:
The lung may have been punctured
Wheezing R/T Asthma:
Movement of air through narrowed airways
CPAP
Maintains a continuous pressure in the airway to avoid apnea
Major sources of infection for COPD patient:
Stasis of respiratory secretions
Combat anorexia in COPD by:
Perfoming oral hygiene before meals
Sign of R-sided heart failure is:
Decreasing urine output
To enhance the nutritional status of pt with COPD:
Offer small, frequent meals
Typical feature of CBC in pt with chronic bronchitis:
Increased RBC’s
Normal Babinski reflex:
Downward curl of the toes
Positive Brudzinski:
Flex hips when the neck is flexed by the nurse, indication of meningitis
Cushing Triad associated with increased ICP:
Bradycardia, HTN, and widening pulse pressure
ALS uniquely prone to depression because:
Intellectual capacity is not affected
Homonymous hemianopsia, important items are visible and available on:
The affected side
Brown-Sequard syndrome results in which neurologic deficit?
Ipsilateral loss of motor function and contralateral loss of pain sensation and temp
DMARD Arave (Leflunomide)
Retard the progression of RA
Why are systemic glucocorticoids used as the last choice for TX of RA?
For short periods due to many side effects
Characteristic of RA:
Symmetrical bilateral joint swelling
A patient with gout should avoid seafood because
They are high in purine
Patients with gout should be alert for the signs of:
Kidney stones
Probenecid (Benemid) is prescribed to:
Increase the excretion of uric acid
Diagnostic test result for polymyositis is:
Muscle biopsy, positive for muscle degeneration
Patient with crushed forearm, swollen, cool and cyanotic with weak distal pulses:
Compartment syndrome
Risk for constipation R/T pelvic fracture:
Drink 2-3L of fluid per day
Pelvic fracture assessment that would cause the biggest concern:
No urinary output for 8 hours
Alendronate (Fosamax) requires the patient to:
Sit or stand for 30 minutes after administration
Teaching plan for teen with sickle cell anemia
Maintain adequate hydration
Sickle cell crisis occurs when sickle shaped RBC’s:
Obstruct major arteries
Hydroxyurea
Produces a hemoglobin that will reduce sickling
Sickle Cell Anemia
Recessive trait, both parents are carriers
SLE, systemic lupus erythmatosus characteristic
Butterfly rash on face
Plan of care for HIV
Careful aeseptic technique to prevent infection
Increase in HIV in over 50 because
Usually not asked about sex or drug use, mistake S/S as normal aging, are less likely to seek HIV screening, and less likely to use condoms
HIV cannot have potted plants due to
Aspergilliosis
HIV observed in
Heterosexual partners of HIV infected person, newborns of HIV infected mom, health care workers that mishandle sharps,. breast-fed infants of HIV moms
Teaching plan for microsporidiosis in HIV patient:
Drink 3 quarts of fluid daily to combat dehydration
AIDS develops when:
CD4 cell level drops to 200
TTP having plasmapheresis daily alert for the indication of
Hypotension
Cutaneous Kaposi Sarcoma the nurse would report signs of
Abdominal pain
If ELISA positive
Another sample for testing
Acute glomerulonephritis, when can they become more active
When BP drops to normal
Acute glomerulonephritis is most usually caused by
Streptococcal infection
In acute glomerulonephritis, inflammation of the capillary loops in the glomeruli lead to
Moderate-to-high BP
AV fistula, the thrill is absent when palpating the venous side of the fistula the nurse should
Report to the charge nurse that the fistula is occluded
Chronic renal failure receiving dialysis is prone to injury because
Bone demineralization and peripheral neuropathy
Peritoneal dialysis is less expensive and has fewer dietary restrictions and…
Gives more independence and more closely resembles normal kidney function
Erythropoietin produced by the kidney. With a deficiency R/T chronic renal failure, will result in
Anemia as a result of diminished RBC’S being produced
Grey Turner sign
Retroperitoneal bleeding and bruising over the flank
Tzanck smear
Test for viral culture of herpetic lesions
In a burn patient with eschar formation around the entire arm, the nurse will frequently assess
Capillary refill
Primary Infertility
Been unable to conceive after 1 year of regular unprotected sex
Semen analysis for infertility
Microscopically assess the sperm for number and motility
Trichomonas, the sexual partner
Even asymptomatic must be treated
Flagyl for Trichomonas
Avoid alcohol
Candida Albicans
Cottage-cheese like appearance
HPV and Genital warts association
Eventually develop cervical cancer
To avoid getting cervical cancer
Get regular pap smears
Flutamide (Eulexin) side effect for prostate cancer
Hot flashes
Antiviral drug used in HSV
Acyclovir (Zovirax)
Acyclovir (Zovirax) side effects
Dizziness, H/A, Nausea
Glaucoma patient treated with Timolol (Timoptic) should be monitored for
Wheezing
After enucleation when can a prosthesis be fitted
1 month or 4 weeks
Caloric test result indicating a hearing disorder in the labyrinth
Nystagmus
Meniere Disease patient should
Avoid the use of alcohol and tobacco
Teaching plan for frequent laryngitis
Observe voice rest
Most common cause of laryngitis
Respiratory infections and voice strain
Laryngectomy 3 months ago, patient complaint of increasing dyspnea, this is common complication of
Tracheal stenosis
Priority for patient after laryngectomy
Establish communication system
After supraglottic laryngectomy, major postop difficulty
Teaching pt to swallow without aspiration
Total laryngectomy to maintain airway clearance
Turn, cough, deep breath, semi-fowler position, trach collar, maintaining hydration
Rifampin for exposure to TB side effect
Body fluids become red-orange
Promethazine (Phenergan) for nausea, extra precautionary implementation due to common side effect
Put up side rails to prevent falls
HCTZ (HydroDIURIL) for HTN, dietary teaching
Increase intake of bananas
Propranolol (Inderal) teaching
Never stop abruptly taking the drug
COPD and Asthma patients arent candidates for what antihypertensive drug
Beta Blockers, Propranolol
Patient taking antihypertensive therapy complains of fatigue and pulse of 54, this side effect is most likely cause by
Diltiazem (Cardizem)
Patient taking Furosemide (Lasix) for HTN, older patients at risk for
Hypokalemia
Patient taking Aldomet (Methyldopa) for HTN, severe H/A, blurred vision, BP 200/94 the nurse would suspect
Abrupt cessation of medication
TPA must be used within how long after CVA
3 Hours
Nimodipine every 4 hours for hemorrhagic stroke. Pulse is 82, the nurse should
Give the medication. In beta blockers hold drug is pulse is <60 apically
