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
