2020 final Flashcards
A patient diagnosed with peptic ulcer disease reports asudden onset of sharp abdominal pain and presents with a tense, rigid abdomen.
manifestations of a perforated ulcer? (Hint: What would the priority nursing action be?)
Patient teaching for a patient who is complaining of pain in the should blade status post laparoscopic cholecystectomy
drink a carbonated beverage and ambulate in the hall at least twice per day
Nursing interventions to reduce discomfort for a patient with acute pancreatitis.
administer IVfluids(maintainhydration)and remainNPO (bowelrest)
This is a similarity in the disease process of ulcerative colitis and Crohn’s disease.
an inflammatory process of the gastrointestinal tract?
Patient teaching for a patient with an infected knee replacement who states he does not need antibiotics for the pain
teach the patient that treating the infection(aka the antibiotic)will reduce the swelling and will subsequently relieve the pain
A patient who is being treated for sepsis could progress to multiple system(organ) failure. The nurse knows that this is how the patient’s vital signs will be affected.
low blood pressure (compensation) tachycardia, tachypnea, and low urinary output
This is a priority action when determining a treatment plan for a patient who might have sepsis.
obtain cultures
The nurse knows that this has occurred when a child with an earache and severe pain no longer has any pain.
rupture of the tympanic membrane
Patient teaching for a patient who has been newly diagnosed with hepatitis B should include this.
limit activity (provide rest periods)until symptoms of hepatitis have subsided, avoid medications(acetaminophen)that are metabolized by the liver, and consume a diet with moderate amounts of protein(metabolized in the liver)
Priority actions by the nurse who is admitting a patient suspected of having TB
place the patient in a negative pressure room and obtain an N95respirator
Reasons why a patient with a spinal cord injury would benefit from physical rehabilitation
preventing further disability, maintaining current functional ability, restoring function, and learning a new technique
A paraplegic patient who has reddened areas.
at risk for skin breakdown [Hint: what would the priority nursing action(s) be?]
The cornerstone of treatment for Parkinson’s disease
levodopa/carbidopa
Manifestations of Parkinson’s
disease.
oily skin orthostatic hypotension, bradykinesia(difficulty moving), and uncontrolled drooling
Manifestations of early osteoarthritis
pain with activity and pain relief with rest
Primary prevention related to visual impairments
education on preventing visual impairments such as a class on healthy lifestyles
How a patient may describe peripheral neuropathy
pain, numbness tingling, burning, or a loss of feeling in the extremities
A priority action when providing teaching to a patient with a hearing deficit.
assess if the patient uses an assistive device(hearing aides
Priority actions when assessing the home of a patient with decreased vision
remove rugs/cords in walkways, assess for the need to install safety devices, and do not rearrange the furniture
Teaching the nurse should provide to a patient who is taking an antibiotic and complains of an altered sense of taste.
explain that many medications cause a change in the sense of taste but that it is temporary and will resolve when no longer taking the antibiotic? (Note: Finish taking the antibiotic!
This occurs when a patient with dementia makes up stories when they can not remember the actual events
confabulates/confabulation
Teaching the nurse should provide to the family/caregiver of an older adult who has a new diagnosis of dementia.
characterized by gradual onset, progressive disorder, and not curable
Differences inmanifestations of delirium versus dementia.
sudden onset, caused by an outside etiology (e.g.medication, infection), and can be corrected if the cause is identified (reversible)
A hallmark sign of dementia.
short-term memory loss
Interventions appropriate for a patient in the mild stages of dementia.
providing emotional support, providing gentle reminders, and ensuring safety (injury prevention)
A patient states they are afraid to leave the house. The nurse uses this interpersonal therapeutic communication technique
clarification? The nurse may clarify the patient’s statement by asking about specific fears or examples of what scares the patient.
Interviewing a patient in a psychiatric unit is a patient-centered activity. This an appropriate way for the nurse to begin the interview
ask the patient what they would like to talk about today
The nurse is using the SBARcommunicationtool. The nurse-correctly identifies the S step as this.
What is the situation? (Note: You should be able to identify each step of SBARand be able to select examples of each
A nurse is caring for a patient who admits to being noncompliant with the prescribed medication regimen. This is an example of therapeutic communication by the nurse
using reflective comments to describe the patient’s feelings and repeats what the patient has said? (For example, “You seem worried about your medication regimen.”)
The nurse is using this technique when she focuses on the problems and gathers more information from the patient.
focusing
A patient who is overwhelmed with discharge instructions is rude when the nurse comes into the room. This is the best response by the nurse.
assess for more information
A patient with a degenerative condition talks to the nurse about wanting to live independently. The best action by the nurse is this.
discuss resources, provide appropriate referrals, and work with the interdisciplinary team to help the patient achieve her goals safely
These people should be involved when creating a treatment plan.
the patient, the provider, the nurse, the discharge planner/social worker, etc.
Benefits of coordinating care.
continuum of care (services/agencies working together), cost-effectiveness, and better patient outcome
These may occur when care coordination is not provided.
disconnected/fragmented care, wasted funds, and poor patient outcomes
This occurs when a nurse provides the patient with the information necessary for making healthcare decisions.
being an advocate
According to the Institute of Medicine, professional nurses do these things
teach, advocate, assess, and nurture
Effective nursing leadership skills for a director of nursing.
have a plan, explain the plan, and get support from the staff nurses
An essential quality for a nurse leader.
flexibility
Nurses improve public health through this.
their scope of practice, specialized knowledge, and code of ethics? (Hint:GiddensConcept 39)
A type of research where one group receives treatment and the other group does not.
What is experimental?(Hint:GiddensConcept 49)
This is why nurses implement evidence-based practice.
What is to improve patient outcomes/quality of care?
This type of research describes a phenomenon, experience, or perception.
qualitative research
This type of research collects information (data) using numbers.
quantitative
Nursing theory and the theorist who described how students learn from the beginning of nursing school to practicing as a nurse.
Novice to expert theory by Patricia Benner
An unexpected occurrence involving death or serious physical or psychologic injury and that signals the need for immediate investigation and response.
sentinel event
A medication error is this type of error.
What is a treatment error?
A term coined by the Institute for SafeMedicationPractices to describe this practice which helps-differentiate look-alike-medication names (e.g.BenaDRYLandBenaZEPRIL
Tallman lettering
These are aspects of nursing that contribute to a culture of safety.
leadership, teamwork, evidence-based, communication, learning, a just culture, and patient-centered care?
In promoting a culture of safety, the nurse manager may do this.
fluctuate workloads or staff for census/acuity
This is a comprehensive approach to clinical judgment that includes noticing, interpreting, responding, and reflecting.
model of clinical judgment
A patient tells his nurse that he is not taking the medication the doctor prescribed because he could not afford it. These are the steps the nurse should follow to help the patient get optimal treatment.
notify the prescriber, explain why the patient isn’t following the orders, and offer a less expensive alternative medication?
A patient is admitted fora surgical procedure and complicated recovery. The nurse will start teaching and discharge planning at this time.
admission
The nurse manager overhears a new nurse asking an experienced nurse to call a doctor for her because she doesn’t think she can answer the doctor’s questions. The nurse manager gives each nurse some advice
advising the experienced nurse to mentor the new nurse and advising the new nurse to reflect/learn/grow from the experience
Describe processes used in care planning.
the nursing process, clinical judgment, and collaboration
The nurse notices a NativeAmerican patient guarding their surgical site. This is the nurse’s best action.
assess (e.g.ask the patient about pain, check vital signs)
The nurse is providing teaching to aPhillipinopatient with a new diagnosis. The patient keeps smiling when asked if she has any questions. This is the nurse’s best action
open-ended questions
The nurse is counseling a middle-aged patient about preventative treatments and testing. The patient states he does not see a reason to test anything if he feels fine. This is the nurse’s best action related to planning care.
develop short-term goals
This is an important reason that there is an emphasis on cultural competence in healthcare.
increasing global diversity, global economy, or worldwide travel?
These are components of cultural competence.
cultural desire, self-awareness, knowledge, and skill?(Giddens p.32-33)
These are examples of HCO3, PaCO2, and pH for a patient with metabolic acidosis.
will vary. HCO3 normal, PaCO2 increased, and pH decreased.
These are symptoms for a patient with metabolic alkalosis
bicarbonate excess, circumoral paresthesia, prolonged vomiting
The assessment of a patient who has a history ofCHFincludescrackles, difficulty breathing, and edema in both ankles. The nurse anticipates an order for this.
furosemide
A patient with this fluid and electrolyte imbalance may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness.
low potassium or hypokalemia
A patient with fluid volume deficit may exhibit these symptoms.
orthostatic hypotension, confusion, and low urine output
A patient is being seen for flu-like symptoms including excessive vomiting. The patient may be at risk for this acid-base imbalance.
metabolic alkalosis?
A patient’s lab results show
PH low, PaCO2 high, HCO3-high. The patient’s diagnosis could be this.
pneumonia, hypoventilation, or COPD
Tingling in extremities, circumoral numbness, muscle cramps, and confusion are indicative of this acid-base imbalance
respiratory alkalosis
ABG values are as follows pH7.36, PaO298 mm Hg,PaCO2 33mm Hg, andHCO3- 18mEq/L (18mmol/L). This is indicative of this acid-base imbalance.
metabolic acidosis
A patient’s ABG values areas follows pH 7.32, PaO2 94mm Hg,PaCO2 34mm Hg,and HCO3-18 mEq/L(18mmol/L). The nurse would assess for these symptoms.
reduced deep tendon reflexes, drowsiness, and increased respiratory rate? (metabolic acidosis)
The nurse may teach a post-operative patient this technique to expand their lungs.
cough and deep breath or turn, cough, and deep breath
A patient reports symptoms of malaise, upset stomach, and a runny nose. This would be the nurse’s best action.
further assessment
The nurse is assessing a patient with a 50-year history of smoking 2 packs per day. The patient is complaining of hoarseness that won’t go away. The nurse suspects the patient might have this.
laryngeal cancer
Describe the characteristics of squamous cell carcinoma, basal cell carcinoma,and malignant melanoma.
A squamous cell tumor appears as a rough, thickened ulcerated tumor that can bleed.
- A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearl borders.
- Malignant melanoma is often varied in color, ranging from shades of red to white to blue. It
These are ominous changes after a head injury.
widening pulse pressure, bradycardia, and respiratory changes (Cushing’striad)
These are the components of GCS
eye-opening, motor responsiveness, and verbal responsiveness
The first action by the nurse who sees a patient having a seizure this.
maintain the patient’s safety
Patient teaching for the spouse of a patient with a TBI should include these.
signs and symptoms to report (fever, difficulty breathing) , potential changes in personality, and memory loss
Describe a patient who scores a 3 in each section of the GCS.
Eye open to speech. Inappropriate words, Decorticate (abnormal flexion score ) score 9
The nurse should include this information in preop teaching related to fundoplication
the patient will have dietary changes after the procedure (e.g small, frequent meals)
The patient with cholelithiasis should avoid these foods.
foods high in fat and cholesterol (e.g dairy, fried foods
This should be the nurse’s first response when a patient with a tube feeding begins vomiting
stop/hold the tube feeding
The nurse should assess these in the patient who is on TPN.
electrolytes and glucose
Habits to promote good nutrition in the elderly include these
allow uninterrupted time for eating, assess for mouth/tooth pain, assess for sores in the mouth make sure dentures fit appropriately, make sure the patient can see and reach the food, and serve high-calorie/high-protein foods? (You should know3-4.)
This is an indicator of a positive outcome for a patient with a DVT.
clear lung sounds or SpO2 >90%?
The priority of care for a patient with internal bleeding is this.
stop the bleeding or perfusion
Risk factors for impaired cognition include these
advancing age, hypoxia,medication-related, dementia, Alzheimer’s Parkinson’s
The nurse would provide this in the teaching to a patient with a new implantable cardioverter-defibrillator.
What are carry an I.D. (e.g.airports), avoid tight clothing, avoid strenuous activities, and avoid strong electromagnetic fields (e.g.MRI)?
The proper treatment for a patient’s inv-tach is this.
What is elective cardioversion when the patient is awake and responsive
The goal for medications to treat autoimmune responses is this.
What is control the symptoms
Symptoms of acute rejection of a renal transplant include these.
What are signs of kidney failure (e.g.decreasedurinary output, weight gain, increased blood pressure, and other signs of fluid overload)
Chronic steroid use in a patient with an autoimmune disorder may lead to this.
osteonecrosis
These are initial symptoms that may be experienced with HIV infection.
flu-like symptoms and night sweats
The nurse is assessing a patient for an anaphylactic reaction. What should the nurse assess first?
breathing/airway
