75Qx2 Jan 5th

Question 1

three-point crutch-walking gait

Answer 1

affected leg is moved forward at the same time as the crutches, followed by the strong leg

Question 2

crutches with stairs

Answer 2

GOING UP: the crutches are advanced to the upper step,the strong leg leads the way going up stairs; then the weaker leg GOING DOWN: the crutches are advanced to the lower step, the weaker leg is advanced, and then the stronger leg follows

Question 3

Proper SCD fitting

Answer 3

need to be able to fit two fingers, not just one, between the sleeve and the leg; correct fit prevents irritation to the leg; it also allows for the device to reach adequate inflation pressure and prevents slipping out of position when deflation occurs; the fit can be checked by inserting two fingers in the knee opening

Question 4

What can a 2yo do?

Answer 4

kick ball w/o falling pick up object w/o falling builds tower of 6 blocks can turn doorknobs can unscrew lids uses 2 - 3 words phrases states first name

Question 5

propranolol effect on aminophylline

Answer 5

may decrease metabolism of aminophylline and lead to toxicity

Aminophylline: Treats asthma and other lung diseases.

Question 6

why are ACE inhibitors prescribed?

Answer 6

treat HTN and Heart Failure

• Accupril is an ACE inhibitor that blocks the release of aldosterone, which promotes potassium retention; client should avoid foods high in potassium
• I should take the medication at the same time each day
• I should check my blood pressure weekly

Question 7

Assessment of burns

Answer 7

• superficial burn; skin appears pink, increased sensitivity to heat, some swelling, healing occurs without treatment
  
  • Reddened blotchy painful areas
• partial-thickness burn; only part of skin is damaged or destroyed; large, thick-walled blisters develop; underlying tissue is deep red, appears wet and shiny; painful with increased sensitivity to heat; healing occurs by evolution of undamaged basal cells, takes about 21–22 days
  
  • Redness and swelling with fluid-filled vesicles
  • Blistering and blanching of the skin
• full-thickness burn; all skin is destroyed and muscle and bone may be involved; substance that remains is called eschar, dry to touch, doesn’t heal spontaneously, requires grafting
  
  • Charred, waxy, white appearance of skin

Question 8

Halo vest traction

Answer 8

• physician tightens screws 24 to 48 hours after halo is applied
• if pain occurs with jaw movement 24 to 48 hours after traction applied, may indicate that skull pins have slipped onto the thin temporal plate; notify physician immediately
• wash chest and back daily and carefully dry; assess skin for pressure areas; dry damp sheepskin with hairdryer; apply light dusting of medicated powder or cornstarch to prevent itching

Question 9

LSA position

Where is FHT heard?

Answer 9

LSA indicates that the presenting part is the sacrum (breech) and the fetal back is on the mother’s left side; because infant is breech, FHT heard at or above the umbilicus.

Question 10

ROA position

Where is FHT heard?

Answer 10

ROA indicates vertex is the presenting part with fetal occiput on the mother’s right side toward the front of her pelvis; because infant is vertex, FHT heard below the umbilicus.

Question 11

Buck’s traction CARE

Answer 11

• The nurse removes the foam boot three times per day to inspect the skin
  
  • important to observe for skin breakdown; a second nurse should support the extremity during the inspection
• The staff turns the client to the unaffected side (when there is a fracture).
• back care should be provided every 2 hours to prevent pressure sores
• assess function of the peroneal nerve by asking pt to dorsiflex; weakness of dorsiflexion may indicate pressure on the nerve
• elevating the foot of the client’s bed provides countertraction

Question 12

diet for ulcerative colitis

Answer 12

is high protein, high calorie and low residue

• diet high in fat, high in protein, and low in residue is a risk factor for colorectal cancer

Question 13

Presumptive signs of pregnancy

Answer 13

• amenorrhea
• N/V
• increased size and increased feeling of fullness in breasts
• pronounced nipples
• urinary frequency
• quickening (16-20th week)
• fatigue
• discoloration of the vaginal mucosa

Question 14

Positive signs of pregnancy (only 3!)

Answer 14

• FHT detected by doppler at 10-12 weeks
• active fetal movements palpable by examiner
• outline of fetus via radiography or ultrasonography

Question 15

most important to Jewish persons regarding end of life care?

Answer 15

control of pain (palliative treatment)

Question 16

The nurse cares for a young adult woman undergoing peritoneal dialysis. The nurse notes that the outflow is bloody. Which action should the nurse take FIRST?

Answer 16

Determine if the client is menstruating

because of hypertonicity of dialysate, blood from uterus can be pulled through the fallopian tubes into the effluent; blood-tinged effluent can also be noted if the client has been lifting heavy objects or exercising; no intervention is required.

Question 17

Electroencephalogram (EEG)

Answer 17

• records electrical activity of brain; preparation for EEG: explain procedure, painless, wash hair to remove oils, procedure done by technician in a quiet room, tranquilizer and stimulant medications withheld for 24–48 h, stimulants such as caffeine, cola, tea, and cigarettes withheld for 24 h, may be asked to hyperventilate 3–4 minutes and watch bright, flashing light, meal not withheld, kept awake night before test so can sleep during test
• no pricking sensations, and the electricity does not enter the brain or give a shock
• patient usually needs to be sleep-deprived (from 2 or 3 A.M. onward) in order for one part of the test to be most effectively carried out; it is during sleep that some abnormalities are most evident
• hair is washed after the test, usually with acetone and shampoo, in order to remove the electrode gel and glue or paste from the scalp and hair; however, hair should also be shampooed clean before the test, with no spray, oils, or hairpins used, to ensure that EEG patches or electrodes remain firmly in place during the test
• because hypoglycemia affects brain activity, food and fluids can be consumed beforehand; caffeine-containing fluids such as tea or coffee should be avoided for 24 to 48 hours before the test