ATI Flashcards
What is the normal TSH level?
0.4 - 4.2
What can be expected with a TSH level of 8.3?
Elevated TSH level indicates hypothyroidism. So weight gain and bradycardia are expected.
Weight gain, bradycardia, cold intolerance, paresthesia, hearing loss, depression, are clinical manifestations of?
Hypothyroidism.
A client is just diagnosed with malignancy. What psychosocial intervention is appropriate?
Providing emotional support with presence.
What is a nerve block?
Nerve block is a form of treatment that interrupts the conduction of pain with chemical agents.
How does the aging process related to an increase in diastolic and systolic blood pressure?
An expected age-related change is decreased elasticity of blood vessels. When arterial walls stiffen, blood pressure increases.
How are a patient’s psychosocial needs met when placed in isolation?
Scheduling time separate from care to talk. Providing time away from routine distraction and promotion of a relaxed atmosphere will enhance communication.
What is the normal amylase level?
56 - 90 unit/L.
An increase in serum amylase (56 - 90 unit/L), indicates what?
Increased WBC and Amylase indicates acute pancreatitis.
What is an intervention for a client taking mannitol (Osmitrol) IV for ICP?
Monitor intake and output. Osmotic diuretics, like mannitol, are used to decrease cerebral edema. Strict intake and output is necessary to assess the effect of the medication and monitor for severe dehydration and indications of acute renal failure.
What is the first step in preparing an automated external defibrillator (AED)?
Steps include:
- Obtain AED
- Apply defibrillator pads to client’s chest
- Stop CPR and move away from the client.
- Press the analyze button on the machine.
- Push the charge button to prepare to shock.
Which findings indicate myocardial infarction?
Nausea. Nausea is an expected finding with MI.
Nausea, chest pain, vomiting, diaphoresis, dyspnea, fatigue, palpitations, and dizziness are clinical manifestations of what disease process?
Myocardial Infarction.
Client receives home peritoneal dialysis, what assessment finding should be reported to the provider immediately?
Cloudy effluent. Cloudy dialysate drainage indicates a possible bacterial infection in the peritoneum and should be reported to the provider immediately.
Regarding a patient-controlled analgesia (PCA), which treating indicates a need for further instruction?
Instructs the family to press the PCA button when the client is asleep. Pushing the PCA pump’s button by “proxy” is discouraged due to the possibility of overdose.
When communicating with a hearing-impaired patient, what is the appropriate action?
Facing the client when speaking; Facing the client will allow facial expressions to be observed and to lip read during the communication process.
Regarding a radial arterial line in place for blood pressure monitoring, which observation requires corrective action by the nurse?
The transducer is positioned at the level of the right wrist; The level of the right wrist is not correct, and will result in an inaccurate reading.
Where should the transducer be positioned for a patient that has a radial arterial line in place for blood pressure monitoring?
The transducer should be positioned at the level of the right atrium, known as the phlebostatic axis, located at the fourth intercoastal space, midaxillary line.
Teaching has been effective regarding health care-associated infections (HAIs) when the newly licensed nurse states that an iatrogenic infection is one that results from?
HAIs of iatrogenic infections result from a diagnostic or therapeutic procedures.
Improper hand hygiene is an example of?
Breaks in infection control protocols are sources of nosocomial HAIs.
Drug resistance is an example of?
Drug resistance is a source of nosocomial HAIs.
Inappropriate waste disposal is an example of?
Inappropriate waste disposal is a source of nosocomial HAIs.
A flash of light and sudden loss of vision are symptoms of what?
Retinal detachment.
As a nurse, what are you likely to document for a left intracranial hemorrhage?
Right-sided hemiparesis; intracranial bleeding in the left hemisphere of the brain results in right-sided paralysis.
How do you perform the Babinski’s test?
The test is performed by stroking upward along the lateral edge.
P110, R18, BP 160/100 should be reported to the provider?
Yes, the Pulse rate is elevated as well as the BP.
What is the desired outcome for Health and Wellness?
Desired outcomes are to obtain and maintain optimal state of wellness and function.
How can one obtain and maintain an optimal state of wellness and function?
This can be achieved through health education and positive action (smoking cessation, weight loss, seeking health care).
The _______ is a model used to compare the present state of health of a client to that of his previous state of health.
The health/wellness continuum is a model used to compare the present state of health of a client to that of his previous state of health. It is useful as an assessment guide and also as a tool to set goals and find ways to improve the client’s state of health.
What are examples of modifiable variables?
These may be changed; such as smoking, nutrition, health education and awareness, and exercise.
Gender, age, developmental level, and genetic traits, are examples of what?
Non-modifiable variables.
What is the Weber Test used for?
The Weber Test is used to support the diagnosis of sensorinueral hearing loss.
What test supports the diagnosis of sensorineural hearing loss in the left ear?
Weber test lateralized to the right ear.
What is an unexpected finding when performing the otoscopic examination?
Black cerumen partially occluding the TM. Black cerumen that is packed and partially occluding the TM is an unexpected finding and indicates that the client uses cotton-tipped swabs and is pushing the cerumen back into the ear against the TM.
What does black cerumen indicate?
Black cerumen indicates that the client is using cotton-tipped swabs and is pushing the cerumen back into the ear against the TM. This is not a normal finding.
Age 85, Antibiotic therapy with reduced renal function, employed as a ground crew member at a large airport, Presbycusis, High doses of IV furosemide (Lasix) for heart failure exacerbation, and Chronic use of NSAIDs for rheumatoid arthritis management are what?
Age 85, Antibiotic therapy with reduced renal function, employed as a ground crew member at a large airport, Presbycusis, High doses of IV furosemide (Lasix) for heart failure exacerbation, and Chronic use of NSAIDs for rheumatoid arthritis management are factors that can contribute to sensorineural hearing loss.
How should a hearing aid be cleansed?
The earpiece of a hearing aid should be cleaned with mild soap and water, not alcohol.
A client is newly fitted with a hearing aid. A statement of “____” indicates a need for intervention.
“I was the earpiece of my hearing aid with alcohol”.
What is a tympanogram?
A tympanogram measures the mobility of the tympanic membrane and middle ear structure relative to sound.
What is Audiometry?
An audiogram identifies if hearing loss is sensorineural and/or conductive.
What is Otoscopy?
An otoscope is used to examine the external auditory canal, the tympanic membrane (TM), and malleus bone visible through the TM.
When do you use an Otoscopic examination?
Otoscopic examinations are done is audiometry results indicate a possible impairment or if a client is reporting ear pain.
When using an Otoscopic examination on an adult with curved ear canals, what is the nursing action?
If the ear canal curves, pull up and back on the auricle of adults to straighten out the canal and enhance visualization.
When using an Otoscopic examination on children with curved ear canals, what is the nursing action to enhance visualization?
The appropriate nursing action to enhance visualization if the ear canal curves, pull down and back on the auricle of children.
The tympanic membrane should be a waxy gray color. What does it indicate when there is an indication of fluid of infection?
In the presence of fluid of infection in the middle ear, the tympanic membrane will become inflamed and may bulge from the pressure of the exudate.
How should an Audiogram examination be performed?
Test should be done with the client wearing audiometer headphones and facing away from person performing the test.
What are the 2 types of hearing loss?
(1) Conductive hearing loss
(2) Sensorineural hearing loss
What is conductive hearing loss?
Conductive hearing loss occurs when there is an alteration in the middle ear and sound waves are blocked before reaching the inner ear.
When does sensorineural hearing loss occur?
Sensorineural hearing loss occurs when there is an alteration in the middle ear that involves cranial nerve VIII and/or cochlear damage.
Which type of hearing loss occurs when sound waves are blocked before reaching the inner ear?
Conductive hearing loss is the type of hearing loss that occurs when sound waves are blocked before reaching the inner ear.
What cranial nerve is involved in sensorineural hearing loss?
Cranial nerve VIII and/or cochlear damage is involved in sensorineural hearing loss.
A cochlear implant is used for which type of hearing loss?
A cochlear implant is used for Sensorineural hearing loss because it involved cranial nerve VIII and/or cochlear damage.
What is an cochlear implant?
A cochlear implant consist of a microphone that picks up sound, a speech processor, a transmitter and receiver that converts sound into electric impulses, and electrodes that are attach to the auditory nerve.
True or False? Client education: for cochlear implant, the unit is turned on immediately after surgery.
False. Educate the client that immediately after the surgery the unit is not turned on. Two to six weeks after surgery, the external unit is applied and the speech process is programmed.
What is Labyrinthitis?
Labyrinthitis is an infection of the labyrinth, usually secondary to otitis media. (This is a middle and inner ear disorder).
What is Ménière’s disease?
Ménière’s disease is a vestibular disease characterized by a triad of symptoms: tinnitus, unilateral sensorineural hearing loss, and vertigo.
What are the triad symptoms of Ménière’s disease?
The triad symptoms of Ménière’s disease are: Tinnitus, unilateral sensorineural hearing loss, and vertigo.
Tinnitus, unilateral sensorineural hearing loss, and vertigo are the three triad symptoms of what?
Ménière’s disease.
A hearing aid is used for which type of hearing loss?
A hearing aid is used for conductive hearing loss (when sounds are blocked before reaching the inner ear).
Do hearing aids help the client interpret what they are hearing?
No, hearing aid amplify the sounds, but DO NOT help the client interpret what they are hearing.
What is the right setting for a hearing aid?
Client’s with a hearing aid should use the lowest setting without feedback noise.
True or False: The client with a hearing aid should use the HIGHEST setting without feedback noise.
FALSE! Client’s with hearing aids should use the LOWEST setting without feedback noise.
How to communicate with a client with client with hearing disability?
- Get the client’s attention before speaking.
- Stand/sit facing the client in a well-lit, quiet room without distraction.
- Speak clearly of slowly to the client without shouting and without hands or other objects overing the mouth.
- Arrange for communication assistance (sign language, interpreter, closed-caption, TTY capabilities).
If a client is taking ototoxic medications (drugs for the ear) for more than 5 days, what should to want to check?
The appropriate action is the nurse to check the hearing in client’s receiving ototoxic medications for more than 5 days.
Who should the client be referred to if an abnormality is identified during an Audiometry examination?
If there is an abnormality identified during an audiometry, the client should be referred to audiologist for more sensitive testing.
True or False: Refer the client to an Audiologist for further examination if an abnormality is identified during an audiometry.
True.
You have a client with a newly prescribed hearing aid, as a nurse you know that amplification of sound in a load environment can be distracting and disturbing, what nursing action would you recommend regarding the settings of a hearing aid?
Regarding the setting, always teach the client to use the lowest setting that allows for hearing without feedback noise.
Regarding the use of a newly prescribed hearing aid, how should a client be taught how to clean it?
To clean the ear mold, use mild soap and water while keeping hearing aid dry.
True or False? Client education: using soap and water while keeping the hearing aid dry is okay!
True! Clean the ear mold with soap and water! Not Alcohol.
Client education regarding the use of hearing aids when not in use.
When the hearing aid is not in use, make sure to turn it off to conserve the life of the batteries. Replacement batteries should always be kept on hand.
Client education regarding batteries of a hearing aid.
Replacement batteries should always be kept on hand.
What is a Tympanoplasty/Myringoplasty? And which type of hearing loss are they used for?
Tympanoplasty: is surgical reconstruction of the middle ear structures.
Myringoplasty: eardrum repair.
They are surgical interventions used for conductive hearing loss.
A client just had a Tympanoplasty/Myringoplasty (surgical interventions for conductive hearing loss), what are appropriate nursing actions?
- Place sterile packing postoperatively.
- Position the client flat with the operative ear facing up for 12 hours.
What is the appropriate position for a client who just had surgical intervention for conductive hearing loss?
- The nurse should position the client flat with the operative ear facing up for 12 hours.
Client education for Tympanoplasty/Myringoplasty?
- Avoid forceful straining, coughing, sneezing with the mouth close, and air travel.
- Hair can be washed if the ear is covered with a dressing. Not water should enter the ear.
- Remind the client that hearing will be impaired until packing is removed from the ear.
Regarding a tympanoplasty/myringoplasty, can a client’s hair be washed?
Yes, hair can be washed if the ear is covered with a dressing. No water should enter the ear.
What is the postoperative nursing action after surgical interventions for conductive hearing loss? Also, what are the surgical interventions called?
The nurse should place sterile packing postoperatively.
The surgical interventions are Tympanoplasty (reconstruction of middle ear structures), and Myringoplasty (eardrum repair).
True or False: These statements indicate understanding of how to safely manage an external fixation device:
- “I will clean the pins three times a day”
- “I will use on cotton swab on each pin”
- “I will report loosening of the pins to the provider”
True. Pin care protocols are based on provider preference and institution policy. Every 8 hours is a common parameter for a pin care schedule. A primary concept of pin care is that one cotton-tip swab is used per pin to avoid cross-contamination. Loosening of the pins may indicate infection and should be reported to the provider.
Regarding pin care protocols, what does the loosening of pins indicate? And what should be done?
Loosening of the pins may indicate infection and should be reported to the provider.
Client education: The client uses the same cotton swab for each pin, what should the nurse do?
The client needs further teaching, the nurse should educate the client to use one cotton-tip swab per pin to avoid cross contamination.
Client education: Regarding external fixations devices, how often should pins be cleansed?
Every 8 hours is a common parameter for a pine care schedule.
Regarding external fixations devices, a client states “I will lift my arm by the middle of the device to reposition it”. Do you re-educate the client?
The client need to be re-educated, the external devices should not be used to move or lift the extremity.
Does the client need to be re-educated if he states “I should remove any crusting that forms around the pins”?
Yes! The client needs re-education! Teach them that crusting is part of the normal healing process and that crusting around the pins should be allowed to develop as it produces a natural barrier to bacteria.
What immobilization device should the nurse anticipate for a client admitted for surgery after being diagnosed with a right hip fracture?
The nurse should anticipate Buck’s traction as the immobilization device, which is a boot applied to the lower part of the affect extremity. This will temporarily immobilize the extremity until surgery can be done.
What is Buck’s Traction?
Buck’s traction is an immobilization device that should be anticipated for an older adult client who is admitted with a right-hip fracture and has surgery scheduled for the next morning.
Is skeletal traction necessary for a older adult client who is admitted with a right-hip fracture and has surgery scheduled for the next morning.
Skeletal traction will not be necessary, since a surgical repair is scheduled for the next day.
What is an EARLY sign of neurovascular compromise for a client who has a compound fracture of the right forearm?
Paresthesia is an early sign of neurovascular compromise.
What are LATE signs of neurovascular compromise?
LATE signs of neurovascular compromise include: Pulselessness, paralysis, and polar or coldness of the extremity.
Is Paresthesia an early or late sign of neurovascular compromise? But first, what is paresthesia anyways?
First, paresthesia is an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves. Secondly, it is an EARLY sign of neurovascular damage.
Pulselessness, paralysis, and polar or coldness of the extremities are signs of what?
These are later signs of neurovascular compromise.
What is compartment syndrome?
Compartment syndrome is a complication that occurs when pressure within one or more of the muscle compartments in an extremity compromises circulation, resulting in an ischemia-edema cycle.
How is compartment syndrome monitored?
Compartment syndrome is monitored with a handheld device or with a catheter connected to a transducer.
