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Nursing School > Exam 1: 462 & Patho > Flashcards

Exam 1: 462 & Patho Flashcards

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1
Q

What is the most appropriate thing to do when interviewing an older adult

A

All assistive devices, such as glasses and hearing aids, should be in place when interviewing an older patient.

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2
Q

Which assessment findings would alert the nurse to possible elder mistreatment

A
  1. Agitation
  2. Depression
  3. Weight Loss
  4. Hypernatremia
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3
Q

What is the patient bill of rights for patient admin

A
  • right for someone to review med history
  • informed about meds
  • receive drugs safely, not unecessarily
  • refuse
  • consent prior to investigation
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4
Q

A 67-year-old woman who has a long-standing diagnosis of incontinence is in the habit of arriving 20 minutes early for church in order to ensure that she gets a seat near the end of a row and close to the exit so that she has ready access to the restroom. Which tasks of the chronically ill is the woman demonstrating

A
  • Controlling symptoms
  • Preventing & Managing Crisis
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5
Q

A 70-year-old man has just been diagnosed with chronic obstructive pulmonary disease (COPD). At what point should the nurse begin to include the patient’s wife in the teaching around the management of the disease?

A

As soon as possible

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6
Q

Which criterion must a 65-year-old person meet in order to qualify for Medicare funding?

A

Being entitled to Social Security benefits

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7
Q

What is an LIP

A

Licensed Independent Practitioner

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8
Q

Who is responsibile for med admin

A
  • healthcare provider,
  • pharmacy, (change make recommendations)
  • nurse,(call provider)
  • patient/family
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9
Q

What are illnesses associated with aging

A
  • Obesity
  • diabetes
  • hypertension
  • cancer
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10
Q

male patient has a history of hypertension and type 1 diabetes mellitus. Because of these chronic illnesses, the patient exercises and eats the healthy diet that his wife prepares for him. Which factors will most likely have a positive impact on his biologic aging

A
  1. exercise
  2. social support
  3. good nutrition
  4. coping resources
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11
Q

This is a social, recreational, and health-related services in a safe, community-based environment that would keep this patient safe

A

Adult Day Care

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12
Q

This is used when the patient has rapid deterioration, the caregiver is unable to continue to provide care, and there is an alteration in or loss of the family support system

A

Long Term Care

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13
Q

This is used when there is supportive caregiver involvement for patients with health needs

A

Home Health Care

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14
Q

Aging primarily affects the _________of drugs.

A

Metabolism

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15
Q

What are 4 components of med admin

A
  1. An Order
  2. Transcription into Electronic Health Record
  3. Dispensing of the meds (pharmacy)
  4. Administration of the meds
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16
Q

What must you do prior to administering a med for clarification?

A
  • all orders with the prescriber before administering medications.
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17
Q

1 tablespoon =

A

15 ML

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18
Q

What can LIP do

A
  • assess patient,
  • prescribe meds
  • verbal orders
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19
Q

How can LIP prescribe med

A

computer, written, telephone (repeat back)

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20
Q

When should you respond to verbal order

A

urgen situation, repeat back

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21
Q

What does pharmacy do

A
  • receive/review order
  • asess/evaluate
  • pt history
  • prep distribute
  • educate
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22
Q

A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient’s ear when administering the medication?

A

upward and outward (greater than 3 yrs)

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23
Q

Whos is responsible for med administration

A

nurse

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24
Q

What is the nurse’s role x5

A
  • med administer,
  • provide education,
  • assess patient,
  • monitor
  • document
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25
Q

A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, “I don’t remember my child having that medication before.” What is the nurse’s next action?

A

Withhold the medications and verify the medication orders

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26
Q

What are resources for researching medications

A
  • med texts
  • pharmacist
  • package inserts
  • computer (micromedex)
  • DocuCare
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27
Q

What is something IOM reported due to med errors

A

be careful of abbreviations

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28
Q

when patients have home care needs or difficulty understanding their medications, what is the nursing responsibility?

A
  • Collaborate with community resources
  • Ensure that the home care agency is aware of medication and health teaching needs
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29
Q

What are the 7 Essential Elemens for Med Order

A
  1. patient name
  2. date ordered
  3. name of the drug
  4. dosage (amt, #)
  5. route
  6. frequency
  7. Signature of LIP
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30
Q

What type of med orders can we receive x7

A
  • standard written
  • PRN (as needed)
  • STAT order
  • Now
  • One Time
  • On Call (awaiting a procedure as prep)
  • Standing orders and Protocols
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31
Q

What does PO mean?

A

by mouth

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32
Q

How does a nurse determine appropriateness of medication

A
  • assessment findings,
  • subj, obj data,
  • document reason/results of medication
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33
Q

How long should you respond to an order that says “now”

A

within the hour

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34
Q

What is a standing order used for

A
  • to treat occurrences
  • if patient meets certain criteria
  • pre-written protocols
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35
Q

The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse’s next best course of action?

A

Ask the prescriber to change the order

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36
Q

The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse’s next action?

A

Ask the patient’s reason for refusal

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37
Q

A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse:

A

Stops the administration of the medication and follows agency policy.

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38
Q

What Orders for medications can change

A
  • health parameters
  • surgery
  • transfer between different services
  • transfer to another hospital or facility
  • ORDERS MUST BE REWRITTEN
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39
Q

Redness, warmth, and tenderness at the IV site are signs of

A

phlebitis.

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40
Q

What are the 6 rights of medication administration

A
  1. Right Patient
  2. Right Med
  3. Right Time (30min window)
  4. Right Dosage
  5. Right Route (oral, respiratory, parenteral, topical, PO)
  6. Right Documentation
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41
Q

A nurse accidently gives a patient a medication at the wrong time. The nurse’s first priority is to

A

Assess the patient for adverse effects

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42
Q

Assessment priorities x8

A
  • health hx
  • med history, review MAR
  • allergies
  • diet history
  • lab values
  • coordination problems
  • current condition
  • pregnancy/lactation status
  • compliance- will patient take meds?
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43
Q

suggest or indicate that (a particular technique or drug) should not be used in the case in question

A

contraindicated

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44
Q

What would affect a patients adherence

A
  • memory problems
  • alcohol
  • ability to pay
  • transportation to pharmacy
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45
Q

What is the phys assessment prior to meds? x7

A
  • vital signs
  • ability to swallow- gag reflex
  • GI motility
  • Muscle mass
  • Venous Access
  • Body sys assessment
  • right to refuse
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46
Q

What is the 3 part statement for a nursing diagnosis

A
  1. Diagnosis
  2. Related To
  3. As Evidence By
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47
Q

What are examples of nursing diagnoses related to med admin

A

anxiety, deficity of knowledge, impaired mobility, impaired swallowing, fall risk

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48
Q

What is stock-supply of medication?

A
  • bulk quanitity
  • central location
  • not client-specific
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49
Q

What is a unit dose

A
  • individually packaged meds
  • client specific drawers
  • 24 hr supply
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50
Q

What is self administration

A
  • Individual containers
  • kept at patients bedside
  • (eye drops)
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51
Q

What is automated dispensers

A
  • password accessible locked cart
  • computerized tracking
  • can combine stock and unit
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52
Q

What is “COW”

A
  • Computer on Wheels
    • automated dispenser
  • Not appropriate term
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53
Q

What are nurse’s 3 checks?

A
  1. Remove meds from drawer//Label against order
  2. After your pour//verify label again MAR
  3. At Bedside//Check ID band against MAR
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54
Q

What are basic rules for administering medication x9

A
  • prep for ONE patient at a time
  • compare order with me davailable
  • calc drug dose
  • Verify order
  • Check if it seems excessive
  • take meds directly to the patient
  • Check 2 patient identifiers
  • complete required assessent prior to giving
  • DO NOT LEAVE at bedside, stay until that complete
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55
Q

How should you prepare liquid medications?

A

at eye level

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56
Q

What is the 3 Bears Rule

A

“just the right amount”

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57
Q

When applying topical meds what PPE do you need

A
  • gloves
  • (otherwise you will be taking it)
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58
Q

Where do you put medications applied sublingual?

A

under the tongue

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59
Q

What do you do for enteral medications

A
  • crush and dissolve in water
  • flush with water/saline between medications
  • make sure wont clog tube
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60
Q

What is a PEG tube?

A
  • percutaneous
  • endoscopic
  • gastric
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61
Q

What are precautions for phthalmic medications

A
  • make sure it says for ophthalmic use only
  • no cross contamination
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62
Q

Precautions for Ear-Otic Medications

A
  • Proper temperature
  • child vs adult
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63
Q

What are nebulizer precautions (MDI)

A
  • coordinated movements required
  • local effect
  • a fine spray of liquid
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64
Q

What are precautions for rectal admin

A
  • Past internal sphincter and against the rectal mucosa (side)
  • local or systemic effects
  • suppositories/enemas
  • WEAR GLOVES
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65
Q

What are precautions for vaginal administration

A
  • foams, jellies, creams
  • body temperatures
  • standard precautions (gloves)
  • privacy if client self administer
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66
Q

What are precautions for parenteral medications

A
  • med by injection
  • invasive
  • proper administration (location!!)
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67
Q

What is a needle’s gauge

A

thickness of the needle

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68
Q

Is 25 gauge bigger or smaller than a 16 gauge needle

A

smaller

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69
Q

Needle Precautions

A
  • do not recap a dirty needle
  • place directly into a sharps container
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70
Q

If you do have to recap a needle what is the technique?

A
  • scoop, with no touching!
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71
Q

What did the Occupational Health and Safety ACt require

A

to use safety engineered needles

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72
Q

Layers for parenteral Medications Sites x4

A
  • Intradermal
  • subcutaneous
  • intramuscular
  • intravenous
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73
Q

What are intradermal injections for?

A
  • Skin Testing
  • 26 gauge
  • light pigmentation, free of lesions, hairless
  • Mantoux TB Skin test
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74
Q

How do you do a mantoux TB Skin Test

A
  • 0.1 ml of Protein Purified Derivative
  • read 48-72 hrs later
  • diamter of the “induration”
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75
Q

How do you administer a Subcu Shot

A
  • 45-90 degree angle
  • stomach, back, shoulder, thighs
  • into the fat
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76
Q

Characteristics of SubQ

A
  • Abbreviations SC, SubQ, SQ
  • 0.5-1ml fluid
  • 25-27 gauge
  • Absorbs slower that IM route
  • do not require aspiration
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77
Q

Insulin Syringes

A
  • subq
  • syringe depend on manufacturer
  • orange, must be specific
  • units
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78
Q

IM injections

A
  • intramuscular, assess muscle
  • 90 degree
  • dont go too low with deltoid
  • absorbs faster more blood supply
  • 1/2 - 3” in length
  • need to aspirate before injecting
  • 21-25 gauge
  • Less than 3 mL
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79
Q

What is Z-Track IM

A
  • medications that could damage tissues
  • 1-1.5 “
  • hold skin and keep needle in place 10 sec
  • withdraw needle and release skin
  • (example: iron)
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80
Q

Mixing Meds precautions

A
  • have to be “compatible”
  • don’t contaminate, change needles
  • final dose is accurate
  • insulins can be mixed
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81
Q

What is sliding scale insulin

A

If blood glucose level is within a specific range, this is how much you will give

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82
Q

When giving a shot, how do you minimize anxiety?

A
  • educate patient
  • be calm
  • calm family
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83
Q

If med error occurs what ACTIONS do you take

A
  • assess the patient immediately
  • report to charge nurse
  • be honest
  • report error and findings to primary care provider
  • incident reports
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84
Q

Why is older adults in US growing

A
  • increase avg life span
  • baby boomer (1946-65)
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85
Q

What common challenges for the older adult

A
  • losses
  • decrease ability to respond to stress
  • phys changes
  • high risk for illness and functional loss
  • ASSESS
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86
Q

Normal Phys changes with aging

A
  • body composition
  • body cells less able to replace themselves
  • reduces lean body mass
  • loss of subq fat
  • body shrinkage due to loss of cartilage
  • body fat atrophy (sagging)
  • hard to maintain body temp
  • increas risk of dehydration, decrease intracellular fluid
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87
Q

Cardiovascular changes for aging

A
  • decreased contractility
  • impaired blood flow
  • alter preload/afterload
  • vessels tortuous
  • heart valves rigidity
  • increase atherosclerotic
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88
Q

Respiratroy changes in older adult

A
  • rigid thoracic cage
  • decrease vital capcity
  • decrease cough efficiency
  • decrease in ciliary action- (flow of mucous)
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89
Q

Endocrine changes in adult

A
  • thyroid- decreased metabolism
  • pancreas-insufficient release of insulin
  • pituitary-decrease release in hormones
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90
Q

Renal Changes in Adult

A
  • decrease bladder capacity
  • decreased concentrating / diluting abilities
  • decrease creatinine clearance (buildup)
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91
Q

GI changes in adult

A
  • tooth loss
  • decrease saliva
  • altered digestion
  • weakened esophageal sphincter
  • decrease in blood flow
  • decrease size in organs
  • decrease peristalsis
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92
Q

Nervous sys changes in adult

A
  • decrease in neurons & speed of conduction (driving)
  • decrease brain weight
  • decrease peripheral nerve function
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93
Q

Sensory changes in adult

A
  • presbyopia
  • glaring
  • difficult distinguishing btwn blue & green
  • presbycusis
  • ear wax build up
  • decrease taste
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94
Q

Reproductive changes in adult

A
  • vaginal mucosa thinning and atrophy
  • decrease breast tissue
  • decreased libido
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95
Q

skin changes

A
  • heat regulation
  • elasticity
  • epidermal renewal
  • screation of oil/perspiration
  • decrease infammatory response
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96
Q

How much of the body’s water is intracellular

A
  • 2/3
  • ICF Intracellular Fluid Compartment
  • within the cells
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97
Q

How much of the body’s water is extracellular

A
  • 1/3
  • interstitial fluid 25%
  • intravascular (blood plasma) 8%
  • transcellular (lymph, synovial, pleural)
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98
Q

What are the 2 components of extracellular compartment:

A
  1. interstitial
  2. intravascular
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99
Q

What percent of total body water is part of body weight?

A

60%

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100
Q

How does water move throughout the body

A

freely across membranes

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101
Q

What is aldosterone

A

it is a hormone that is secreted when sodium levels are depressed.

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102
Q

What is hyperchloremia

A
  • electrolyte disturbance in which there is an abnormally elevated level of the chloride ion in the blood.
  • is a result of an underlying disorder
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103
Q

What is hypo(na)tremia

A

an outcome of serious burns, vomiting, or diarrhea

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104
Q

What is hyperkalemia

A
  • It often occurs in acidosis.
  • MACHINE (meds, acidosis, cellular destruction, hemolysis, intake, nephrons, excretion, impaired)
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105
Q

A patient has deep and rapid respirations. Laboratory tests reveal decreased pH and bicarbonate. This patient is experiencing:

A

metabolic acidosis

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106
Q

increased filtration of fluid from capillaries and lymph into surrounding tissues (edema) is caused by: x4

A
  1. increased hydrostatic pressure
  2. decreased plasma oncotic pressure
  3. increased capillary membrane permeability
  4. lymphatic obstruction
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107
Q

causes of hypernatremia

A
  1. admin too much hypertonic saline solution
  2. too much aldosterone.
  3. Cushing syndrome
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108
Q

common clinical manifestations of hypokalemia

A
  1. carbohydrate metabolism is affected due to decreased insulin secretion.
  2. Renal function is impaired.
  3. neuromuscular excitability is decreased
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109
Q

intravascular water is

A

blood

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110
Q

Children vs Adult Water Retention

A
  • 70% kids
  • 45% older adults
  • prone to dehydration
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111
Q

Water composition of the body

A
  • primary body fluid
  • varies with age, sex adipose tissue
  • contains solutes (electr or non electric)
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112
Q

What are solutes

A
  • solid substances that dissolve in the body
  • Na+ or glucose int the blood plasma 90%
  • 60% in interstitial fluid
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113
Q

Functions of body fluid

A
  • maintain blood volume
  • regulate body temp
  • sweating (insensible loss)
  • transports material to and from cells
  • food digestion
  • medium for excreting waste
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114
Q

What are non electrolytes

A
  • most organic molecules
  • do not dissociate in water
  • carry NO net electrical charge
  • (example: protein, glucose)
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115
Q

What are electrolytes

A
  • dissociate in water to ions
  • inorganic salts, acids, bases, some bases
  • more osmotic pwr (attract water)
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116
Q

Functions of electroylyes

A
  • regulate nerve/muscle function
  • hemodynamically stable
  • stay hydrated
  • manage pH
  • blood pressure
  • damaged tissue repair
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117
Q

Common ECF electrolytes

A
  • NA+
  • Chloride Cl-
  • Biocarbonate HCO3-
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118
Q

Common Electrolytes ICF

A
  • Potassium (K+)
  • Phosphate (PO42-)
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119
Q

This is a physical barrier that encloses a fluid space within the body. It i Selectively permeable

A

Cellular membrane

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120
Q

relating to the flow of blood within the organs and tissues of the body

A

hemodynamic

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121
Q

How do we maintain homeostasis

A
  • movement of fluids & electrolytes
  • fluid intake and fluid output
  • hormonal regulation
  • adh, Adosterone, Renin, Angiotensin, Natriuretic Peptides
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122
Q

Pressure exerted by a fluid within a closed system

A
  • hydrostatic pressure
  • causes a leak (like a soaker hose)
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123
Q

What changes the hydrostatic pressure

A

force of the weight of water molecules pressing against the confining walls.

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124
Q

What are the results of hydrostatic pressure

A
  • movement from an area of Greater pressure to lower pressure
  • makes cell wall more permeable
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125
Q

Exerted by proteins, notably albumin, in a blood vessel’s plasma (blood/liquid) that usually tends to pull water into the circulatory system.

A
  • Oncotic pressure
  • (egg white, dense less permeable)
  • keep fluid in
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126
Q

Low Serum Albumin causes…

A

pitting edema

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127
Q

ROME mneumonic

A
  • Respiratory Opposite (pH up PCO2= Alkalosis)
  • Metabolic Equal (pH up HCO3 up= Alkalosis)
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128
Q

What is RUB MUM

A
  • Respiratory Uses Bicarb
  • Metabolic Uses Breathing
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129
Q

Signs of hyerkalemia MURDER

A
  • Muscle weakness
  • Urine, oliguria, anuria
  • Respiratory distress
  • Decreased cardiac contractility
  • EKG changes
  • Reflexes, hyper, or hypo
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130
Q

Capillary Bed

A
  • Where all the action happens. CO2 converts to O2
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131
Q

fluid getting backed up in the tissue

A

edema

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132
Q

hydrostatic pressure=

A

osmotic/oncotic pressure (not inflamed)

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133
Q

the concentration of a solution expressed as the total number of solute particles per liter.

A
  • osmolarity
  • high, means high concentrates of solutes
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134
Q

3 Classification of Osmolarity

A
  • isotonic (same as blood)
  • hypotonic (water, more inside)
  • hypertonic (gatorade, more outside)
135
Q

Normal serum osmolarity

A

280-295 mOsm/L

136
Q

How does the body passively tranport

A
  • no energy used
  • diffusion, osmosis, filtration
137
Q

How does the body actively transport

A
  • requires energy ATP to move substances
138
Q

What directions to solutes diffuse?

A

high to low

139
Q

What direction does osmosis move?

A

towards higher concentration

140
Q

Moves both water and small solutes from high pressure to low pressure

A

Filtration

141
Q

This moves a solute against the gradient

A

Active Transport

142
Q

Where is energy produced in your cells?

A

mitochondria

143
Q

What happens to the brain when osmolality increases

A
  • hypothalamus is stimulated and the person gets thirsty
  • stimulates hormone
144
Q

What foods stimulate osmolality and hypothalamus

A

salt

145
Q

Fluid Output methods

A
  • kidney
  • gi tract
  • skin
  • lungs
146
Q

What are 7 mechanisms for fluid balance

A
  1. hypothalamic,
  2. pituitary
  3. Adrenal cortex (on top of kidneys)
  4. Kidneys
  5. Heart
  6. GI Tract
  7. Insensible water loss
147
Q

These hormones regulate body fluid x4

A
  • Renin Angiotensin
  • Aldosterone
  • Natriuretic Peptides
  • Antidiuretic hormone (keep water)
148
Q

chief mineralocorticoid secreted by the adrenal glands. Causes sodium to be reabsorbed by the kidneys

A
  • Aldosterone
  • adrenal gland
  • decreased BP
  • high potassium
  • low sodium
149
Q

body exchanges sodium for potassium because

A

it wants to get rid of potassium

150
Q

is released in response to low renal blood flow and low BP by the kidneys

A
  • RAAS (renin angiotensin sys)
  • in response to low BP and low volume
  • natriuretic peptides oppose this sys
151
Q

RAAS stimulates

A
  • Angiotensinogen* (renin)> Angiotensin I (enzyme) > Angiotenin II > potent vasoconstrictor, stimulates aldosterone secretion
    ex: ace inhibitor (decreases BP), low sodium
152
Q

hormones secreted by your heart in response to BP and blood volume that stretch heart tissues

A

NP- Natriuretic Peptides

153
Q

lowers your blood pressure

A
  • NPs
  • vasodilation
154
Q

losing water thru kidneys

A

diuresis

155
Q

excreted by hypothalamus and stored in posterior pituitary gland

A
  • ADH (antidiuretic hormone)//Vasopressin
  • vasoconstrictor (increases BP)
  • maintains water balance
  • promotes water reabsorption
156
Q

When does ADH respond

A
  • to serum osmolaltiy,
  • fever,
  • pain,
  • stress,
  • opiods
  • (LOW BLOOD VOLUME)
157
Q

It is better to be lacking fluid than

A

osmolarity

158
Q

When do you need to keep water

A

when osmolarity is high

159
Q

With a decrease in ADH release, urine will be more

A

dilute

160
Q

with a decrease in ADH release, specific gravity of urine will be

A

low

161
Q

Types of fluid volume imbalances

A
  • deficit
  • excess
  • shift
  • ECF it is accompanied by changes in the serum sodium levels
162
Q

Causes a fluid volume deficit

A
  • shift of fluid from plasma into insterstitial fluid
  • (other obvious ones)
163
Q

Causes for fluid volume excess

A
  • renal fail (decrease urine formation)
  • cardiac dysfunction
  • head injuries
  • meningitis
  • tumors
  • too much ADH release
164
Q

Fluid Volume Shift causes

A
  • EDEMA
  • severe sepsis (3rd spacing)
  • excessive accumulation of fluid w/in the interstitial spaces
  • cant get BP UP
  • increased hydrostatic pressure
  • increased capillary membrane permeability
  • lymphatic channel obstruction “lymphedema”
165
Q

What is 3rd spacing

A
  • constantly leaking out
  • not easily exchanged with ECF
166
Q

Cations have a positive or negative charge?

A

positive

167
Q

Table page 102

A
168
Q

Can we measure intracellular electrolytes

A

NO

169
Q

Normal Serum Sodum Level

A

135-145 mEg/L

170
Q

What is the major cation in the blood

A

Sodium (Na+)

extracellular

171
Q

Excess sodium

A
  • hypernatremia
  • kidney failure
  • steroids
  • cushings disease
172
Q

Low Sodium/Causes

A
  • Hyponatremia
  • Diuretic
  • GI fluid loss
  • Aldosterone
  • excessive intake of hypotonic fluid (nursing error)
173
Q

How much potassium is in ECF

A

2%

174
Q

Norm level of Potassium

A
  • 3.5-5 mEq/L
  • must be ingested daily by diet
175
Q

How much potassium per day

A

40 mEq/d

176
Q

What causes low potassium

A

Severe nausea and diarhea

177
Q

Function of the potassium

A
  • transmits electrical impulses in multiple body sys
  • regulates conduction of cardiac rhythm
  • contracts skeletal, smooth & cardiac muscles
  • Maintain Acid Base Balance
  • works with Na+
178
Q

What regulates potassium

A
  • aldosterone.
  • Increase aldosterone increase excretion of potassium
  • everytime you pee lose potassium
  • Na+ & K go opposite one another
179
Q

High potassiums is greather than

A

5

180
Q

Causes for hyperkalemia

A

renal failure

high potassium intake

ACE inhibitors, aspirin, beta blockers, chemo

hypoaldosteronism

181
Q

Following a bilateral mastectomy, a 50-year-old patient refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. How should you reply?

A

“I see that you’ve combed your hair and put on makeup.”

matter-of-fact approach and acknowledges a change in the patient’s behavior or appearance, it allows the patient to establish its meaning.

182
Q

A patient diagnosed with major depressive disorder has a nursing diagnosis of chronic low self-esteem related to negative view of self. What would be the most appropriate cognitive intervention by the nurse?

A

Focus on identifying strengths and accomplishments

to minimize the emphasis on failures assists the patient to alter distorted and negative thinking

183
Q

“Should I have a cup of coffee or a cup of tea?” and “Should I take a shower now or wait until later?” How should you interpret the patient?

A

Inability to make decisions reflects a self-concept issue.

184
Q

An adult woman is recovering from a mastectomy for breast cancer and is frequently tearful when left alone. What does the patient need?

A

support in dealing with the loss of a body part.

encourage the patient to talk about the threats to body image, including the meaning of the loss, the reactions of others, and the ways in which the patient is grieving.

185
Q

When caring for an 87-year-old patient, the nurse needs to understand that ___________affects the patient’s current self-concept

A

role change, loss of loved ones, and physical energy

186
Q

A 20-year-old patient diagnosed with an eating disorder has a nursing diagnosis of situational low self-esteem. What nursing interventions would be best to address self-esteem?

A

Offer independent decision-making opportunities

187
Q

The nurse asks the patient, “How do you feel about yourself?”
The nurse is assessing the patient’s:

A

Self Esteem

188
Q

The nurse can increase a patient’s self-awareness by these actions…

A
  1. Helping define her problems clearly
  2. Allowing to openly explore thoughts/feelings
  3. Reframing thoughts/feelings in a positive way
189
Q

When developing an appropriate outcome for a 15-year-old girl, the nurse considers that a primary developmental task of adolescence is to:

A

Form a sense of identity

190
Q

involves attitudes related to the body, including physical appearance, structure, or function

A

Disturbed Body Image

191
Q

In planning nursing care for an 85-year-old male, the most important basic need that must be met is

A

Self-esteem is essential for physical and psychological health across the life span

192
Q

The home health nurse is visiting a 90-year-old man who lives with his 89-year-old wife. He is legally blind and is 3 weeks’ post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her.

A

Risk for Situational Low Self Esteem as his mobility improves, his low self-esteem will also resolve

193
Q

Pulmonary Edema Treatment

MAD DOG

A
  • Morphine- vasodilation, decrease BP
  • Aminophylline- relazes airways to make breathing easier
  • Digitalis- improve heart function
  • Diuretic(Lasix)- pull excess fluid off
  • Oxygen- improve oxygenation
  • Gasses- assess respiratory status
194
Q

Signs of Hypernatremia

You are FRIED

A
  • Fever
  • Restless
  • Inc BP
  • Edema
  • Dec urinary (too much aldosterone)
195
Q

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate:

A

Metabolic Acidosis

196
Q

A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first?

A

Serum potassium

197
Q

Heart failure commonly causes ICF or ECF & why?

A

ECF,

because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water

198
Q

You assess four patients. Which patient is at greatest risk for the development of hypocalcemia?

A

28-year-old who has acute pancreatitis

because calcium binds to undigested fat in their feces and is excreted

199
Q

Assessment findings consistent with intravenous (IV) fluid infiltration include

A
  1. Edema and pain
  2. Pallor & Coolness
200
Q

Which of the following defi ning characteristics is consistent with fluid volume deficit?

A

Dry mucous membranes, thready pulse, tachycardia

201
Q

Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl?

A

auscultate dependent portions of the lungs

202
Q

While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action?

A

Stop the transfusion

ndication of an acute hemolytic reaction. incompatible blood.

203
Q

The health care provider’s order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid?

A

Oliguria, can cause hyperkalemia

204
Q

your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient’s breathing?

A

Provide frequent oral care to keep her mucous membranes moist. Hyperventilation should be ALLOWED to continue

205
Q

Which patient is most at risk for respiratory depression related to opioid administration for pain relief?

A
  • those who are older
  • lung disease
  • history of sleep apnea
  • receiving other central nervous system depressants
206
Q

Before administering celecoxib (Celebrex), the nurse will assess the patient’s medical record for which medication that would increase the risk of adverse effects?

A

aspirin, increase risk of bleeding

207
Q

Which assessment is of highest priority for the nurse to complete before administration of morphine?

A

Respiratory Rate

208
Q

The nurse should question an order written for Percocet for a patient exhibiting which clinical manifestation?

A

Severe jaundice

Percocet contains Acetaminophen and oxycodone which is metabolized in the liver

209
Q

The nurse is caring for a patient who is receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication?

A
  • pain control less than 3
  • normal respirations
  • alert
210
Q

The nurse should teach a patient to avoid which medication while taking ibuprofen?

A

Aspirin, Risk for GI bleed

211
Q

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient

A
  • itching
  • nausea
  • urinary retention
212
Q

The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8/minute. Which medication would the nurse prepare to administer to treat these symptoms?

A

Naloxone (Narcan)

213
Q

nonpharmacologic comfort measures include

A
  • comfort massage
  • provide distractions
  • heat or cold therapy
214
Q

he patient’s neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient’s pain

A
  • Antiseizure drugs,
  • tricyclic antidepressants,
  • SNRIs,
  • transdermal lidocaine,
  • α2-adrenergic agonist
215
Q

The patient is a known abuser of narcotics and just had surgery. The nurse is frustrated by drug addiction and worried about the high dose of narcotic analgesic prescribed for this patient. What is the best action for the nurse to take?

A

This patient has the right to appropriate assessment and management of pain.

216
Q

This is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss.

A

Spironolactone (Aldactone) (contraindicated w/ hyperkalemia)

217
Q

The nurse is caring for a 76-year-old woman admitted to the clinical unit with hypernatremia and dehydration after prolonged fever. Which beverage would be safest for the nurse to offer the patient?

A

orange juice

218
Q

The nurse on a medical-surgical unit identifies that which patient has the highest risk for metabolic alkalosis?

A

NG tube

219
Q

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine?

A

Metabolic Alkalosis

220
Q

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician?

A

Loop Diuretics, cause the kidneys to excrete sodium and potassium.

221
Q

Hyperkalemia may result from

A

Hyperglycemia

222
Q

Signs of Hyperglycemia 3Ps

A
  1. polyphagia
  2. polydipsia
  3. polyuria

Hot dry, sugar high

223
Q

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention?

A

Listen to the patient’s lung sounds and assess respiratory status. Should have infused after 4 hours.

224
Q

When planning care for adult patients, which oral intake is adequate to meet daily fluid needs of a stable patient?

A

2000 to 3000 mL

225
Q

While performing patient teaching regarding hypercalcemia, which statements are appropriate

A
  1. Renal calculi may occur as a complication of hypercalcemi
  2. Weight-bearing exercises can help keep calcium in the bones.
  3. The patient should increase daily fluid intake to 3000 to 4000 mL
226
Q

The dehydrated patient is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions

A
  • lung sounds
  • blood pressure
  • Serum sodium level
227
Q

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse’s priority action?

A
  • Administer Oxygen
228
Q

When should you never crush a medication?

A
  1. Sublingual
  2. Enteric-coated
  3. Extended Release
229
Q

A.C. means

A

administer before meal

230
Q

P.C. means

A

Administer med after a meal

231
Q

Acidosis Characteristics

A
  • hyperkalemia
  • hypernatremia
  • renal failure
  • ECF to ICF
  • Oligaria
  • Hyperventilation
  • Hypoaldosterone
  • RAAS
  • LOW BP
  • vaso-dilation
232
Q

Alkalosis Characteristics

A
  • Hypokalemia
  • hypertonic
  • hypoventilation
  • hypoaldosterone
  • hypoventilation
  • polyuria
  • nausea
  • diarrhea
  • burns
233
Q

Psychosocial changes for older adult

A
  • Sexual (intimacy)
  • Economic,
  • Intra-family changes
  • Ageism
234
Q

Nursing Assessment

A
  • ADLs/IADL (cooking, driving)
  • cognitive evaluation
  • phys assessment
  • functional
  • Social
  • Environmental
235
Q

Wellness in aging

A
  • Unique approach
  • Lifestyle changes
  • Treatment of Chronic Illness
  • Outreach (AARP)
236
Q

Health Definition according to World Health organization

A

“complete physical, mental, and social well-being” (not just absence of disease)

237
Q

Sociologic Definition of Health

A

ability to conduct ADL’s

238
Q

Illness-Wellness Continuum

A
  • we manage a person at any point on the continuum
239
Q

How would you encourage higher level of wellness on a person who is well?

A

Maintenance, preventive, mammograms, prostate checks, encourage independence

240
Q

What is health promotion?

A
  • wellness
  • self care
  • health screening
  • nutrition ed
  • genetic testing
241
Q

Ilness Definition

A
  • the result of a disease or injurty that affects functioning
  • How do they view their illness? Any symptoms?
242
Q

Acute illness

A
  • 3-6 months
  • reversile
  • pneumonia, delirium, shingles, apendicitis
243
Q

Chronic Illness

A
  • longer than 6 months
  • gradual onset
  • irreversible
  • diabetes, alzheimers, parkinsons, MS
244
Q

What is illness behavior?

A
  • the way a person acts when their sick
    • sociocultural
    • past experiences
    • acceptance
245
Q

What happens to a person in chronic illness vital signs

A
  • stays the same
  • body adapts
246
Q

4 Typical “modifiable” behaviors of chronic illness

A
  1. physical inactivity
  2. poor nutrition
  3. use of tobacco
  4. excessive alcohol
247
Q

Characteristics of chronic illness

A
  • long term and persistant
  • predictable
  • wellness/illness shift
  • overwhelming for the family
  • adjust and adapt
  • requires a caregiver
248
Q

Chronic Management

A
  • Flu vaccines
  • mamograms
  • prevention of acute conditions
  • independence
249
Q

ADA disability defintion

A
  • record of impairment
  • physical/mental problem that limits disability
  • regarded as having a disability
250
Q

What are types of disabilities

A
  • body system
  • developmental
  • acquired (after your born)
    • MS, SCI, COPD, age related
251
Q

Challenges for caregivers of those with disability

A
  • prejudice
  • lack of respite
  • conflict of decisions
  • time/energy
  • not meeting their own needs
  • financial
  • lack of education
252
Q

A treatment/treatments designed to facilitate the process of recovery

A

rehabilitation

253
Q

Types of Rehab

A
  • Physical Therapy
  • Occupational therapy (ADL’s)
  • Speech
  • Dietitician
254
Q

Nursing Interventions for Disability

A
  • Listening, patients
  • Increase Socialization
  • Encourage independence
  • Ask for feedback
  • promote dignity
  • Do not remove personal belongings
  • Touch
255
Q

Normal Osmolality Levels

A

285-295

256
Q

CBC Means

A
  • Complete Blood Count
    • RBC, Hemoglobin, WBC, Hematocrit, Platelets
257
Q

BMP

A
  • Basic Metabolic Panel
    • glucose, electrolyts, creatinine
258
Q

BUN

A

Blood Urea Nitrogen

259
Q

Creatinine

A

by product of muscle metabolism

260
Q

Liver Enzymes

A

AST, ALT

261
Q

Normal Range for WBC

A

5,0000 -10,000

262
Q

Normal range platelet count

A

150,000- 300,000

263
Q

Cholestorol Normal

A

less than 200

264
Q

Good Cholestoerol

A

>30

265
Q

Bad Cholesterol

A

Less than 130

266
Q

What is specific gravity

A

Concentration of urine

267
Q

Urine Tests

A
  • Creatinine Clearance (kidney function)
  • Presence of Protein
268
Q

Sputum Testing

A
  • Culture organisms and Sensitivty (antibiotics)
269
Q

Stool Samples

A
270
Q

Specific Gravity Norm

A

1.002-1.030

271
Q

Protein, Bilirubin, Glucose, Ketones, Occult, Bacteria Test

A

should be negative

272
Q

Ketones is common in

A

diabetic patients

273
Q

Occult Blood Test are commonly used

A
  • in stools
  • looking for hidden blood
274
Q

What is a urine dipstick

A
  • color coding
275
Q

What is telemetry EKG Monitory

A
  • can be mobile
  • Tech constantly monitoring
276
Q

Patient short of breath, fever, cyanosis around moth, coughing up thick green sputum. What labs should you get

A
  • X-ray
  • Sputum
  • CBC- WBC (5-10,000)
  • MBP
277
Q

Patient has chest pain moving down left arm, SOB, weak, nausea, what labs would you get?

A
  • EKG
  • CBC
  • BMP
  • Cardiac Enzymes
278
Q

Think Potassium, think

A

Heart

279
Q

Patient 36 wks pregnant, burning w/ urination, back aches, fever, which labs?

A
  • Urinalysis
  • CBC
280
Q

Patient has small bruises all over. Skin is dry, tenting, turgor, dry oral mucosa. Patient is frail, malnourished. Which labs?

A
  • BMP
  • CBC
  • electrolytes
  • Serum Albumin (malnourished)
  • Blood Clotting
281
Q

Tricks to remember What are the best years of your life

A

35-45

282
Q

Who is potassiums little brother

A

Magnesium (1.5-3.5)

283
Q

BiCarb

A

22-26

284
Q

Hemoglobin

A

Women 12-16, Men 14-18

285
Q

Hematocrit Level

A

35-45

286
Q

Calcium Level

A

10

287
Q

BUN level

A

10

288
Q

Fluid located in between the cells

A

Extracellular

289
Q

What do lab values tell you

A

concentration of the particles in the plasma

290
Q

Nursing Interventions for Fluid MGMT

A
  • Measure Ins/Outs
  • Record hourly (ICU), every 4 hrs, every shift (follow protocol)
  • Totals recorded every 24 hrs
  • Why? Kidney Function, to prevent dehydration or fluid overload
  • Daily Weight- most accurate measurement of fluid MGMT
291
Q

IOM recommendation for fluid intake

A
  • 2700 ml for women, 3500 for women
292
Q

How much fluid comes from food metabolism

A

20%

293
Q

Fluid intake regulated by thirst associated with

A

change in plasma osmolality, hypothalamus

294
Q

How do we measure oral fluid

A

mL (30mLs per ounce)

295
Q

How many mLs in tablespoon

A

15

296
Q

How many mLs in teaspoon

A

5 mLs

297
Q

How do you measure ice chips

A

1/2 the measured container volume

298
Q

The average person should have how much urine output per hour?

A
  • 30mL per hour ***
299
Q

Average outmut of feces per day

A

100-200 mL

300
Q

Do you add in the stool with the calculation?

A

NO

301
Q

Reasons for hypovolemia

A

ng drainage, burns (3rd spacing), dehydration, shift of plasma into interstitial spaces, peritonitis, ascites (abdomen)

302
Q

Lab Findings Hypovolemia

A
  • Hemoglobin/Hematocrit will be ELEVATED
  • Everything will be elevated
303
Q

Nursing Role for hypovolemia

A

report findings, assess & monitor, call physician

304
Q

What clinical manifestation of hypovelmia

A
  • Pulse: weak/thready, tachycardic
  • BP Low
  • orthostatic
  • hyperthermic
  • neuro: confused, lethargic
  • Gi: thirsty, weight loss, anorexia(appetite loss)
  • Renal: oliguria, concentrated
  • flat veins, decrease cap refill, seizure, sunken eyes, coma
305
Q

What is “related to”?

A

Etiology

Example: Diarrhea, Burn, Confusion, Loss of body fluid

306
Q

What is “As Evidence By”

A

Objective Data

307
Q

Does Risk for include “aeb”

A

no

308
Q

What is considered ECF x2

A

blood vessel, interstitial fluid

309
Q

Hypervolemia clinical findings

A
  • Respiratory changes
  • dyspnea, orthopnea, crackles
  • tachypneic (fluid in the lungs)
  • neuro:muscle spasms, headache, confusion
  • peripheral edema
310
Q

2.2 kg of fluid equals how much mLs

A

1000

311
Q

What pathos associated with edema

A

vascular insufficient, pregancy, heart failure, cirhossis, renal failure

312
Q

Edema in the lungs

A

pulmonary edema

313
Q

Extremties edema

A

peripheral edema

314
Q

Abdomen edema

A

Ascites (3rd spacing)

315
Q

This type of pitting is a vascular cause

A

pitting

316
Q

nonpitting edema is caused by

A

lymphatics

317
Q

What is Anasarca?

A

generalized edema (systemic)

318
Q

Is “heart failure” a nursing diagnosis or medical diagnosis?

A

Medical Diagnosis- say “decreased heart function”

319
Q

What is RESTRICT

A
  • Reducie IV flow rate
  • Evaluate breath sounds
  • Semi Flower’s Positi
  • Treat w/ oxygen and diuretics
  • Reduce fluid and sodium
  • I&O and daily weight
  • Circulation, color
  • T
320
Q

Primary regulator of sodium balance

A

kidneys

321
Q

Adrenal insufficiency

A

cant retain sodium, related to Aldosterone

322
Q

True hyponatremia (not hypervolemia)

A
  • tachycardia, hypotension
323
Q

Wherever sodium goes..

A

water follows. Cant hold on to water without sodium

324
Q

Major Problems with Sodium imbalances

A

Neurological (seizures, coma)

325
Q

Hypernatremia True (hypovolemia)

A
  • hyperthermia, tachycardia, orthostatic hypotension
  • NEURO
326
Q

Clinical Manisfestation of Hypokalemia

A
  • weak pulse, bradycardia, hyperthermia
  • EKG changes- inverted T waves
  • Heart monitor
327
Q

How do you replace potassium?

A
  • Never do IV push
  • oral
  • potatoes, bananas, avocado
328
Q

HyperKalemia

A
  • IV, or salt substitutes
  • Renal Failure
  • tissue damage
  • hypotension.
  • PEAKED T waves
  • Diarhhea
  • Insulin
  • Dialysis
329
Q

Hypocalcemia Characteristics

A
  • blood transfusion
  • alkalosis
  • decrease intake of calcium rich foods
  • Renal Disease
  • NEUROMUSCULAR
  • decrease heart rate, myocardial contractility
330
Q

A 5-year-old male presents to the ER with delirium and sunken eyes. After diagnosing him with severe dehydration, the primary care provider orders fluid replacement. The nurse administers a hypertonic intravenous solution. Which of the following would be expected?

A

Intracellular Dehydration

331
Q

Which of the following conditions would cause the nurse to monitor for hyperkalemia?

A

Acute Acidosis

332
Q

Signs of HypoKalemia 6L’s

A
  1. Lethary
  2. Lethal Cardia Arrhythmia
  3. Leg Cramps
  4. Limp Muscles
  5. Low Shallow respiration
  6. Less Stools (constipation)
333
Q

Which of the following buffer pairs is considered the major plasma buffering system?

A

Bicarb

Nursing School (33 decks)

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