Exam 1 Flashcards
Which population group is more likely to be diagnosed with fibromyalgia syndrome?
Women between 30 and 50 years of age
The nurse is assessing a patient who has undergone a total knee arthroplasty for which continuous nerve block was used. The nurse notes the patient is anxious, vital signs are BP 92/58, HR 62, RR 12, and SpO2 89%. What is the priority nursing intervention?
Notify Rapid Response Team— nerve block became systemic and is affecting multiple areas
During a health history assessment, a patient with RA, chronic HTN, and recent CVA states she is taking 2 fish oil capsules daily as an RA supplement. What additional questions should the nurse ask?
Are you taking anticoagulants Have you found fish oil to be helpful What other supplements do you currently take How long have you been taking fish oil Have you notified your physician? --- fish oil is a natural blood thinner
The nurse understands which of the following is a risk factor associated with the development of MS in women?
Smoking
Which couple has the highest risk for sexual transmission of HIV without the use of a condom or dental dam?
An infected male performing vaginal intercourse with an uninfected female
— due to large surface area of mucous membranes in the vagina
During a health assessment of a healthy 22 yr old college student, she tells the nurse that she is sexually active and protects herself from HIV and STIs by using oral contraceptives. What is the nurse’s best action?
Inform the student that oral contraceptives protect against pregnancy but not STIs
A 30 year old man with HIV is admitted to the acute care unit. Which assessment findings does the nurse recognize that may indicate that the patient currently has AIDS?
Kaposi’s sarcoma
Wasting syndrome
Esophageal candidiasis
The patient is very weak. During this admission he has experienced anorexia, painful swallowing, severe diarrhea, and occasional vomiting. Frequent mouth care is to be delegated to the CNA? What instructions should the nurse give the CNA?
Use PPE- standard precautions
Soft bristle toothbrush
Educate/expect mouth sores
frequent mouth cares– frequent rinses with sodium bicarbonate and water or NS, no alcohol mouth rinse
After 8 days, the patient is being discharged home, where he lives with his mother and father. The nurse is completing discharge instructions for him and his family. What infection control teaching should the nurse provide to the patient and family?
Do not share needles/razors/toothbrush/etc.
Proper precautions
Soiled linens wash in hot water and bleach
bleach and water to disinfect.
S/Sx of worsening conditions and CNS changes
As the nurse is talking to the patient, the patient comments that he doesn’t know why he must live with such a horrible disease, and states that he knows he will die soon. What is the appropriate nursing response?
Provide education about living with the disease, support groups and community resources…
Assess why he is fearing death/disease…
True or false: genetic testing has no benefit in the treatment plan of a patient with HIV.
False…. Used to determine appropriate medications and how they work on the body… Genetic testing is key!
A patient tells the nurse that she has recently engaged in unprotected sex. The nurse recognizes that which symptoms may be consistent with acute infection, following infection with HIV?
Fever Chills HA Night sweats Muscle aches
A patient is fearful that he has been infected with HIV. The nurse recognizes which as the first symptom associated with possible HIV infection?
Fever, night sweats, muscle aches
The nurse is caring for an older adult patient at risk of shock. What is an early sign of shock in this patient?
Restlessness — a change in LOC occurs first
The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hypo dynamic state. Several hours later, the patient’s BP is elevated and pulse is bounding. How does the nurse interpret this change?
Worsening of the condition rather than improvement—- Severe sepsis is the calm before the storm, a hyper dynamic state.
The nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations is markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition?
metabolic acidosis—- resp compensation for metabolic changes causing metabolic acidosis with resp alkalosis.
A patient receives dopamine 20mcg/min IV for treatment of shock. What does the nurse assess for while administering this drug?
Chest pain and hypertension
When administering norepinephrine (Levophed), what does the nurse monitor for in the patient?
Extravasation
HA
chest pain
HTN
A 59 yr old male is 3 days post-op after a colon resection. The nurse has delegated to the CNA to take his morning VS. At 8:00 am the CNA reports the patient’s oral temp as 101.6. What is the nurse’s priority action?
Go assess the patient.
Infection or inflammation, or atelectasis
Upon assessment, the nurse notes that the patient is flushed and slightly diaphoresis. He appears lethargic but responds to simple questions. His VS are now BP90/40, HR 134, RR 26 and deep, and his temp has risen to 102.8. Lungs are clear throughout. His abdominal wound has a dressing that is moist with a moderate amount of purulent drainage. What is the nurse’s interpretation of this data?
Abd. Infection, symptomatic
Twenty minutes later, the nurse calls the physician to report the abnormal findings. The provider orders:
Blood cultures x2; 5 minutes apart.
Over the next hour, the patient continues to decline with a decreased LOC and a temp of 103.8, BP 80/40, HR 134, RR 34. the nurse calls teh provider to report these findings and obtain orders to transfer the pt to the ICU. When preparing the transfer, the nurse notes that the O2 sat is 87% on RA. What is the priority nurse action?
Apply oxygen at 2-3 L/min per NC.
Within 30 minutes of transfer to the ICU, his condition continues to deteriorate. His SaO2 continues to fall, RR 36, and the IU nurse notes blood oozing around the catheter sites. A foley cath is placed, and his urine output is minimal. What is the nurse’s interpretation of these findings?
DIC with septic shock
A 37 yr old is admitted with a severely abscessed tooth. BP 90/42, HR 136, RR 28, SpO2 90%, temp 38.7. The nurse suspects the pt has developed sepsis. what is the priority nursing intervention?
Initiate IV fluid resuscitation. — to increase BP and perfusion.
