exam 3 Flashcards
The nurse cares for a pt with stage IV cervical cancer receiving chemo. The client states “I don’t want chemotherapy anymore but my children isist I keep going” What role will the nurse be acting for this client after her comment
The role of patient advocate
A nurse is caring for a pt receiving an arthroscopy what post op information will the nurse give
Inspect your incision daily
Apply ice packs to the area for the first 24 hrs
Perform isometric exercises
Seizure interventions
Time the seizure
stay with child
move furniture away
The nurse is caring for a pt who begins to experience seizure activity while in bed. Which action should the nurse take
Loosen restrictive clothing
removing pillow and raising padded side rails
positioning the pt to the side with head flexed forward
The nurse is instituting seizure precautions for a pt being admitted from the emergency room. Which measures should the nurse include in planning for the pts safety
Padding the side rails of the bed
Placing an airway at the bedside
Placing oxygen and suction equipment at the bedside
Flushing the IV catheter to ensure the site is patent
A nurse is providing discharge teaching to parents whose infant had a VP shunt placed for the tx of hydrocephalus. Which of the following statements by the parent indicate an understanding of the teaching
We will notify right away if he has a fever
Important to communicate to the surgeon after a VP shunt is placed
3yo returned to peds units and the right pupil is 1mm larger than the left pupil
Stroke on the right side of the brain what would you see
Left sided neglect, paralyzed left side, hemiplegia
The nurse is assigned to care for a client with complete right sided hemiparesis from stroke. Which characteristics are associated with this condition
The client is aphasic
The client has weakness on the right side of the body
The client has weakness on right side of face and tongue
When caring for a pt with new right sided homonymous hemianopsia resulting from stroke, what intervention should the nurse include in plan of care
Place objects needed on the pts left side
A 73yo pt with a stroke experiences facial drooping on the right side and right sided arm and leg paralysis. When admitting the pt which clinical manifestations will the nurse expect to find
Difficulty comprehending instructions
Risk factors for stroke
High BP, TIA, Smoking, Oral contraceptives
The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully
Consistently uses adaptive equipment in dressing self
Risk factors for stroke
High BP, TIA, Smoking, Oral contraceptives
A child is dx with reyes syndrome. The nurse assists to develop a nursing care plan for the child. Which statement would indicate a need for further teaching
Parents watch tv in the child’s room with high volume
A child is dx with reyes syndrome. The nurse assists to develop a nursing care plan for the child and should include which intervention in the plan
Providing a quiet atmosphere with dimmed lighting
When preparing the discharge plans for a pt with chronic anxiety. Which goal is most appropriate to be included in the plan of care requiring evaluation
The pt is able to identify triggers that produce anxiety
A client is admitted with a recent hx of severe anxiety following a home invasion and robbery. During the initial assessment interview which statement by the client should indicate to the nurse the possible dx of PTSD
I keep reliving the robbery
I see his face everywhere i go
I might have died over a few dollars in my pocket
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior
Communicate expected behaviors to client
Assist the client in identifying ways of setting limits on personal behaviors
Follow through on the consequences of behaviors in a non punitive manner
Have the client state the consequences for behaving in the ways that are view as unacceptable
Intervention for client experiencing mania
Provide frequent breaks
When working with a pt with dissociative amnesia the nurse should begin by
identifying and supporting the pts strengths
EPS side effects
Parkinsonism, tremors, mark like face, drooling, dysphagia, shuffling gait
Quetiapine side effects
Urinary retention
Parkinsonism
Restless
HTN
Alcohol withdrawal protocol
When was your last drink
What type of alcohol, how much, for how long, and when was it last consumed
Seizure precautions
Which interventions are most appropriate for caring for a client in alcohol withdrawal
Monitor vital signs
Provide a safe environment
Address hallucinations therapeutically
Provide reality orientation as appropriate
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse “I should get out of this bad situation” Which is the most helpful response by the nurse
What do you find difficult about this situation
Post laryngectomy
Avoid Shower
Wear high collar shirt
Keep home humidified
Avoid people with infection
A nurse arrives for work to find that the medical unit is short staffed. Nursing administrators has called several staffing agencies but they are unable to send a replacement nurse for three hours. The nursing care coordinator sends a recently oriented PCA to help relieve the burden of care. Which activities should the nurse delegate to the PCA
Making occupied beds
Taking routine vital signs
Answering clients call lights
When caring for a preoperative pt on the day of surgery which actions included in the plan of care can the nurse delegate to UAP
Polish and apply pulse ox
Transport the pt by stretcher to the operating room
Obtain and document baseline vital signs
Which nursing actions can the nurse working in a women’s health clinic delegate to UAP
Assist the HCP with performing a pap test
Draw blood for a CA 125 levels for a pt with ovarian cancer
Accountability is the acceptance of responsibility for one’s choices, decisions, and actions. The nurse is always responsible for their actions when providing care to a client. Which actions in the delegation process represent accountability
Monitoring client care
Seeking the outcome report
Which activity performed by the by the RN indicates effective delegation
Supervising and monitoring the LPN about the different activities
Patient slurring words and has right sided weakness what would the nurse assess first
Airway, Breathing, Circulating
Consider when creating a care plan for a client in a crisis state
Clients response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client
An 8yo child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parents wonder if this abnormal behavior picked up from playing video games. What is the best response
School aged children are inquisitive and ask a lot of questions about death
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which action in care of this client
Obtain a telephone consent from a family member following agency policy
Hepatitis A
Fecal
Oral
Wash hands
No sea foods
clean toilets
A client with hepatitis A is newly admitted to the unit. Which action would be the priority to include in this pts plan of care within the initial 24 hours
Wear gown a gloves during pt contact
Following change of shift report on an orthopedic unit which client should the nurse see first
72yo recovering from surgery after a hip replacement 2 hours ago
During nursing rounds which of these assessments would require immediate corrective action and further instruction to the LPN about proper care
a client with a hip prosthesis 1 day post op is lying in bed with internal rotation and adduction of the affected leg
The nurse is teaching a client who has a hip prosthesis following a total hip replacement which of the following should be included in the instructions for home care
do not cross your legs
A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially
Ensure that the stump is elevated the first day post op
Who’s at risk for osteoporosis
Menopausal
Sedentary
over 65
excessive alcohol intake
cigarette smoking
female
family hx
early menopause
steroid use
insufficient intake of calcium or vitamin D
A registered nurse (RN) cares for a client with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching?
The RN checks the initial blood pressure in one arm.
The RN palpates the neck to assess thyroid size
The RN offers warm blankets for the clients cold feet
What information will a review of a patient’s glycol hemoglobin (A1C) results provide to the nurse?
Glucose control over the past 90 days
The nurse is instructing a 65 vear-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
exercise doing weight bearing activities
The nurse is teaching a group of women in a community clinic about prevention of osteoporosis. Which of the following over-the-counter medications should the nurse recognize as having the most elemental calcium per tablet
Calcium carbonate
In preparation for which test should the nurse teach the patient to minimize physical and emotional stress?
A 24-hour urine test for free cortisol
Which finding for a 77-yr-old patient seen in the outpatient clinic is the highest priority for further nursing assessment and intervention?
History of recent loss of balance and fall
The nurse assesses a client who is 30 minutes postoperative from an insertion of a permanent pacemaker. Which finding would require immediate follow up by the nurse
Report of shortness of breath
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is MOST APPROPRIATE
document the findings
The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?
“I need to report a fever or swelling to my health care provider.
The nurse is reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the health care provider before surgery?
White blood cell count of 16,000
The nurse is conducting discharge teaching for a client with a new dx of HTN. What should the nurse include in the teaching
Keep a diary of regular bp readings
instruct client to bake, roast, and boil food
Avoid OTC meds
The nurse is caring for a child who was admitted with chronic renal failure. What assessment finding would the nurse expect in this client
Increased BUN
Decreased GFR
Azotemia
Oliguria
Stage one HTN education
diet, exercise, low sodium, no caffine, veggies daily
What are dietary teachings that should be provided to the client post cholecystectomy
Instruct the client with chronic cholecystitis to eat small, low-fat meals.
avoid gas forming foods (beans, cabbage, cauliflower, broccoli)
take fat-soluble vitamins or bile salts as Rx
