Final Flashcards
The first symptom of volume loss is
thirst
The nurse gathers the following data: BP=150/94Hg; neck veins distended; P-104 beats/min; pulse bounding; respiratory rate= 20 breaths/min; T=98.6F. What disorder should the nurse suspect?
Hypervolemia
Identify the mechanism(s) involved in acid-base balance. (Select all that apply)
a. buffer system
b. renal mechanisms
c. respiratory mechnisms
When providing discharge planning you should include all of the following except:
There are no restrictions on consuming caffeine containing beverages
The nurse assess that her patient’s intravenous solution has infiltrated into the tissue. What should the nurse do?
Stop the infusion immediately
The nurse is checking a patient for skin turgor and mobility. Which of the following statements are true regarding skin turgor and mobility? (Select all that apply)
a. poor skin turgor indicates dehydration
b. decreased elasticity of the skin in the elderly can cause decreased turgor mobility
c. The sternum and forearm are sites to check skin turgor and mobility
True or false? capillary refill assess circulation to the periphery
True
A nurse is caring for a patient who is post-op following knee surgery. Which of the following should the nurse examine to assess the patient’s peripheral vascular system? (Select all)
a. skin color
b. edema
c. skin temp
A nurse is instructing a group of nursing students in the priorities of care in performing skin assessment for their patients. Which of the following findings should the students recognize as requiring immediate intervention?
a. cyanosis
A Wood’s light is a diagnostic tool that is used to produce specific colors on the skin. The examination is performed in a dark room. The Wood’s Light uses:
UV light
ABCDE’s of a Skin Cancer Lesion Assessment:
Assymmetry Border color Diameter Evolution
A patients chief complaint is excessive hair growth. The provider suspects it is due to an imbalance in hormones. The nurse considers a nursing diagnosis of “body hair as a result of ______”. Choose the most likely diagnosis.
Hirsutism
Which of the following biopsies is the most common?
punch
Name 4 contributing factors for pressure ulcers
edema, moisture, lack of ambulation, pressure on bony prominences
The nurse is preparing to change a patients stage 4 pressure ulcer dressing. Which of the following characteristics should the nurse expect when doing the dressing change?
All of the above – slough/eschar, tunneling, thickness
A sunken fontanelle is a clinical sign for an infant who is suffering from
Hypovolemia
The most specific sign of hypovolemia in the elderly is
acute weight loss
A nurse is caring for a patient who is dehydrated. Which of the clinical manifestations should the nurse assess that is indicative of volume deficit?
Hypotension
Which of the following is the major electrolyte in the ECF?
sodium
There is a predetermined order of developmental and specific tasks associated with specific periods in a person’s life according to Erikson’s Developmental Theory. For the older adults the developmental stage is:
ego integrity vs. despair
Screening tests, counseling,, immunizations, or medications to prevent disease are considered:
Preventative services
Denver Developmental Screening Test is a standardized tool that screens for developmental problems in children from:
Birth – 6 years old
The nurse is reviewing her patients ABGs. Which diagnosis would the following results indicate? pH 7.35, PaCO2 35, HCO3 – 22
Homeostasis
Children with multiple middle ear infections are at risk of:
Hearing loss
For preschoolers, more than 90% of U.S. poisonings occur in the child’s”
home
Once a 4 month old child begins to roll over they are at greater risk for unintentional:
falls
The nurse walks into a room of a baby is a conscious-choking victim. The nurse assess the baby and immediately gives:
5 back blows and 5 chest thrusts
Because they put everything in their mouths, 1-2 years old children are at heist risk of
poisoning
A frequently misdiagnosed childhood illness that causes nighttime coughing, wheezing, chest tightness, and shortness of breath may indicated which of the following disorders?
asthma
When severe limited air flow, lack of wheezes on inspiration or expiration leads to a medical emergency with children it is called:
“silent chest”
List 4 triggers for childhood asthma attacks
Perfumes, pet dander, pollen, seasonal changes
MMR vaccine is a pediatric vaccine given to children at age 12-15 month old. MMR stands for
Measles, Mumps, & Rubella
T or F
“family planning” is one of the 10 greatest public health achievements of the 21st century
True
List 4 methods of non-hormonal birth control
a. abstinence
b. condoms
c. diaphragm
d. spermacide
List 4 methods of hormonal methods of birth control
a. the pill
b. the patch
c. the shot
d. implant/IUD
Hormonal birth control methods work by
Changing (thinning) the lining of the uterus
All of the following are true about the goal of emergency contraception except:
Plan B works best 6-8 days after unprotected intercourse
As the nurse you are educating a young woman about her contraceptive choices. Which of the following are appropriate websites to recommend?
plannedparenthood. org
reproductiveaccess. org
bedsider. org
Sexually transmitted infections are most prevalent in which of the following age groups
15-25 years old
Of the following, which STIs are bacterial
a. syphilis
b. chylamydia
c. gonorrhea
A preventable infection that extends into the nearby pelvic tissue that can cause an ecptopic pregnancy and infertility is
Pelvic inflammatory disease
Erythromycin 1 gram po single dose or Doxycycline 100 mg BID for 7 days are treatments of choice for which infection?
Chlamydia
Of the following, which are characteristics of the latent phase of syphilis?
All of the above – no symptoms, contagious, over 40 years
List 2 triggers for HSV
immunosuppression
stress
Which of the following vaccines is the one approved for the prevention of HPV virus in both boys and girls?
gardasil
A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group?
wear a helmet while skiing
secure firearms in safe location
keep bullets in a seperate location
A nurse is talking with the patients of a 10 year old child who expresses son is suddenly secretive, for example, closing the door and does his homework in his room. Which of the following responses is appropriate?
“At this age, children tend to become more modest and value their privacy”
All of the following statements are true about HBV except
Healthcare workers are not at risk of HBV virus, just IV drug users.
A patient constantly interferes with activities on an inpatient unit. The nurse, speaking in a loud voice, tells the patient, “If you don’t go to your room immediately, I will give you medication that will make you sleep”. The nurse’s behavior demonstrates:
assault
A gravely disabled psychiatric patient has a guardian. What is the essential implication for nursing care?
The guardian participates in treatment planning on behalf of the patient
A patient was restrained after assaulting a staff member. Which nursing measure has priority?
Maintain constant supervision
A nurse at the mental health center prepares to administer a scheduled injection of haloperidol (Haldol depot injection) to a patient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts “Stop, stop. I don’t want to take that medication anymore. I hate the side effects” Select the nurse’s first action:
Stop the med admin procedure and say to the patient, “Tell me more about the side effects you’ve been having”
A patient experiences severe panic attacks and uses denial, repression, and displacement. Nursing interventions should be directed toward:
Teaching more effective coping strategies
A patient tells the nurse, “The reason I use drugs is because everybody nags me to do things that don’t interest me.” The patient shows use of which defense mechanism?
Rationalization
Effective use of the nursing process is dependent on communication that
Is structured and goal-directed
A patient tells the nurse, “I was raped a month ago. Since then I’ve felt anxious and have been unable to talk normally to my husband. I’ve had frequent thoughts about cutting my wrists.” What is the priority nursing concern regarding this patient?
The risk for self-directed violence
The nurse is performing a mental status exam wants to assess for hallucinations. The nurse should ask:
“Do you hear or see things when others don’t?”
A patient in a support group says, “I’m tired of being sick. Everyone always helps me, but I’ll be glad when I can help someone else.” This statement reflects:
altruism
A leader begins the discussion at the first meeting of a new group. Which comment would be most appropriate?
“Let’s start by establishing some rules for our group”
Which information is the nurse most likely to find when assessing the family of a patient with a serious and persistent mental illness?
The stress of living with a mentally ill individual has negatively affected family
Which statement accurately applies to personality disorders?
Personality traits are dysfunctional and inflexible
A patient demonstrating borderline personality disorder says, “When I met him, he gave me everything. Now I know how bad he really is. He left me alone tonight to go out with others, so I had to cut myself” Which feature is evident?
splitting
Characteristic behaviors a nurse would expect when working with a patient diagnosed with narcissistic personality disorder are:
Grandiosity; sense of entitlement; lack of empathy
Personality traits most likely to describe a patient diagnosed with obsessive-compulsive personality disorder are:
Perfectionist; inflexible
A patient say, “I felt good from drinking a six-pack a few months ago. Now I need a few extra cans to get the same high”. The nurse assess this phenomenon to:
tolerance
Which assessment findings would prompt the nurse to suspect a disulfiram (Antabuse) reaction:
Headache, dyspnea, nausea, vomiting, and flushing
The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremors?
Hypertension, changes in LOC, hallucinations
The drug(s) of choice in the management of alcohol withdrawal is(are):
Benzodiazepines
Which of the following is an anti-craving agent used in the management of alcohol dependence syndrome?
Naltrexone
Which of the following instruments is used for alcohol dependence screening?
MAST
A nurse is in the working phase of a therapeutic relationship with a client who has been admitted for alcohol detoxification. Which of the following indicates transference behavior?
The client accuses the nurse of telling him what to do just like his ex-girlfriend
What information about a patient’s perceptions and values would the nurse obtain buy using the HOPE tool?
That which gives the patient hope and meaning in life
Important personal spiritual practices
Role of organized religion in the patient’s life
Sources of strength and comfort
Acamprosate calcium has been prescribe for a patient 666mg by mouth, 3x a day. The med comes in a 333mg enteric-coated tablet. The patient needs a discharge prescription to last for 10 days, when he has a doctor’s appointment. The nurse asks for a prescription for how many tablets for 10 days?
2 tab x 3 times a day x 10 days = 60 tablets
A charge nurse is discussing transcranial magnetic stimulation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
“I will provide postanesthia care following TMS”
Which symptoms would the nurse expect to assess in a client with serotonin syndrome?
Confusion, restlessness, tachycardia, labile blood pressure, and diaphoresis
A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following statements indicates understanding of the teaching?
“I will receive a muscle relaxant to protect me from injury during ECT”
A patient says, “The doctor said I have dysthymic disorder.” What priority assessment data should the nurse obtain to confirm the diagnosis?
How long symptoms have persisted (2 years)
Which information about a patient diagnosed with bulimia nervosa should the nurse document as subjective data
Feeling out of control
A patient for whom phenelzine (Nardil) is prescribed complains of a sudden headache and palpitations. The nurse observes dilated pupils and diaphoresis. The nurse’s first action should be:
Assess the patients blood pressure
A nurse presents a psychoeducational program to patients with bipolar disorder and their families. Information about signs of impending relapse of mania should include:
Sleep disturbances and racing thoughts
An unconscious patient is brought to the emergency department with a suspected heroin overdose. Which vital signs support the suspected diagnosis?
BP 70/40, P 100 beats/min, RR 10 breaths/min
One bed is available on an inpatient eating disorders unit. Assessment findings for four patients are listed as follows. Which patient should receive the bed?
Weight decreased from 150 to 102 lb in 4 months. Vital signs are T 96.9F, P 46, BP 68/48. Amenorrhea for 8 months
Four individuals have suicide plans. Which plan evidences the highest risk for completed suicide?
Jumping from a suspension bridge in a rural location late at night
A patient diagnosed with bipolar I disorder says, “I will lead the next group about medications. I have studied all the effects and problems with drugs on the internet, so I can answer patients’ questions.” How should the nurse document this finding?
Grandiosity
A client says, “I plan to commit suicide” Which of the following should be the nurse’s priority assessment?
Lethality of the method and availability of means
A nurse is planning care for a client who is experiencing withdrawal from alprazolam. Which of the following is the priority nursing intervention?
Implement seizure precations
A patient is 5 feet 4 inches tall and weighs 85 lb, a 20% loss of body weight over the past year. The patient reports amenorrhea for 9 months. Vital signs are T 96.6F, pul.se 38, BP 70/42, R 20. Skin turgor is poor. Lanugo is present. She says, “I need to lose 10 more pounds.” These assessment findings indicate which medical diagnosis?
Anorexia nervosa
A depressed patient prepares for discharge. The patient is prescribed desipramine (Norpramin) and will have outpatient visits. The patient reports, “They gave me only a 1- week supply of my medicine.” Select the nurse’s best reply.
“Prescribing a small amount of drug addresses our concerns for your continuing you safety.”
A client denying suicidal ideation comes into the ER complaining about insomnia, irritability, anorexia, and depressed mood. Which intervention would the nurse implement first?
Complete a thorough physical exam including lab tests
The nurse interviews a patient who restricts food and is 25% underweight. The patient says “I need to lose weight. I’m not thin enough.” The patient is using which defense mechanism?
Denial
A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the clients adult daughter, which of the following statement is the highest priority to report to the provider?
“my mother is currently on furosemide for her congestive heart failure”
Maintenance of a therapeutic serum level if lithium is dependent on adequate serum levels of:
sodium
A patient’s serum lithium level is 2.0 mEq/L. Select the nurse’s priority action.
Assess for signs of toxicity
Which information is most important to obtain during assessment of an older adult with a mental disorder?
Functional ability and emotional status
An individual is experiencing a heroin overdose has been given one dose of naloxone (Narcan) IV. The priority nursing intervention is:
Close observation to determine the need or an additional dose of naloxone
A patient with insomnia reports taking diazepam (Valium) and wine in increasing amounts to be able to fall asleep. The nurse should teach the patient about:
Dangers of CNS depression
A student tells the school nurse, “My friend threatened to take an overdose of pills.” The nurse identifies the friend who verbalized the suicidal threat. Select the most critical question the nurse should ask
“Do you have access to medications?”
