Nclex final test tutorial Flashcards
Planning activities for p w/ acute exacerbation of schizophrenia. Wotf is appropriate?
a. walking w/ a staff member on gated grounds
b. playing Ping-Pong in the dayroom w/ another p
c. shooting baskets w/ several other p’s in the gym
d. riding on a bike alone in the fitness room
a. P. should participate in nonthreatening, noncompetitive physical activities. B and C are both high levels of stimulation and competitive options which require concentration and socialization (something the p might not be able to handle right now). D - p’s should never be alone w/ acute schizophrenia
Child w/ strabismus . RN explains that to prevent amblyopia (lazy eye) it will be necessary to do wotf?
a. patch the unaffected eye
b. administer mydriatic eye drops daily
c. obtain Rx eyeglasses
d. give IV antibiotics
a. patch the unaffected eye. Amblyopia is a d/o of the eye in which unilateral central blindness occurs as a result of another condition, like strabismus. W/ strabismus, muscle weakness allows one eye to wander and the brain eventually ignores signals coming from this eye. This results in central blindness if not treated by 6 years of age. Patching the unaffected eye strengthens the other eye’s muscles
Teaching p undergoing laser assisted in situ keratomileusis (LASIK) surgery, include that he?
a. may need to wear reading glasses after the surgery
b. can drive home after the procedure
c. should continue to wear his contact lenses until the day of surgery
d. will not have to wear glasses after the surgery
a. LASIK surgery corrects the refractive lens w/ myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, many ppl develop presbyopia (farsightedness) w/ age and may need reading glasses despite having had the LASIK surgery. P’s should not drive home after LASIK surgery (blurry vision, tearing, and photophobia common SEs). P’s should not wear contacts for two weeks prior to LASIK (limits O2 intake to the cornea).
astigmatism
refractive error of vision due to diffs in curvature of refractive surfaces of the eye (cornea and lens). Other words, the curvature of the cornea is not perfect and one cannot focus their vision on particular objects. This includes myopia and presbyopia
strabismus
deviation in the axis of the eye (crossed eyes)
amblyopia
lazy eye, failure of one eye to develop central vision. This is an untreatable condition
nystagmus
involuntary, rapid, rhythmic movement of the eyeball
Reinforcing teaching for child w/ Asperger’s syndrome. Wotf is true?
a. Aricept may slow the progression of the d/o
b. grp therapy is important for children w/ cognitive d/os
c. it will help our child if we keep a structured daily routine
d. this d/o is r/t our child’s prematurity
c. Asperger’s syndrome is a high functioning form of autism. Children w/ this have nml to high cognitive skills and they may have problems with sudden schedule changes, socialization requirements and preferences for ritualistic behaviors. Donepezil (Aricept) is used to slow the progression of Alzheimer’s disease. Prematurity is not r/t Asperger’s syndrome
Receiving p. who had a thyroidectomy from PACU. Which emergency equipmt should be available on unit?
a. cardiac monitor
b. defibrillator
c. thoracotomy tray
d. tracheostomy tray
d. In the event of laryngeal edema or tetany, resp distress could result in airway obstruction. Emergency intubation may be difficult due to laryngeal swelling, and endotracheal intubation may increase the risk for hemorrhage by increasing tension on the incision during insertion. A trach tray should be easily accessible. A and B - thyroidectomy pts are not at increased risk for dysrhythmias.
P w/ tracheostomy and receiving mech ventilation. Low pressure alarm sounds indicating?
a. excessive airway secretions
b. a leak w/in the ventilator circuitry
c. decreased lung compliance
d. p. is coughing or attempting to talk
b. low pressure alarm = p is disconnected from tubing or that tubing has come apart.
a - a high pressure alarm would sound from excess secretions due to increased resistance of air movement into the p’s lungs
c - decreased lung compliance would increase resistance to air movement, causing a high pressure alarm
d - coughing/talking causes increased resistance for the ventilator to deliver air, causing high pressure alarm
P. to have EEG in the am. teaching includes?
a. you will be given a sedative, so you wont feel the small electrical shock
b. after midnight you will not be able to ear or drink
c. you need to shampoo your hair tonight, and avoid applying hair products
d. its common to exp. temporary short-term memory loss following the procedure
c. EEG is a painless test that records the electrical activity of the brain. During the test, electrodes are attached to the scalp and will not adhere properly if the p’s hair is not clean and free of oil/products. Sedatives are not given for an EEG, p’s are not required to be NPO as anesthetics are not used, and short-term memory loss is r/t electroconvulsive therapy.
Receiving IV ampicillin and p. develops urticaria and dyspnea?
a. give diphenhydramine (Benadryl)
b. call the HCP
c. obtain pulse ox reading
d. stop the infusion
d. stop the infusion. Then monitor pulse ox, call HCP, and give Benadryl
Body mechanics
sit with your back supported, knees should be at the hip level, wrist and forearms should be parallel to the ground (also, arms kept close to body, head should be level when looking at computer screen)
P. suspected of SLE, RN expects to note an increased?
a. aPTT
b. RBC count
c. Hgb and Hct
d. ESR
d. ESR - SLE is a chronic autoimmune disease that causes skin, heart, lung, and renal inflammation and is characterized by exacerbations and remissions. P’s typically die from end stage renal disease. Most p’s will have an increased ESR. Most SLE p’s have anemia, so decreased RBCs, Hct, and Hgb
cataracts
clouding of the lens of the eyes that causes gradual visual impairment, decreased contrast and blurred vision
