OB and mental 2 Flashcards
A pt states that she believes she is pregnant. What probable signs of pregnancy does the nurse expect to see? SATA
1) Amenorrhea
2) Abdominal enlargement
3) Fetal movement
4) Breast tenderness
5) Positive pregnancy test
6) Urinary frequency
2,5
the primary healthcare provider will identify
Presumptive sign-pt can feel or state
Positive sign-fetal HR, fetal movement,ultrasound
A client in 1st trimester has been attending educational sessions on pregnancy. What statements indicate understanding? SATA
a)Good food sources of iron includes spinach, raisins, and dark chocolate
b)I will eat at least 40 grams of protein a day.
c)Swimming is an acceptable exercise for me while I am pregnant
d) I can gain 2 pounds (0.9 kg) per week during my first trimester
e) I need to stay out of hot tubs while pregnant
a,c,e
b- should increase protein intake to 71 grams per da
c-1st trimester, total 1-4 lb total
A client in her third trimester has a routine prenatal visit. The nurse notes a weight gain of 4 pounds (1.8 kg) in a week. What action should the nurse take?
a) Check urine for protein.
b) Educate on proper weight gain during pregnancy
c) Send client to the labor and delivery unit.
a
We are worried about pre-eclampsia, so we need to check the client’s BP and check urine for protein.
1st 1-4lb total
2nd 1lb per week
3rd No more than 1lb
What interventions should the nurse provide when caring for a client prescribed oxytocin IV? SATA
a) Label IV bag and IV tubing with oxytocin sticker.
b) Monitor for late decelerations
c) Position client supine.
d) Piggyback oxytocin at the lowest primary IV site.
e) Provide one one-on-one care.
a,b,d,e
c-flat on their back is contraindication
A client diagnosed with mastitis about treatment. The client states she wants to continue breastfeeding. What interventions should the nurse include? SATA
a) Get plenty of bed rest.
b) Wear a support bra.
c) Place chilled cabbage leaves on breasts.
d) Take antibiotics prior to breastfeeding
e) Offer the unaffected breast first at each feeding
a,b
The nurse is developing the plan of care for a mania. Which interventions should the nurse include? SATA
a) Give one cigarette to client at a time
b) Discuss delusional belief with client
c) Have finger foods available at mealtime
d) Give high calorie fluids between meals
e) Provide soothing music in room during waking hours
a,c,d
They have no control or awareness of these hazards. If they smoke, only give the client one or two cigarettes at a time, or the client will light a whole pack at once.
Which signs/symptoms expect to see in a client diagnosed with schizophrenia? SATA
a) Auditory hallucinations
b) Grandiose delusions
c) Religious preaching all the time.
d) Flat affect
e) Abstract reasoning
a,b,c,d
Religiosity is common. The client may carry a bible all of the time and preach to everyone all of the time.
A primary healthcare provider has prescribed restraints for a violent adult client. Which measures would the nurse provide as proper interventions for this client? SATA
a) Observe the client in restraints every hour
b) Ensure that circulation to extremities is not compromised.
c) Assist client with needs related to nutrition and elimination
d) Provide help with personal hygiene
e) Renew restraint prescription in 4 hours if needed
b,c,d,e
a-should be observed every 15 minutes.
The nurse is planning care for a client with Alzheimer’s Disease. What interventions should the nurse include? SATA
a) Encourage participation in light exercise.
b) Identify doors with pictures
c) Monitor food intake.
d) Assign unlicensed assistive personnel to bathe client daily.
e) Reminisce about successful and unsuccessful life events.
f) Weigh weekly
a,b,c,f
f-the client can easily forget to eat and drink. This is one reason the client should be weighed weekly as well.
d-Have the client dress in their own clothes whenever possible and perform their own activities of daily living for as long as possible. This helps to maintain self-esteem.
A nurse in mental health is attempting to develop a therapeutic relationship with a pt. What action should the nurse take?
a) Set limits for the relationship
b) Promote the use of transference by the pt
c) Instruct the pt on how he should behave
d) Engage in friendly interactions with pt
a
The nurse should set professional boundaries through limit setting regarding when and where to meet, roles of the relationship, personal space, and other parameters
b
feelings about a significant person to the nurse so they should not use this
A home health nurse drives up to the house who has schizophrenia with manic episodes. the client is sitting on his front porch wit a shotgun in his arms. which of the ff actions should the nurse take?
a. honk the horn to get the client’s attention
b. calmly speak the client’s name out of the car window
c. keep driving in a path that is going away from the client’s house
d. stop the car in the client’s driveway and call the authorities.
c
This is an appropriate action for the nurse to take as it removes her from immediate danger.
a,b,d
These action draws the client’s attention to the nurse and increases the risk for injury.
A pt who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?
a) act to the pt if the hallucination is real
b) ask the pt direct questions about the hallucination
c) Tell the pt that the hallucination is not a part of reality
b
Asking the client direct questions about the hallucination provides important data to identify the client’s risk level and current mental status.
c-Telling the client that the hallucination is not real will increase the client’s anxiety level and is therefore not an action the nurse should take.
A pt who is experiencing mania. Which medication should be used to reduce the pt’s mania?
a) Fluvastatin
b) Carbamazepine
c) Lorazepam
d) Propranolol
b
an antiseizure medication and a mood stabilizer, is prescribed to treat and prevent mania in clients who have bipolar disorder
c-a sedative, hypnotic medication is used to treat anxiety
d- is used to treat hypertension and other heart conditions, as well as certain anxiety disorders
What disorer should the nurse suggest offering the guided imagery therapy to?
PSTD
Sleep disorders, anxiety, and pain.
to relieve the anxiety associated with those disorder
A client who has paranoid personality disorder. Which of the following findings should the nurse expect? SATA
A. believes that others are deceiving him
B. desires to be the center of attention
C. views himself as inferior to others
D. demonstrates a grandiose sense of self-importance
E. persistently holds onto grudges
a,e
deceiving-騙す
grudges-恨み
b-histrionic personality
c-avoidant personality
worries constantly about being criticized, and does not fully engage in new interpersonal relationships. inferior-劣った
A pt who has chronic anxiety for discharge from the psychiatric unit. What instructions should the nurse include in the discharge plan?
a) Contact crisis counselor once a week
b) Identify anxiety-producing situations
c) Eliminate stress and anxiety from daily life
b
Treatment for anxiety disorders includes helping the client recognize signs that her anxiety level is rising and the triggers that cause this type of reaction. The nurse should include this information so the client can limit anxiety-provoking situations or intervene early to reduce anxiety levels.
What are the s/s of acute cocaine toxicity?
Tremors
Agitation
Fever
HTN
Ventricular dysrhythmias
A client who has a personality disorder and demonstrates manipulative behavior. Which of the following interventions is appropriate to include in the plan of care?
a) Allow manipulation so as to not raise the client’s anxiety.
b) Create a strict schedule for the client’s activities to discourage manipulation.
c) Institute consequences result from manipulative behavior.
d) Bargain with the client to discourage manipulative behavior.
c
Institute=star using
Consequences=punishment
Uterine atony(hypotonia of the uterus)?
What this cuses?
PPH is defined as?
a) uterus doesn’t contract properly after delivery
hypotonia=floppy
b) PPH
c) cesarean birth 1L loss, virginal birth 500mL
10% decrease hematocrit
A client with posttraumatic stress syndrome (PTSD) that is experiencing social isolation.
Which intervention should be included in the plan of care?
a)Refer the client to vocational services.
b) Encourage the client to identify positive relationships
c) Teach the client and family about posttraumatic behavior.
d) Help the client to practice stress management techniques.
b
d-Stress management techniques are essential for a client with a nursing diagnosis of posttrauma syndrome. This intervention, however, does not directly address social isolation.
a) If a person who lost his finger says that I am plying piano again once my injured heals, what would say?
If a alcoholic says that I am not alcoholic but he already had 6 beers at 10am, what would say?
Both denial but lost need support and abuse needs confronted
a) what songs did you like to play?
b) OK you say your not alcoholic, but you already had beer at 10am
How to deal with a pt with Wernicke and Korsakoff who is confabulating about going to a meeting with Barack Obama this morning?
Redirect them
“Why can we go watch TV to see what is on the news today?”
The pt admitted ER with a cocaine overdose. What are s/s?
Cocaine=upper
overdose=too much
irritability
4+ reflexes
increase temp
Drug abuse in the new born(toxication or withdrawal?)
Always assume frist 24hrs?
after 24 hrs after birth?
first 24hrs-toxication
after 24hrs-withdrwal
An infant born to quaalude-addicted mother 24 hours after birth. what are s/s?
This is downer
after 24hr=withdrawal=too much
Difficult to console, seizure risk, shrill, high-pitched cry
In what two situations would respiratory arrest be a priority?
upper,downer, overdose, withdrwal
downer overdose
upper withdrwal
In what two situations would seizures be a risk for?
upper,downer, overdose, withdrwal
overdose upper
withdrawal downner
Alzheimer pt is the lobby of the waiting area of her nursing home. It is Sunday and she is all dressed up. You ask “you are all dressed up” she says “yeah, my husband is going to pick me up but her husband died 10 years ago.
What should you do?
Pychotic
Dementia
so first acknowlegem then redirect
That sounds nice, why don’t we sit down here and talk about chargh?
Don’t tell her husband dead!!!!
a) A pt with schizoaffective who points to 2 people talking across the room. The pt says, “Those people are plotting to kill me” what would you say?
b) what about pt is Alzheimer?
c) What about pt is delirium?
a) I can see that would be frightening but they are not plotting, We are not going to talk about that, I can see you are too ill. We are ending the conversation
b) I can see that is frightening. Let’s go to somewhere safe
c) I can see that is frightening. But you are safe and your fear will go away when you get better
What is urinary incontinence?
How do you deal with it?
a)a person leaks urine by accident.
after sneezing, coughing, or laughing to complete inability to control urination.
b) void every 2hrs until 6 weeks postpartum
A pregnant woman complains of back pain. What to teach?
Pelvic tilt
Lie on your back with knees bent and feet flat. tighten your buttocks and roll your pelvis, hold for 5 secs and relax
What is the #1 priority of the 2nd phase?
What is the #1 priority of the 2nd stage?
Pain management
Clearing baby’s airway
What is the #1 priority of the the 3rd phase?
what is the #1 priority of the the 3rd stage?
Checking cervical dilation, Helping pregnant mother with breathing and pain management
Assess the placenta for smoothness and intactness, and for 3 vessel umbilical cord present
A woman in her 29th gestation. She gained 22 lbs, what is your impression?
A woman at 31 weeks gestation gained 15 lbs. What is your impression?
29-9= 19lb so she gain over the limit
31-9=22lb she supposes to gain 22lb so the nurse needs to assess biophysical profile on fetus
Fundal height cannot be palpated until a week?
The fundus can be palpated at the umbilicus between?
After what week, normal fundal hight is about the same as the gestation week?
Week 12
Week 20-22
After 24 wks
27 gestation=27cm
Positive signs of pregnancy?
Fetal Skelton on x-ray
Presence of fetus on ultrasound
Auscultation of fetal movement(doppler) 8-12wks
Examiner palpates fetal movement
a) 8wks
16wks
b) 10wks
18wks
c) 12 wks
20wks
The fetal HR can be heard? 8-12 wks
Quickening may be first felt? 16-20wks
3 maybe sign of pregnancy?
1:Chadwick sign
Cervical Color Change to Cyanosis
2: Goodell sign
Good and soft cervix
3: Hegari sign
uterine softening
Alphabet order
Painful back pain
treatment?
Position then push
Knee-chest position
Push with fist into sacrum to use counter pressure
Prolapsed cord
Treatment?
Push then position
Push head in off cord then position
Prep for c-section
All other complications
treatment?
LION
Left side position
IV
Oxygen
Notify HCP
A pregnant client at 10 weeks’ gestation report a recent exposure to a child with rubella. What is the nurse’s best response to the client? she has Rubella immune
Your rubella titer indicates that you are immune and your baby is not at risk.”
A client who is positive for HIV and delivers a newborn infant. Which client statement indicates the need for further instruction?
a) I need to chest-feed with my milk, especially for the first 6 weeks postpartum
b) My newborn infant needs to be on antiviral medications for the first 6 weeks after delivery
a
b-is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life
a) Terbutaline
b) Mag sulfate
c) Oxytocin
d) Methylergometrine
e) Betamethasone(steroid)
f) Surfactant
a) relax muscle
s/s tachycardia
b) act like sedation
c) No more than 90 seconds and closer to 2 mins
d) remember another M is stimulate
e) Give mother before birth IM Neonatal lung med
f) Give baby via transtracheal route (after birth)
A nurse call security and restraints to a pt who was admitted voluntarily when the pt became verbally abusive demanding to be discharged from the hospital. Which represents the possible legal ramifications?
a) Libel
b) Battery
c) Assault
d) slander
f) false imprisonment
b,f
f-if the nurse prohibits a pt from leaving the hospiral if the pt has been admitted voluntarily
a) Histrionic personality disorder s/s?
b) narcissistic personality disorders/s?
Need to be the center of attention
a) Overly friendly, dramatic emotional behavior while demanding immediate gratification
b) sense of self-importance
Seeks constant reinforcement
Lack of empathy towards others
Grandiosity
a) Situational crisis
b) Adventitious crisis
a) everyday will happen crisis
loss or change job, death of loved one, divorce, severe illness
b) Not part of everyday life
natural disaster, fire, a crime of violence(rape, murder etc)
a) What is a gynecoid pelvis?
b) Thin, colorless, or yellow vaginal drainage?
c) Insulin dose for 1st trimester?
a) normal pelvis and the most favorable for successful labor
b) this is normal
c) decrease because insulin production will increase
