QB 5 Flashcards

Question

An abnormal rise in body temperature above 38℃ (100.4℉)

Answer 1

Fever **Individuals who are at risk for complications associated with fever are children and older adult clients**. For diagnostic purposes, fever patterns need to be assessed since patterns vary based on the causative agent. There are four fever patterns: sustained, intermittent, remittent, or relapsing. As older adults may show atypical signs of infection, mental status should be regularly assessed as well.

Answer 2

Manifestations of infection in an older adult client are not the same as those seen in young adult or middle-adult clients. **The most common indication of an infection is a change in mental status.** Because of changes in immune status, an older adult client may not develop a fever in the presence of an infection. **In the older adult client, fever may be absent even when bacteremia or pneumonia is present.** The baseline temperature in the older adult population is low. An oral temperature of 100°F (37.8°C) or greater (or an increase of 1.4°F or 0.6°C or more in baseline temperature) should cause the provider to suspect infection.

Answer 3

baseline health status he plan of care has, as its central goal, the client’s return to the desired functional status or state of being. Client goals should be measurable and realistic. For example, if the client typically requires the use of a wheelchair, anticipating the client’s ambulation upon hospital discharge likely is an unrealistic goal. If the client engaged in gardening, mowing the lawn, and tending to grandchildren prior to the acute illness, the nurse would not anticipate the client’s need for a referral to a long-term care facility unless some debilitating event or major change in health status has occurred. Content Refresher The older adult population faces multidimensional problems that affect health and quality of life. Therefore, older adult care delivery requires strategies to attain the highest possible level of quality functioning. For the hospitalized older adult client: Assess changes in body systems and organs related to aging and resulting from disease. **Assess visual, hearing, and cognitive problems that may interfere with daily life.** **Assess losses in taste and smell that may lead to poor nutrition. Assess mental health**. **Assess for impediments to mobility.** Provide training to improve muscular strength, balance, and reaction time. Teach cognitive enhancement strategies, accident and fall prevention, and provide education on nutrition.

Answer 4

Neurovascular assessment is the main focus in clients with an external fixator. This includes monitoring for the color, temperature, capillary refill, peripheral pulses, paresthesia, and edema on the affected extremity. Motor function should be evaluated at frequent intervals (e.g., dorsiflexion and plantar flexion), unless contraindicated. Both sides should be assessed and compared. The nurse should note that partial or full loss of sensation is a late sign of neurovascular impairment

Answer 5

Pallor, paresthesia, pain, pulselessness, pressure, paralysis Compartment syndrome results from swelling and increased pressure within a muscle compartment. The fascia surrounding the muscle has limited ability to stretch, so as swelling continues, the function of blood vessels and nerves within the compartment are compromised. Trauma, fractures (especially of long bones), extensive soft tissue damage, and crush injuries are usually associated with compartment syndrome.

Answer 6

**Unrelenting pain** is a characteristic of compartment syndrome. **Parethesia** is a characteristic of compartment syndrome. **Cold and edematous extremity** are characteristics of compartment syndrome. An **alteration in pulse strength** in the affected extremity is a characteristic of compartment syndrome.

Answer 7

Vitamin D2 supplement As a supplement it is used to prevent and treat vitamin D deficiency. . Ergocalciferol (vitamin D 2) is often taken in low doses as a supplement, but doses up to 200,000 units are used for hypoparathyroidism and doses up to 500,000 units daily are used for clients with rickets.

Answer 8

A nicotine patch assists the client with smoking cessation, because the patch provides a steady level of nicotine. The patch can be used up to 8 weeks. Teach the client common side effects of the nicotine patch (e.g. transient itching, burning, redness at patch site, insomnia, nausea, and headache). Instruct the client to rotate sites to reduce skin irritation. **Nicotine causes vasoconstriction, so the use of multiple forms of nicotine can dangerously increase the client’s blood pressure and lead to a myocardial infarction.** **Clients who use the nicotine patch should be advised not to smoke while wearing the nicotine patch**. Smoking while wearing the nicotine patch can cause serious complications, including myocardial infarction. It is important for the nurse to inform the client that smoking while wearing the patch causes nicotine overdose. The nurse should also inform the client of the **signs and symptoms of nicotine overdose such as, nausea, vomiting, dizziness, weakness, and rapid heartbeat.** The nurse has the responsibility to understand that the nicotine patch reduces nicotine cravings associated with smoking cessation by providing the client with nicotine.

Answer 9

**Jaw Thrust Maneuver** Do not use head tilt-chin lift when cervical injury is suspected because it hyperextends the neck and can further compromise cervical injury

Answer 10

input from the staff. The nurse manager should use the expertise of all staff members. This decision impacts everyone and the decisions should be as collaborative as reasonable.

Answer 11

A systemic disorder of nerve impulse transmission due to a deficiency of acetylcholine Muscular Weakness produced by repeated movement that soon dissapears following rest, Diplopia, Ptosis, Dysphagia, respiratory distress Our number one priority is to prevent choking and aspiration We also want to provide good eye care - artificial tears, a patch if they are experiencing double vision, and a restful environment Medications include anticholinesterases, corticosteroids and immunosup **the client may have ptosis (drooping of the eyelids)**, and one or both eyelids may not close completely. Instillation of artificial tears as prescribed is especially important for clients who experience incomplete closure of the eyelids. To prevent corneal abrasion and other eye injuries, the client also may tape the eyelids closed for short intervals.

Answer 12

characterized by a normal or elevated blood glucose at bedtime, hypoglycemia between 0200 and 0300, and a rebound hyperglycemia in the morning. A rebound phenomenon that occurs in clients with Type 1 diabetes. Normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at about 2-3 AM. Counterregulatory hormones, produced to to prevent further hypoglycemia, result in hyperglycemia. (evident in the prebreakfast blood glucose level) Treatment includes decreasing the evening (predinner or bedtime) dose of intermediate-acting insulin or increasing the bedtime snack.

Answer 13

Characterized by hyperglycemia upon morning awakening that results from excessive early morning release of GH and cortisol Treatment requires an increasein the clients insulin dose or a change in the time of insulin administration

Answer 14

**hypoglycemia in the middle of the night.** ***The Somogyi effect is typically seen with the use of NPH insulin.*** If the client is suspected of experiencing the Somogyi effect, the client will be asked to perform a fingerstick glucose test between 0200 and 0300. No changes to the insulin coverage should be made until it is determined necessary to avoid profound hypoglycemia in the early morning hours.

Answer 15

An acute bacterial infection caused by Legionella pneumophila Clients diagnosed with Legionnaire disease develop pneumonia caused by Legionella pneumophila The risk of infection is increased by advanced age, end stage kidney disease, immunosuppression, diabetes, smoking and pulmonary disease fever, body aches, and cough are S/S Legionella is found in warm, stagnant water (e.g., hot water tanks, decorative fountains, hot tubs) and is spread by the aerosolized route from the environmental source to the client.

Answer 16

Complete heart block (CHB), or third-degree atrioventricular (AV) block, is a form of AV dissociation characterized by an absence of conducted impulses from the atria to the ventricles. Essentially, there is no relationship between the atria and ventricles. CHB is associated with diseases such as coronary artery disease, myocarditis, myocardial infarction, cardiomyopathy, amyloidosis, and progressive systemic sclerosis (scleroderma). Digoxin, beta blockers, and calcium channel blockers can also cause CHB. Consequences of CHB include decreased cardiac output, ischemia, shock, and heart failure.

Answer 17

CONTRAINDICATED In CHB, the atrioventricular node blocks all impulses from the sinoatrial node, so the atria and ventricles beat independently. Because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response, causing cardiac arrest. **Lidocaine is not given to a client who is bradycardic.**

Answer 18

A medical emergency in which a thin layer of tissue (the retina) at the back of the eye pulls away from the layer of blood vessels that provides it with oxygen and nutrients. Retinal detachment is often accompanied by flashes and floaters in your vision ## Footnote The appearance of many bits of debris (floaters), sudden flashes of light, or a shadow in the vision field are symptoms. Prompt medical treatment can often save vision in the eye. **Clients with retinal detachment report light flashes, floaters, and a "cobweb," "hairnet," or ring in the field of vision.** **The nurse should anticipate visual acuity measurement as the first diagnostic procedure**. The detached retina can be directly visualized using ophthalmoscopy or slit lamp microscopy. The nurse should prepare the client for surgery following a standard protocol. Bed rest prevents further detachment of the retina. Lying on the affected side prevents further detachment of the retina. The client should be on strict bed rest with the head elevated to decrease pressure in the eye, slow detachment progression, and minimize trauma. The client should be NPO in anticipation of surgery to correct detachment of the retina.

Answer 19

External beam radiation therapy is a form of cancer treatment that uses highly charged electrons to penetrate malignant tumors with pinpoint accuracy. With external radiation, the nurse needs to anticipate skin changes, possible nausea, and fatigue. The nurse should also monitor for signs of infection. Effects of radiation therapy vary according the type and length of treatment. The client should be taught which signs and symptoms to report to the provider indicating potential complications (e.g., fever and increasing fatigue). **Redness or desquamation** can occur from radiation and can be severe if not managed properly. At a minimum, the nurse must assess that the client is not using deodorant or applying commercial lotions to the area. Difficulty swallowing indicates pain and/or swelling and requires further intervention. Radiation therapy causes inflammation of nearby epithelial cells, and this can result in further consequences such as malnutrition. **Fatigue**, a common side effect of radiation therapy. If the fatigue is severe enough to interfere with daily activities, further assessment and possible intervention is warranted.

Answer 20

**Unit-to-unit assignment is the process of reassigning nurses from their regular unit assignments to areas where nurse staffing levels have fallen below certain nurse-to-client ratios required to provide safe, effective client care** (e.g., critical care, labor and delivery, and post-anesthesia units require one nurse per two clients). **Understaffing can result in health care-associated infections, medical errors, falls with injuries, higher mortality rates, and greater levels of nurse burnout and job dissatisfaction.** Every hospital has established processes on how to monitor client census and adjust staffing. **The nurse in charge is expected to communicate openly with the nursing supervisor (or equivalent direct report) to report low census**. An appropriate goal is to ensure that adequate skilled workforce is available to meet the clients’ needs. Floating staff members to other units depends on local union and labor regulations.

Answer 21

When caring for the client with Alzheimer disease , the nurse should: Implement fall and safety precautions. Orient frequently, providing verbal, written, and visual cues. Maintain consistent caregivers and routine. Monitor for anxiety and agitation and determine whether cause is physiological, such as the result of dehydration or infection. Offer relaxing activities such as listening to soothing music or walking in a safe and pleasing environment. Anticipate medicating with cholinesterase inhibitors and/or memantine. Provide client/family with information about medication use, potential effects, and side effects. Refer client/family/caregiver to social and support programs.

Answer 22

When both upper and lower GI series are ordered, the lower GI series should be done first in order to avoid the barium from the upper GI exam traveling down the GI tract and interfering with the results of the lower GI series. The upper gastrointestinal (GI) series includes radiographic imaging of the esophagus, stomach, duodenum, and the upper portion of jejunum. The client swallows barium sulfate prior to imaging. The lower gastrointestinal series should be scheduled first in order to prevent barium traveling from the upper GI tract to the lower GI tract and obscuring the study. This is often referred to as a barium enema examination. It is a radiographic visualization of the large intestine and encompasses the rectum, sigmoid, descending, transverse, and ascending colon going to the ileocecal valve. The barium is administered through a rectal catheter, which has an inflatable balloon. ***When both upper and lower GI series are ordered, the lower GI series should be done first in order to avoid the barium from the upper GI exam traveling down the GI tract and interfering with the results of the lower GI series.*** Upper GI disorders can interfere with the motility or biochemical functions of the esophagus, stomach, and duodenum. Lower GI disorders affect the small and large intestines as well as the rectum.

Answer 23

using a cuff that is too short repeating assessments too quickly positioning the brachial artery below the heart Deflating the cuff too quickly (Deflating the cuff too quickly may cause a false high diastolic reading, as the last sound may be missed.

Answer 24

upright; arteriovenous fistula; caffeinated products, smoking, or exercise

Answer 25

Supine hypotensive syndrome (also referred to as inferior vena cava compression syndrome) is caused when the gravid uterus compresses the inferior vena cava when a pregnant woman is in a supine position, leading to decreased venous return centrally. Symptoms usually occur within 3–10 minutes after lying down. As the pregnancy proceeds, the uterus grows with increasing gestational age, and compression becomes more common. **Symptoms include pallor, dizziness, low blood pressure, sweating, nausea and increased heart rate**; these are transient symptoms which resolve with maternal position change, such as leftward tilt. As the uterus enlarges, the client's internal organs become compressed or displaced. This includes the descending aorta within the abdominal cavity. **To maximize cardiovascular functioning, the nurse should instruct the client to lie on the left side, which prevents compression of the descending aorta.** Elevating the lower extremities may further press the gravid uterus onto the aorta if the client does not shift the abdomen to the side. **In the supine position, particularly during the second half of pregnancy, the weight of the gravid (pregnant) uterus partially occludes the vena cava and the aorta.** This reduces cardiac output and can lead to the development of supine hypotensive syndrome. **Lying on left side takes the weight of the uterus off the vena cava and increases blood return to the heart, which will promote cardiac output.**

Answer 26

Assessment: 1st 2 hours there is nausea, vomiting, pallor, slow weak pulse Latent period- 1 to 1.5 days symptoms abate If no treatment, hepatic involvement Diagnostic tests: kidney & liver function **Interventions:** **Induce vomiting** **Maintain hydration** monitor kidney and liver function Administer antidote (Acetylcysteine) **Hepatic toxicity is a serious complication resulting from an acute acetaminophen overdose that manifests approximately 1 to 3 days after initial ingestion.** Signs of hepatic toxicity include an *increase in the serum transaminase liver enzymes, ALT and AST.* The prothrombin time should also be monitored, as acetaminophen overdose prolongs it.

Answer 27

For adult clients, the maximum dose of acetaminophen is 4 gm per day. Acetaminophen consumption of greater than this may cause toxic liver effects (i.e., hepatotoxicity). The client’s treatment plan will be based on factors including the amount of acetaminophen consumed, as well as physical and psychological assessment findings. In severe cases of acetaminophen toxicity, liver dialysis may be necessary. Serum alanine transaminase does not rise quickly, but it will gradually increase as liver damage is sustained. Clotting times (prothrombin time [PT] and international normalized ratio [INR]) are also monitored closely as they are indirect indicators of liver function. Renal function tests become relevant if hepatorenal syndrome (Medical condition characterized by rapid kidney function deterioration in clients diagnosed with severe, sudden onset of liver failure or liver cirrhosis; is a life-threatening condition) develops. Content Refresher Signs and symptoms of acetaminophen overdose may include right upper quadrant abdominal pain; nausea; vomiting; jaundice; confusion; stupor; coagulation abnormalities; pallor; hypothermia; and slow, weak pulse. Depending on the elapsed time between medication ingestion and hospital admission, **activated charcoal may be prescribed to decrease acetaminophen absorption.** N-acetylcysteine, which is the antidote for acetaminophen overdose, may be administered orally or intravenously. **N-acetylcysteine is most effective within the first 8 to 10 hours and must be given within 24 hours.**

Answer 28

TRUE One nutrient that is present in breast milk is iron. Because the baby is breastfeeding, the mother's iron stores will support the baby for the first few months When providing care for a pregnant or postpartum client, ask about the mother’s plan for feeding the newborn. Assess the mother’s understanding that breast milk is the best form of nourishment for newborns and infants, particularly in the first six months of life. Assist mothers in learning to breastfeed their babies and in recognizing the signs that indicate adequate nutrition. Educate mothers about the number of wet and soiled diapers the baby should have each day. Breastfed infants benefit from the introduction of iron-fortified cereal, fed with a spoon, between 4 to 6 months of age. Babies who were born early (before 37 weeks) or at a low birth weight (less than 5 pounds, 8 ounces, or 2.6 kg) need special nutrition to meet their growth and development needs.

Answer 29

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It primarily affects the lungs, but it can infect any organ. Infection can be dormant or active. Active infection is known as TB disease. Tuberculosis that is dormant is known as latent TB infection (LTBI). Tuberculosis risk factors include immunocompromised clients (especially those who are HIV/AIDS positive); clients who have traveled to places with high rates of TB; and those residing or working in hospitals, prisons, skilled nursing facilities, and homeless shelters. Age at time of exposure, including the very young and the very old, are at increased risk of infection. **The mycobacterium that causes tuberculosis is believed to cause an opportunistic infection.** This means that if a client has a healthy immune system, exposure to the bacteria will not necessary lead to disease. If the nurse keeps this in mind, **the client who is the most at risk is the one whose immune system is compromised.**

Answer 30

Can be life threatening and occurs when a fertilized egg implants itself outside the uterus the embryo is implanted in a fallopian tube instead of the uterus. The growth of the embryo is restricted by the fallopian tube, which can rupture. This causes pain and possible bleeding within the lower abdominal region. - can be due to PID, tubal surgery, and anomalies of the fallopian tubes **Shock is a real possibility due to blood loss** **Assessment:** unilateral lower quadrant pain, rigid, tender abdomen, referred shoulder pain (results from blood irritating the subdiaphragmatic phrenic nerve , low hematocrit and low hCG levels in blood and urine, bleeding (gradual oozing to frank bleeding) **IMPLEMENTATION-** **Monitor for shock- potentially life threatening** Administer Rho(D) immune globulin provide support An ectopic pregnancy will most likely terminate early in the first trimester. The common location of implantation for an ectopic pregnancy is a fallopian tube, which ruptures when the embryo grows beyond the capacity of the space.

Answer 31

Hypotension A fluid bolus is given Epidural blockade produces vasodilation and typically causes a decrease in blood pressure. ***Administration of an IV fluid bolus prior to an epidural block is intended to offset potential hypotension by increasing the fluid volume in the intravascular space.*** To optimize the effects of the fluid bolus, the IV fluid **should be administered over 20–30 minutes and the epidural procedure begun shortly thereafter.** The purpose of the fluid bolus is not hydration, but **to rapidly increase circulatory volume and cardiac output.** When administering a bolus to a client who is about to have an epidural placed, **a bolus is a prophylactic measure that avoids the adverse effect of hypotension**. Prevention is essential to the mother and baby's well-being.

Answer 32

1) INCORRECT - Maternal hypotension causes a decrease in placental perfusion. Positioning the client on the left side is appropriate, as this position increases placental perfusion. 2) INCORRECT - A sustained fetal heart rate of less than 110 beats/min is considered bradycardia. Administration of oxygen to the client is indicated in the event of fetal bradycardia. **3) CORRECT— Epidural blockade produces vasodilation and typically causes a decrease in blood pressure. Administration of an IV fluid bolus prior to an epidural block is intended to offset potential hypotension by increasing the fluid volume in the intravascular space. To optimize the effects of the fluid bolus, the IV fluid should be administered over 20–30 minutes and the epidural procedure begun shortly thereafter.** 4) INCORRECT - A sustained fetal heart rate of less than 110 beats/min is considered bradycardia. Administration of IV fluid (without any medication) as prescribed or per protocol is an appropriate intervention for fetal bradycardia.

Answer 33

**Monitor vital signs, being especially alert to possible hypotension and respiratory paralysis**. Assist in positioning the client and allaying anxiety during the procedure. Assess effectiveness of the anesthetic. Maintain hydration.

Answer 34

Depression is defined as a mood disorder characterized by sadness and/or irritability, difficulty concentrating, negative thinking, weight gain or loss, lack of interest in activities, and problems sleeping. Complications associated with depression include injuries and self-harm. **A client with depression is at risk for suicide and may feel "better" once a plan to commit suicide is made.** **This client should be assessed immediately for suicide ideation and placed on suicide precautions.**

Answer 35

Non-organic failure to thrive (NOFTT) means **a child, typically under 2 years old, has stunted growth for no known medical reason.** The child will measure below the fifth percentile for height and weight standards, or show a marked decrease in weight. Consistency of the staff is important to gain the trust of the child and the parents. The child with FTT often requires an environment without interruption, especially during meal time NOFTT is marked by low weight and small height, or significant weight loss. Additional symptoms are related to delays in development, including: Avoids eye contact Doesn’t make sounds Delayed mental and age-appropriate social skills (smile or laugh) Delayed motor development and physical skills, including rolling over, sitting, standing or walking Easily tired and sleeps too much Irritable

Answer 36

Hyperthermia is an abnormal rise in body temperature above 100.4℉ (38℃). The hypothalamus is responsible for temperature regulation in the body. **Very high body temperatures may damage the brain or other vital organs.** Those at highest risk of developing a heat-related illness are infants, children up to 4 years of age, people 65 years of age and older, overweight people, and people who are ill or taking certain medications. Treatment includes seeking an air-conditioned environment, fluids for hydration, removing excess clothing, and taking a cool shower.

Answer 37

Can be caused by hypokalemia S/S include nausea, vomiting, anorexia, weakness, abdominal pain, cardiac dysrhythmias, and visual changes to include blurred vision, halos around objects and diplopia

Answer 38

neural tube defects; Down syndrome. Pregnancy is an exciting time and one in which the client undergoes many physical and psychological changes. Healthy development of the fetus often depends upon the health of the client. Should the client have nutritional deficiencies or engage in a lifestyle practice that is harmful, the fetus is at risk for alterations in development. One condition is a neural tube defect. The exact reason for this defect is unknown. However, it is believed to be caused by genetic predisposition, nutrition, and lifestyle factors. Assessing for this defect is routinely done mid-way in the client's pregnancy. An elevated alpha-fetoprotein level is linked with neural tube defect. Content Refresher **Alpha-fetoprotein (AFP) is a protein that the fetus produces. An abnormally high AFP level may mean that the fetus has a chromosomal disorder or neural tube defect**, such as spina bifida or anencephaly (underdeveloped brain and an incomplete skull). An abnormally high AFP level may also indicate that the fetus has an omphalocele, which is an abdominal wall defect with organ exposure. **A maternal serum alpha-fetoprotein (MS-AFP) screening is a blood test performed between 15 to 20 weeks (second trimester).** Further diagnostic testing such as a high-resolution ultrasound or amniocentesis may be recommended if the AFP levels are elevated. Treatment is recommended based on the abnormality diagnosed. Referral to a geneticist or high risk obstetrician may be warranted.

Answer 39

The neural tube is the structure that develops into the infants brain and spinal cord. In those with spina bifida, a part of the neural tube does not properly close. (It normally closes early in pregnancy) - infants with spina bifida have increased risk of infection. ICP needs to be thoroughly monitored **Spina Bifida Occulta-** mildest form. There is a small gap in one or more of the vertebrae of the spine. There will be dimplign at the site. Infant will not experience any neurological problems **Meningocele - bulging, saclike lesion filled with spinal fluid. The protective membrane of the spinal cord pushes through the defect. The spinal cord develops normally** **Myelomeningocele-** worse of 3 types. bulging, saclike lesion filled with spinal fluid and the spinal cord. Neurological deficits are present **Implementation-** cover bulging sac with moist sterile dressing b/c tissues/nerves are exposed which makes infant prone to infection. Position on abdomen or semi-prone to prevent any damage or trauma to bulging sac Observe for symptoms of increased ICP - changes in LOC, motor functions, vital signs Observe for meningitis **Surgical repair will take place within 24-48 hours after infant is born. Postoperatively, nurse should observe for shock and respiratory difficulty**

Answer 40

Sodium should not be restricted during pregnancy. The Dietary Reference Intakes (DRI) for iron is 15 mg/day for nonpregnant adult women and 30 mg/day for pregnant women. It is difficult to obtain this much iron from the diet alone, and most health care providers prescribe iron supplements of 30 mg/day beginning in the second trimester, after morning sickness decreases.

Answer 41

increase; fetal circulation; double

Answer 42

Transmission of the virus is through parenteral drug abuse, sexual contact, and blood and body fluids. High risk groups include immigrants from endemic areas, drug addicts, fetuses from infected mothers, unprotected sexual contact between multiple partners, transfusion clients, and health care workers. **Hepatitis B is caused by a virus that is transmitted through blood and body fluids**. Because of this, nursing actions should focus on preventing the spread of the infection by limiting exposure to the client's blood, urine, stool, and semen. The client can safely receive blood products if required. Blood can be safely drawn from this client as long as standard precautions are followed. Infection with hepatitis B increases the client's risk for developing chronic hepatitis, cirrhosis, and liver cancer.

Answer 43

FALSE Within the first 24 hours, to monitor for signs of deterioration, the person should be woken up every 3 hours to assess orientation. **This is done for the first 24 hours for someone who lost consciousness.** For a more minor concussion, the current recommendation is to allow the client to rest for longer periods to prevent brain hyperexcitability and worsening of the condition from lack of sleep.

Answer 44

Aspirin can prolong any bleeding that might occur. and it increases the risk of bleeding inside the head.

Answer 45

**Assessment of Skull fracture** **Battles Sign -** ecchymosis over the mastoid bone **Raccoon eyes-** bilateral periorbital edema **Rhinnorrhea -** clear fluid from the nose **Otorrhea**- clear fluid from the ears **Assessment of Contusion** Slight depression of consciousness to coma Decorticate posturing Decerebrate posturing Generalized cerebral edema **Assessment of Concussion** - Transient confusion or lack of consciousness Headache Long term effects - lack of concentration & personality changes **Assessment of Laceration** - penetrating trauma with bleeding **Assessment of Hematoma** Epidural, Subdural

Answer 46

Antipsychotic A side effect of trifluoperazine is **dry eyes**. The client should use artificial tears to manage this side effect. Side effects of trifluoperazine include **weight gain**. The client should monitor calorie intake and exercise frequently. Trifluoperazine is an antipsychotic and is excreted in the breast milk. Breastfeeding is contraindicated.

Answer 47

Fetal position refers to the location of a specified point on the fetal presenting part in relationship to the client’s pelvis. Position is represented by a three-letter abbreviation. **Left occiput anterior (LOA) is the most common position, indicating that the fetal occiput is facing the left anterior portion of the client’s pelvis.** The left occiput anterior (LOA) position is the most common and favorable fetal position for birthing, followed by the right occiput anterior (ROA) position.

Answer 48

Planning and performing nursing care for a client undergoing surgery is the role of the circulating nurse. **The circulating nurse is the single advocate for client safety during surgical procedures** whose duty it is to report on activities or conditions that place the client as risk. One such safety hazard is the risk for infection. The circulating nurse ensures that all staff act in a manner that reduces this risk.

Answer 49

arterial blood gas The nurse knows this test requires a sample of arterial blood. The blood is analyzed for the amount of oxygen and carbon dioxide in the blood.

Answer 50

Acid-base balance is critical to the functioning of the body. Balance is maintained primarily through lung, kidneys, and pH buffer systems. **Carbon dioxide exchange in the lungs, excretion of acids and bases in the kidneys, and control of carbonic acid/bicarbonate ions in the bloodstream facilitate normal acid-base balance**. Normal acid-base balance is indicated by a pH of 7.35 to 7.45, PaCO 2 of 35 to 45 mm Hg (4.7 to 5.9 kPa), PaO 2 of 80 to 100 mm Hg (11-13 kPa), oxygen saturation of 95 to 100%, HCO 3 of 22 to 26 mEq/L (22 to 26 mmol/L), and base excess of −2 to +2 mEq/L (−2 to +2 mmol/L). Complications from an arterial blood gas (ABG) include hematoma, arteriospasm, pain, infection, trauma to vessel, and air or clotted-blood emboli.

Answer 51

**No, because it will accelerate gastric emptying and speed up drug absorption.**

Answer 52

The use of syrup of ipecac for accidental poisoning has changed. **The direction now is to contact Poison Control to find out the best antidote to use based upon the ingested item.** Syrup of ipecac is used to induce vomiting

Answer 53

A urine glucose test is used to indirectly determine whether your levels of glucose, or blood sugar, are within a healthy range. It's used to monitor both type 1 and type 2 diabetes. **If your blood glucose rises above normal, your kidneys get rid of the extra glucose in your urine.** The proper procedure is to dip the strip in the urine and compare the color changes to the color chart to determine glucose level. A glucose level should be obtained from fresh urine that has not become concentrated from sitting in the bladder.

Answer 54

**Diabetic ketoacidosis (DKA) results from insufficient insulin, which causes hyperglycemia, ketosis, dehydration, electrolyte loss, and acidosis**. Glucose is excreted by the kidney, resulting in osmotic diuresis and electrolyte loss. The liver breaks down fat for energy, resulting in ketosis. A large amount of ketones leads to metabolic acidosis. Appropriate care for this client includes monitoring arterial blood gas results, monitoring hourly blood glucose and titrating insulin infusion per the health care provider prescription, administering IV fluids to restore circulating volume while monitoring for signs of fluid overload, administering supplemental electrolytes, especially potassium, and monitoring the electrocardiogram to assess for any dysrhythmias.

Answer 55

**Hip flexion should be restricted to a 90-degree angle** to prevent accidental dislocation of the hip prosthesis. Frequently used items should be **placed at waist-height to prevent bending.** Flexion of the hip greater than 90 ° should be avoided in a client recovering from hip arthroplasty surgery to prevent dislocation of the prosthesis.

Answer 56

We want to decrease the amount of stimulation (quiet room with television turned off) Monitor for signs of aggression Don't validate hallucinations. Place the client in a quiet, well-lighted room and stay with the client, if possible, to interpret the environment.(a darkened room can produce hallucinations and incite fear rather than inhibit these experiences.) Client safety and injury prevention are major nursing priorities the nurse should provide simple explanations, and questions should be kept to a minimum. visitors are permitted unless client's behavior becomes aggressive

Answer 57

***Chronic kidney disease is a progressive process in which scar tissue replaces functional nephrons. As nephrons are damaged, the kidneys ’ ability to filter waste products from the blood is decreased.*** Waste products accumulate, the kidneys lose the ability to concentrate urine, and electrolyte imbalances occur. If a damaged kidney can no longer secrete erythropoietin, anemia develops. Hypertension results from sodium and water retention. Risk factors for chronic kidney disease include diabetes mellitus, vascular and autoimmune disorders, uncontrolled hypertension, family history, urine obstructions, and increasing age. **With aging, the glomerular filtration rate gradually decreases and kidney function declines**. **Hypertension and diabetes mellitus cause continual kidney damage.** Damage to blood vessels is increased when hypertension and diabetes mellitus are not well controlled, which can lead to kidney disease. ***Diabetes mellitus, hypertension, and kidney failure are more common in the black and African American populatio***n, according to the National Kidney Foundation. This may be accounted for by modifiable risk factors.

Answer 58

TRUE - the incident report should not be mentioned when documenting. It is separate . In writing the incident report, the nurse must objectively describe the incident.

Answer 59

TRUE This means reporting the information to the nurse manager, who will notify the health care provider and the appropriate authorities. The nuse should use the chain of command when there are A= abuse issues C= confidentiality L= legal/ethical issues S= safety issues

Answer 60

Dehydration is the loss of body fluids, mainly water, with resultant changes in serum electrolytes and is caused by a variety of disorders including inadequate fluid intake, diarrhea, vomiting, and disorders that result in fluid losses. **Signs and symptoms include thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy.** Complications associated with dehydration include hypovolemic shock and electrolyte abnormalities. Treatment includes oral and/or IV fluid and electrolyte replacement.

Answer 61

**1) CORRECT— Not taking fluids or food for 8 hours increases the infant's risk for dehydration and acidosis. The infant ’s rate of fluid exchange is significantly higher than an adult ’s and the metabolism rate is nearly twice that of an adult. Because the kidneys are not mature at this age, the infant cannot adequately concentrate urine to conserve water.** This client is at risk for dehydration related to size, metabolic demands, and immaturity of the renal system. 2) INCORRECT— The toddler-age client with elbow pain and a deformity may have a dislocated elbow or fracture. The neurovascular status of the affected extremity should be evaluated and the nurse alerts the client ’s caregiver to report changes while awaiting further evaluation. 3) INCORRECT— The preschool-age client is likely flushed from a fever. The nurse should request an order for acetaminophen or ibuprofen if the client had not received either before arrival, and alert the caregiver to report changes in the client's condition while awaiting further evaluation. 4) INCORRECT— Although vomiting may pose a risk for dehydration, the symptoms that the school-age client is experiencing are likely a result of strep throat or a virus. This client requires urgent evaluation, but with a greater body mass and more mature organ systems, this client is not as acute as the infant.

Answer 62

Smoking Cancer that originates in the lungs is one of three categories: **an aggressive type known as small cell** or oat cell cancer; **a slow growing carcinoid or neuroendocrine tumor**; or, more commonly, **a non-small cell cancer** such as adenocarcinoma, large cell carcinoma, and squamous cell carcinoma.Smoking is the greatest risk for lung cancer. **Cough and dyspnea are symptoms of both small and non-small cell lung cancers, though individuals with these conditions may not have symptoms for years**. **Frequent, unresolved respiratory infections** may be earlier signs of lung cancer. **Chest pain, wheezing, hemoptysis, fever, and general weakness may indicate advanced disease**. Lung cancer may be detected through a chest x-ray; if not, a positive electron tomography (PET) scan can detect small tumors or metastatic lesions.

Answer 63

The patient should **Avoid drinking coffee, tea, or caffeinated beverages before the test. Caffeine is a stimulant and this may affect the results of the EEG.** The client should avoid caffeine-containing beverages or foods for 24 to 48 hours prior to the test An electroencephalogram (EEG) is **a recording of the brain's spontaneous electrical activity over a period of time,** as recorded from multiple electrodes placed on the scalp. Instruct the client to wash hair the night before the EEG and to avoid putting any products (such as sprays or gels) in the hair on the day of the test. Instruct the client to refrain from consuming any food or drinks containing caffeine for at least 8 hours prior to the test, and to hold medications (as prescribed) that may stimulate or depress brain waves.

Answer 64

Blood products include red blood cells (usually RBCs), plasma (thawed or fresh frozen), platelets (random donor, single donor, pooled donor), cryoprecipitate, albumin, gamma globulin, and other components. Each blood product has unique indications for administration and infusion protocols that must be followed. All blood products pose a risk for triggering an immune reaction.

Answer 65

a special, single tubing is used for platelet administration, and the platelets are infused as quickly as possible. Platelets are not administered with normal saline. ***a standard blood transfusion set (Y-tubing) is not used for platelet administration because the filter traps the platelets, and there is increased adherence of platelets to the lumen of the longer tubing.*** An administration set particularly designed for platelets must be used, as it has a smaller filter and shorter tubing.

Answer 66

febrile, nonhemolytic Sudden chills and a temperature increase occur, along with headache, anxiety, muscle pain, and flushing. This reaction is usually treated with antipyretics.

Answer 67

There are a variety of reasons why a client would need to perform exercises that target a specific joint. A client who is on bed rest would need to perform range-of-motion exercises to maintain adequate joint functioning and to promote circulation. However, in the event that the joint is injured, the nurse may need to assist with the movements. One approach is to support below the level of the joint being exercised. This action reduces strain on the muscles surrounding the joint while ensuring the joint is taken through complete range of motion. Content Refresher **Range of motion (ROM) is the degree of flexion and extension of each joint in the body.** Range-of-motion exercises are performed **to prevent muscle contractures and to maintain joint mobility**. Active ROM is the movement of the joints in all directions without assistance. Passive ROM is the movement of joints in all directions by the nurse without the assistance of client. Active-assist ROM is a combination of these approaches in which the nurse reduces the weight load on the joint by supporting the limb distally to the joint while the client actively performs ROM.