QB 8

Question 1

What to remember about Guillane Barre Syndrome - what are the classic symptoms

Answer 1

The classic symptoms of Guillain-Barre syndrome include respiratory failure caused by paralysis of the respiratory muscles, flaccidity of the extremities due to paralysis of the muscles, and urinary retention due to loss of sensation.

Guillain-Barré Syndrome (GBS) is a disorder in which the body’s immune system attacks part of the peripheral nervous system. In the acute phase of the illness, respiratory muscle paralysis can interfere with breathing. The initial symptoms are typically changes in sensation or pain along with muscle weakness, beginning in the feet and hands. This often spreads to the arms and upper body with both sides being involved. The symptoms develop over hours to a few weeks.

Guillain-Barré syndrome results in paralysis and potential respiratory failure. The client may initially present with pain, paresthesia, and hypotonia of the muscles of the extremities. The condition progresses further with diminished or absence of reflexes and weakness and paralysis of the limbs, beginning with the legs and ascending to the upper extremities. Autonomic nervous function may also be affected and present as diaphoresis and episodes of tachycardia and bradycardia. The nurse would also assess for conditions that result from immobility, being especially attentive to signs of respiratory distress.

Question 2

TRUE OR FALSE

Potassium is the primary cation inside the cell and is involved in electrical conduction of the heart and acid-base balance. The sodium-potassium pump and the kidneys regulate the potassium level in the body. The body’s level is maintained through dietary intake and excreted through the kidneys.

Answer 2

TRUE

Question 3

Insulin does not have to be refrigerated. It should be stored in a cool place.

TRUE OR FALSE

Answer 3

TRUE

Question 4

Insulin is released into the body whenever glucose levels in the body reach 90 mg/dL

TRUE OR FALSE

Answer 4

TRUE

Question 5

Principles for teaching the client insulin administration

Answer 5

Assess the client’s knowledge of acceptable subcutaneous insulin injection sites (e.g., upper arms, abdomen, thighs, and buttocks). Teach the client that absorption from the abdomen is quickest, followed by the arm, thigh, and buttock. Instruct the client to visualize the abdomen as a checkerboard, with each 0.5 to 1 inch (1.27 to 2.5 cm) square representing an injection site. Instruct the client to rotate injection sites systematically across the “checkerboard.” Instruct the client to use the shortest acceptable needle and to insert the needle at a 45- to 90-degree angle.

Question 6

What to remember about peritoneal dialysis

Answer 6

This is where the peritoneal membrane is the filter for waste produces. It is the introduction of a fluid into the peritoneal cavity, where toxins from the vascular system are pulled into the peritoneal cavity. At the end of “dwell time” the fluid is drained from the body, carrying waste products with it. This type of treatment can be irritating to the tissues within the peritoneal space and may cause pain and discomfort during the procedure. The nurse should explain the process for this fluid exchange and the reason for the local irritation. In time, the irritation will dissipate

Sterile fluid (dialysate) is infused by gravity into the peritoneal cavity through a surgically-implanted catheter. By using the principles of diffusion, the waste products and toxins in the client’s blood are filtered into the dialysate during the dwell time. Using the principle of osmosis, water is also drawn into the dialysate solution so that the client is able to eliminate excess water. Evaluate as the client demonstrates the infusion, dwell, and drain phases. Note color and amount of dialysate after dwell time. Explain the importance of monitoring serum glucose, as the main ingredient in the dialysate is dextrose. Educate the client about potential complications, which includes peritonitis, sepsis, hypotension, and fluid deficit.

Question 7

Frequent and small amounts of diarrhea may indicate a possible bowel obstruction that can be life-threatening if the bowel perforates.

TRUE OR FALSE

Answer 7

TRUE

Untreated intestinal obstruction can lead to life-threatening complications, including bowel infarction and infection secondary to peritonitis. The resulting inflammation in bowel obstruction can lead to fluid sequestration, increased capillary permeability, and severe reduction in circulating blood volume. The nurse should think of preventing hypovolemic shock in clients with suspected bowel obstruction. The nurse needs to assess this client first in order to escalate interventions, such as an emergency exploratory laparotomy or aggressive fluid resuscitation.

Question 8

What is the most dangerous type of blood transfusion reaction ?

Answer 8

Hemolytic transfusion reaction

Symptoms include nausea, vomiting, pain in lower back, and hematuria. Treatment is to the stop blood transfusion, obtain a urine specimen, and maintain blood volume and renal perfusion.

Question 9

Anesthesia and medications provided during a surgical procedure can adversely effect gastrointestinal functioning. If the client had abdominal surgery, the effects on the gastrointestinal tract are compounded by incision pain. Although uncomfortable, the presence of abdominal gas pain is a positive sign that indicates return of normal gastrointestinal functioning. To aid this client and relieve the discomfort, the nurse should assist the client to ___________________

Answer 9

ambulate. Walking helps facilitate the expulsion of trapped flatus, relieving the discomfort.

Question 10

What to remember about basal body temperature and ovulation ?

Answer 10

Basal body temperature is a method used to determine if a client is ovulating. The client measures body temperature every morning before arising. If the client ovulates, there will be a slight drop and then rise in temperature. Because of the influence of progesterone, the temperature will be increased during the second half of the cycle.

there is a drop in temperature that is followed by a sustained rise in temperature. The time where the temperature drops and then rises is the period of highest fertility.

Question 11

An understanding that objects continue to exist even when they are not heard, seen, sensed, smelled, or touched.

Answer 11

object permanence, whcih develops late in infancy

Question 12

When providing care for an infant who is hospitalized for surgery, the nurse should recognize and promote comforting behaviors that will fill the needs of ______________–The nurse should allow parent(s) to be present and assist with meeting the infant’s needs throughout the hospitalization, especially during _______________. Parent(s) should be encouraged to provide_____________- to the infant during and after painful procedures.

Answer 12

both the client and the parents; procedures: comfort

Question 13

Aspiration syndromes are all conditions in which foreign matter is inhaled into the ________________

Answer 13

lungs

Structures of the mouth, pharynx, larynx, and esophagus are involved in normal swallowing. Swallowing is performed through preparatory, oral, pharyngeal, and esophageal phases. When swallowing is impaired during one or more of the swallowing phases, foreign substances can be inhaled into the lungs.

Question 14

Teaching to provide the client with an implantable cardioverter/defibrillator (ICD)

Answer 14

This device is able to perform cardioversion, defibrillation, and pacing of the heart. The device is therefore capable of correcting most life-threatening cardiac arrhythmias.

1. Continue taking antidysrhythmic medications until the health care provider directs otherwise.
2. Do not wear tight clothing or belts over the ICD generator.
3. Avoid activities that involve rough contact with the ICD.
4. Report symptoms such as nausea, fainting, and weakness.

keep the incision dry for at least 4 to 5 days after insertion.

An implantable cardioverter/defibrillator (ICD) is indicated for clients who survived sudden cardiac death, clients with spontaneous sustained ventricular tachycardia (VT), clients who have syncope with inducible VT or ventricular fibrillation during electrophysiology studies, and clients who are at risk for future life-threatening dysrhythmias as a result of such conditions as cardiomyopathy. After ICD insertion, report signs of infection at the incision site to the health care provider (HCP), avoid lifting the arm on the ICD side until permitted by the HCP, follow the HCP ’s recommendation with regards to resuming sexual activity, avoid driving until cleared by the HCP, and avoid large magnets, strong electromagnetic fields, and metal detectors because they may set off the ICD. Avoid standing near antitheft devices in stores (walk past them at normal pace) and wear a medical alert ID bracelet at all times.

Question 15

What to remember about radiological dispersion devices or dirty bombs and nursing procedures

Answer 15

A dirty bomb is an explosive agent that is combined with radioactive materials.

The primary goal is to limit exposure.

The primary principles for limiting exposure are to observe time, distance, and shield.

If a client is contaminated with radiation, the client should be scanned with a radiation detector meter, with special attention to body orifices and hairy areas.

Question 16

The nurse provides care for a client who has undergone the repair of a gynecologic fistula. Which intervention will the nurse include in the client’s immediate post-operative nursing care? (Select all that apply.)

1. Maintain urinary catheter.
2. Warm sitz baths.
3. Perineal hygiene.
4. Bladder training.
5. Increase oral fluids.

Answer 16

1) CORRECT — The urinary catheter usually stays in place for 7 to 10 days to avoid stress on the repaired areas and to prevent infection.
2) CORRECT — Sitz baths should be taken three to four times each day to promote healing.
3) CORRECT — Perineal hygiene is of great importance to reduce the risk of infection.
4) INCORRECT — Bladder training is not done until several days after surgery, after the urinary catheter is removed.
5) CORRECT — Increasing oral fluids helps increase urine output to keep the urinary catheter irrigated.

Fistulas may develop between the client’s vagina and bladder, urethra, ureter, or rectum. Most urinary tract fistulas are caused by gynecologic procedures. Childbirth and disease processes, such as cancer, may also cause fistulas. While small fistulas may heal on their own, others may require surgical repair. In addition to the post-operative care listed above, the client’s first stool after bowel surgery may be delayed to prevent wound contamination and subsequent infection. If the client’s indwelling urinary catheter requires irrigation because of clots, strict asepsis during irrigation is vital to prevent infection.

Question 17

When providing care for the client with a craniotomy, the nurse should:

Answer 17

A craniotomy is a surgical procedure in which a part of the skull is removed to access the brain. It is performed to remove tumors, repair fractures and trauma, and relieve increased intracranial pressure.

Medicate the client as prescribed.

Monitor intracranial pressure (ICP) continuously and adjust nursing care to maintain ICP less than 15 mm Hg.

Notify the health care provider for elevations in ICP greater than 15 mm Hg.

Observe for endocrine complications, such as syndrome of inappropriate antidiuretic hormone (SIADH) and diabetes insipidus.

Provide emotional support to the client and family.

Perform client teaching as indicated.

Position the client as prescribed and provide comfort measures.

Observe the dressing and change as prescribed.

Question 18

What to remember about concussions

Answer 18

a test that definitively diagnoses a concussion is not available.

A concussion is a common brain injury that is diagnosed according to the client’s symptoms; The client recovering from this type of injury must abstain from engaging in the activity that caused the head injury until full healing occurs.

Repeated and continuous bouts of vomiting after a concussion may indicate that the condition is worsening or intracranial pressure is increasing, and should be reported to the health care provider.

A concussion results from a blow to the head or movement of the brain within the skull that jars the brain, resulting in a temporary loss of neurologic function. Concussions may result from playing contact sports, being involved in an auto accident, or falling. The symptoms of a concussion are usually self-limiting. Mild analgesics may be given for a headache. Repetitive concussions can lead to chronic traumatic encephalopathy, a form of neurodegeneration. A concussion that results in increased intracranial pressure can lead to permanent brain damage, brain herniation, and death.

Question 19

What to remember about the BCG vaccine and Tuberculosis skin testing

Answer 19

The BCG vaccination may result in a false-positive reaction to a tuberculin skin test (TST).

bacillus Calmette-Guerin (BCG) is not generally recommended for immunization in the United States because of the low risk of infection with Mycobacterium tuberculosis. the bacillus Calmette-Guerin (BCG) vaccine is used to promote active immunity to TB, and false-positive reactions to tuberculosis skin testing can occur in individuals who received this vaccine.

Protection against tuberculosis (TB) cannot be predicted by the presence or size of a TST reaction in clients who have received the BCG vaccination.

Question 20

What to remember about Polycystic ovarian syndrome

Answer 20

Polycystic ovary syndrome (PCOS) is characterized by ovulatory dysfunction, polycystic ovaries, and hyperandrogenism. It most commonly occurs in women under 30 years old and may cause infertility

With PCOS, ovulation fails and multiple fluid-filled cysts develop from mature ovarian follicles. Signs and symptoms of PCOS include irregular menstrual periods, amenorrhea, hirsutism, and obesity (80% of women). Metformin may be prescribed to reduce hyperinsulinemia, improve hyperandrogenism, and restore ovulation. Cardiovascular disease and abnormal insulin resistance with type 2 diabetes mellitus may develop if PCOS is not treated.

Polycystic ovary syndrome (PCOS) often occurs just after puberty, which can create emotional complications during a period that is already emotionally challenging. PCOS causes acne, mood changes, stubborn weight gain, and hair growth on the face and other areas of the body. Occasionally, PCOS causes the formation of a brown skin ring on the back of the neck. Hormone alterations responsible for these changes include increased androgens (male hormones), insulin resistance, and too little progesterone. As an adult, the continued insulin resistance and reduced fertility become the central concerns. Symptoms can be managed at any age through a combination of healthy lifestyle and medications

Question 21

The nurse supervises an unlicensed assistive personnel (UAP). Which tasks does the nurse delegate to the UAP? (Select all that apply.)

1. Apply an abdominal binder.
2. Prepare an antibiotic injection.
3. Irrigate a client’s wound using sterile technique.
4. Determine the staging of a client’s pressure injury.
5. Apply an elastic bandage.
6. Assist a client with use of a urinal.

Answer 21

1) CORRECT– Applying an abdominal binder can be delegated to the UAP. However, the nurse is responsible for assessment of the area where the binder will be applied and ensuring the client’s comfort level after application.
2) INCORRECT– Preparing injections cannot be delegated to the UAP.
3) INCORRECT– Wound irrigation cannot be delegated to the UAP. However, in some settings, cleansing of chronic wounds using clean technique can be delegated to the UAP.
4) INCORRECT– Assessment and staging of a pressure injury cannot be delegated to the UAP. This requires a nurse assessment.
5) INCORRECT– Application of an elastic bandage cannot be delegated to the UAP. It is the nurse’s responsibility to assess circulation immediately after application.
6) CORRECT– The UAP can assist with toileting and basic care measures.

Question 22

Assessment of a client’s health condition, medication administration, and sterile irrigations are not included in the UAP’s scope of practice.

TRUE OR FALSE

Answer 22

TRUE

Question 23

An__________________ reflex is the reflex motion that causes your baby’s tongue to move forward as soon as his lips are touched

When should it dissapear by ?

Answer 23

extrusion

The extrusion reflex disappears between 3 and 4 months of age. An infant uses this movement of the tongue as a normal reflex when anything touches the lips. It helps with sucking from a breast or bottle.

Constant protrusion of a large tongue may be a sign of Down syndrome and requires further evaluation

Reflexes follow a pathway called a reflex arc. The reflex arc consists of a receptor, a sensory neuron, a response center in the brain or spinal cord, a motor neuron, and a muscle or gland. Depending on the reflex, a specific response is elicited when stimulated. Injury to the brain or spinal cord can cause abnormal reflexes. Notify the health care provider of reflexes that should have disappeared by 6 months of age, such as the Moro or stepping reflexes.

Question 24

When does constipation occur ?

What can we encourage the client

Answer 24

When peristalsis is slowed or feces contains more solid matter than water

The nurse should instruct the client to eat a balanced diet, including high-fiber (not low-fiber) foods, such as fruits, vegetables, and nuts.

The nurse should encourage the client to establish a bowel routine, as needed (1 hour after meals is typically best).

The nurse should encourage the client to drink eight to 10 glasses of water per day.

The nurse should encourage the client to follow a regular exercise program.

Repeatedly ignoring the need to defecate and using laxatives can inhibit regular sensory reflexes, resulting in chronic constipation. Risk factors for constipation include aging, reduced physical activity, poor diet, limited fluid intake, medications that decrease gastrointestinal motility, overuse of laxatives/cathartic agents, and regular suppression of the urge to defecate. Signs and symptoms of constipation include passage of dry, hardened stools, defecation less than three times per week, decreased bowel sounds, and abdominal distention and discomfort.

Question 25

Repeatedly ignoring the need to defecate and using laxatives can inhibit regular sensory reflexes, resulting in chronic constipation.

TRUE OR FALSE

Answer 25

TRUE

Question 26

A chronic condition of the skin that causes red patches with thick white or silvery scales. The patches result from a rapid build up of cells on the skin. Risk factors for developing psoriasis include _______________________-

TRUE OR FALSE

Answer 26

TRUE;

family history, smoking, obesity, infections, and stress.

The one factor that is linked to the development of the disorder is skin color.

Psoriasis is more likely to occur in lighter-skinned clients of European descent than in dark-skinned clients.

The reasons for the development of psoriasis vary from being a genetic disorder to being an autoimmune reaction. . Regardless of the reason, psoriasis has periods of latency and exacerbation that have been linked to stress and hormone imbalances.

Question 27

What does a nebulizer do ?

What is a complication of prolonged respiratory treatments, such as nebulizer use?

Answer 27

Allows medications to be delivered in the form of a mist and to be inhaled directly into the lungs

Hypervolemia is a complication that can result from prolonged use

The inhaled mist deposits extra fluid in the client’s respiratory system that is absorbed into the general circulation. In this scenario, the device is used on an extended basis, which puts the client at risk for an increased amount of total body fluid. The nurse should assess the client for symptoms of fluid volume overload to include pitting edema, bounding pulses, rapid heart rate, dyspnea, and elevated blood pressure.

Question 28

What can hypercalcemia be caused by?

Answer 28

Calcium is released from the bone for a variety of reasons including immobility, hyper-parathyroid conditions, compromised renal function, or the presence of metastatic disease. In the presence of metastic cancer, cancer cells enter the bone and replace normal tissue, affecting bone structure and calcium stores.

When a serum elevation of calcium is detected, one reason is because calcium is being leeched out of the bones and placed into the general circulation.

Question 29

Clients with renal failure are at risk for hypocalcemia because these clients frequently have elevated serum phosphate levels.

TRUE OR FALSE

Answer 29

TRUE

Question 30

Weights need to hang freely to maintain proper traction

TRUE OR FALSE

Answer 30

TRUE

Also known as skin traction, Buck traction is a non-invasive method to stabilize a fracture of the hip. The purpose of this type of traction is to maintain bone alignment and to immobilize the bone, which promotes comfort by reducing muscle spasms. A boot or wrap/straps are applied to the lower extremity and the pulleys with weights are applied to this, resulting in the needed traction.

Question 31

Risk factors and complications of high blood pressure

Answer 31

Abnormal blood pressures are higher than 120/80 mm Hg or lower than 90/60 mm Hg. Age, heart defects, diabetes, atherosclerosis, obesity, consumption of caffeine, and use of tobacco products are risk factors for hypertension.

Abnormal blood pressure can result in aneurysms, chronic kidney disease, cognitive changes, eye damage, heart attack, heart failure, peripheral artery disease, stroke, hypertensive crisis, cerebrovascular disease, kidney disease, heart failure, and sudden death.

Question 32

It is within the LPN/LVN’s scope of practice to perform a dressing change and identify normal from abnormal changes.

TRUE OR FALSE

Answer 32

TRUE

Question 33

Treating a patient with phobia

Answer 33

When assessing a client with phobias, assess for any history of past trauma or substance abuse. Ask the client about phobias and associated symptoms. Teach relaxation techniques (e.g., deep breathing, listening to music, progressive head-to-toe relaxation). Listen to the client and communicate clearly regarding concerns the client expresses. Encourage the client to use coping strategies that were successful in the past. Administer medications to decrease anxiety. Refer to a mental health counselor.

Question 34

The right neck and the flank are common areas of referred pain from liver damage, so the liver should be examined when dull pain in the anterior and posterior neck occurs.

TRUE OR FALSE

Answer 34

TRUE

The client with liver disease may experience weight loss, weakness, anorexia, edema, elevated blood pressure, presence of ascites, splenomegaly, abnormal bleeding, jaundice, pruritus, clay-colored stools, elevated ammonia levels, confusion, and altered fluid and electrolyte levels. Liver disease often results in right upper quadrant pain, but the client may experience referred pain, felt in the right flank, shoulder, or neck. The client is at risk for altered metabolism and bleeding due to impaired liver function.

Question 35

What is the difference between a tracheostomy tube and a laryngectomy tube?

Answer 35

A tracheostomy is a surgical opening to access the tracheal lumen with the entire larynx remaining intact (D). In contrast, after total laryngectomy, the trachea is brought to the skin as a stoma, which no longer has any anatomical connection with the oropharyngeal cavity and digestive tract

Question 36

The nurse monitors the progress of a client recovering at home from a laryngectomy. Which client behavior requires the nurse to intervene?

1. Uses a finger to apply water-soluble ointment around the stoma.
2. Inserts a few drops of water into the stoma every evening.
3. Leaves the stoma uncovered when taking a bubble bath.
4. Covers the stoma with a cotton scarf when outside.

View Explanation

Answer 36

1) INCORRECT – Water-soluble ointment is used to soften crusts so they can be removed more easily.
2) CORRECT – Humidification should be provided with a humidifier or nebulizer and not by inserting water into the stoma.
3) INCORRECT – Humidification would help liquefy secretions. The stoma should be covered when taking a shower to prevent water from entering the airway.
4) INCORRECT – Covering the stoma with a cotton scarf when outdoors provides protection and prevents mucus from soiling the client’s clothes.

Question 37

When conducting a postpartum assessment, the nurse should:

Answer 37

Examine breasts for engorgement and condition of the nipples. Assess the height of the uterine fundus for location and its degree of firmness. If the fundus is soft (boggy), have the client void and massage the fundus; report an unresponsive uterus to the health care provider. Note any bladder distention and auscultate for bowel sounds. Assess the amount, type, and odor of the lochia. Assess the perineum for intactness of episiotomy or laceration repair, and for bruising and edema. Assess the mother’s legs for sign of thrombophlebitis. Emotional state should also be discussed.

Question 38

A ___________uterus increases the client’s risk of bleeding after delivery, because the blood vessels at the previous site of the placenta are not closed off. A displaced uterus can occur if the bladder is ___________, and the nurse should first assess for the last time the client voided. After voiding, the nurse should reassess the status of the uterus. It may return to midline, but it may continue to be boggy, which can be addressed by _______________

Answer 38

boggy; distended; external massage.

The uterine fundus descends at a predictable rate as the muscle cells contract to control bleeding at the placental insertion site. After the placenta is expelled, the uterine fundus can be felt midline, at, or below the level of the umbilicus as a firm mass. A lateral deviation is related to a distended bladder.

Question 39

What is a situational crisis and how can the nurse respond?

Answer 39

A situational crisis is a specific event where a client is unable to cope. This may be due to ineffective coping, which leads to increased stress and decreased resources. During a crisis, there is an initial period of shock, followed by an inability to function and then a tremendous emotional response. Following a crisis, the nurse needs to create a caring, supportive environment that minimizes stressors. Teach the client relaxation techniques (deep breathing, listening to music, or progressive head to toe relaxation). Listen to the client and communicate clearly regarding concerns that the client expresses. Encourage the client to use coping strategies that were successful in the past with anxiety. Administer medications to decrease anxiety. Assist client to identify available support systems and community resources.

Question 40

Part of providing newborn care is educating parents how to perform said care and which signs and symptoms to report to the health care provider (________________________________________). Specific instruction to parents should include monitoring for ______________wet diapers per day and teaching about stool transition from thin green to ________by the third day.

Answer 40

e.g. increased respiratory rate, grunting, nasal flaring, intercostal retractions, sunken or bulging fontanelles, fever, hypothermia, severe hypo- or hyperactivity, or a moist or red umbilical cord stump

six to 10; brown

Question 41

the circumcision site of a 3-day-old newborn is covered with yellowish exudate

Is this normal finding ?

Answer 41

Yes Yellow exudate at the site of a circumcision indicates normal healing in a newborn of this age.

Question 42

A client arrives at the emergency department experiencing tingling and weakness in the lower extremities that started when getting out of bed. The client reports the symptoms seem to be progressing upward. Which statement by the client is most important for the nurse to pursue during the assessment process?

1. “My grandfather had polio when he was young.”
2. “I have been a vegetarian for several months now.”
3. “Things have been stressful at work lately.”
4. “We have been in the final preparations for a trip overseas.”

Answer 42

1) INCORRECT – These symptoms are not characteristic of polio. Furthermore, polio is an infectious disease, not an inherited condition.
2) INCORRECT – There may be some deficiencies in the diet if the client is not knowledgeable about how to select appropriate foods. However, vitamin deficiencies are unlikely to cause the symptoms being described.
3) INCORRECT – While a concern, this is not the most important statement for the nurse to evaluate. Stress can cause or exacerbate almost any symptoms, and psychologically, people sometimes develop conversion disorders to keep themselves away from the stressful situation. However, the nurse should first explore a physical cause of the symptoms.
4) CORRECT – This needs immediate further investigation. Immunizations may have been given in preparation for this trip and an immunization could trigger the onset of the neurologic symptoms of Guillain-Barré syndrome. The symptom onset in Guillain-Barré is usually abrupt and can progress rapidly. Symptoms often, but not always, progress in an ascending direction (from feet toward head). It is an emergency condition. The most immediate concern is potential respiratory compromise from respiratory muscle weakness.

Question 43

Knowing that Guillain-Barré syndrome occurs in an _____________fashion helps the nurse predict what will be affected next and to intervene proactively.

Answer 43

ascending

Initial symptoms of Guillain-Barré syndrome (GBS) include weakness and strange neurological sensations in the legs bilaterally. If the client reports strange sensations and weakness in the upper legs, the nurse suspects the nerves that provide bladder control will be affected next. At this point, placement of an indwelling catheter is indicated. Phrenic nerve demyelination may result in a poor respiratory pattern or hiccups, alerting the nurse to impending respiratory failure.

Guillain-Barré syndrome is an autoimmune disorder that manifests as an acute inflammatory polyneuropathy. Assess cranial nerve function with attention to facial expression, speech, and gag and swallowing reflexes. Mechanical ventilation may be required. Plan for prevention of health alterations resulting from immobility (e.g. pressure injuries, deep vein thrombosis, and paralytic ileus) and address psychological concerns arising from increasing dependency and loss of function. Administer anticoagulant therapy as prescribed. Apply antiembolism stockings and sequential compression devices to prevent deep vein thrombosis. The client may show signs of recovery within 4 weeks, but complete recovery may take several months.

Question 44

What kind of diet is needed for a client with full thickness burns ?

Answer 44

a high-calorie, high carbohydrate high-protein diet is needed.

The client with a significant burn injury needs to eat frequently throughout the day and pack as much nutrition into every meal as possible. Empty calories are found in cakes, sports drinks, and sodas. These are avoided. High fat foods increase systemic inflammation and are also avoided. The client needs high calories, high carbohydrate, and high protein to sustain the higher metabolism needs for approximately the first year after a burn

Question 45

The mortality rate of pancreatitis may exceed 20% or more in the presence of infected pancreatic necrosis and is largely related to sepsis and multiorgan failure.

What is the key intervention to cure necrotizing pancreatitis ?

Answer 45

Antibiotics are the key intervention to cure necrotizing pancreatitis,

the client can experience sepsis and death if a therapeutic medication level is not maintained.

Question 46

The scope of practice for the UAP includes standard and unchanging procedures for a stable client. Procedures that require assessment or nursing judgment cannot be delegated.

TRUE OR FALSE

Answer 46

TRUE

Question 47

After the nurse assesses the assigned clients, which activity does the nurse delegate to the unlicensed assistive personnel (UAP)?

1. Complete tracheostomy care.
2. Provide oral suctioning using a Yankauer suction tube.
3. Change the appliance of a new colostomy.
4. Obtain a wound culture from a leg ulceration.

Answer 47

After the nurse assesses the assigned clients, which activity does the nurse delegate to the unlicensed assistive personnel (UAP)?

1. Complete tracheostomy care.
2. Provide oral suctioning using a Yankauer suction tube.
3. Change the appliance of a new colostomy.
4. Obtain a wound culture from a leg ulceration.

View Explanation

The correct answer is 2 . You answered 4.

Explanation

Step-By-Step Walkthrough

1) INCORRECT – Completing tracheostomy care requires knowledge of sterile technique and potential problem-solving skills. As such, this skill must be performed by the nurse or respiratory therapist.
2) CORRECT – Providing oral suctioning using a Yankauer suction tube can be delegated to the UAP, for this is not a sterile procedure.
3) INCORRECT – Due to the need to assess the stoma and surrounding skin, the care associated with a new colostomy should not be delegated to the UAP.
4) INCORRECT – Obtaining a wound culture requires application of sterile technique and knowledge of wound healing. Therefore, the task should not be delegated to the UAP.

The scope of practice for the UAP includes standard and unchanging procedures for a stable client. Procedures that require assessment or nursing judgment cannot be delegated. Tracheostomy care is a sterile procedure that requires assessment and evaluation of the airway, so this should not be delegated to the UAP. Care of an established colostomy could be delegated to the UAP, but this is a new colostomy and requires assessment and evaluation. Obtaining a wound culture requires assessment of the wound bed and requires the use of sterile technique. Oral suctioning is a safe procedure that does not require sterile technique, so this could be delegated to the UAP.

Question 48

Familial hypercholesterolemia vs High Cholesterol

Answer 48

Genetic mutations can alter the way the liver removes excess cholesterol. Familial hypercholesterolemia (FH) and high cholesterol differ in that FH has a genetic component. Compared to an elevation in cholesterol due to modifiable dietary factors or lifestyle choices, FH is more difficult to treat and is associated with a higher risk for major complications, including heart disease and premature death. Most individuals with FH require treatment with medication, as changes in diet and lifestyle will not sufficiently reduce blood lipid levels. Further assessment by the health care provider is needed to determine whether the client is experiencing high cholesterol or FH.

Content Refresher

Risk factors for the development of hypercholesterolemia include a family history, a diet high in fat, and a sedentary lifestyle. Anticipate blood being drawn for laboratory tests, including total cholesterol, high density lipoproteins (HDL), low density lipoproteins (LDL), and triglycerides. Review dietary habits and suggest foods low in cholesterol if indicated. Encourage exercise and weight reduction if the client is overweight. Educate the client about potential complications associated with elevated cholesterol, including hypertension, coronary artery disease, myocardial infarction, and stroke.

Question 49

Statins should not be taken during pregnancy

TRUE OR FALSE

Answer 49

TRUE

Statin medications are classified as pregnancy risk category X and should not be taken during pregnancy.

Question 50

What to remember about autism

Answer 50

Autism is also known as autism spectrum disorder and is considered to be a neurodevelopmental disorder. It is diagnosed based on delayed communication development and poor social interactions along with repetitive behaviors. When caring for a client diagnosed with autism spectrum disorder , the nurse should establish a trusting nurse-client relationship. Additionally, the nurse should provide a safe environment, maintain the client’s routines (such as nap time and bedtime), and implement behavioral interventions and modifications that promote positive behaviors.

Question 51

What to remember about breast cancer, including risk factors

Answer 51

Breast cancer may present with a hard lump, thickening, or deformity in the breast, which may be detected through breast self- examination. If an abnormality is detected during breast self-examination, the client should see the health care provider for further examination, which is likely to include scheduling a mammogram. If undetected, a malignant lump in the breast may spread to the lymph nodes and to other organs in the body.

risk factors for breast cancer include early menstruation (before 12), late menopause (after 55), and Caucasian race, over the age of 50, personal history of breast cancer, having a mother, sister or grandmother with breast cancer, and first birth after age 30

Many of the risk factors for breast cancer are directly related to prolonged or increased estrogen exposure. Late menopause, early menstruation, and nulliparous women are all at higher risk. However, clients who have had breast cancer are at risk for recurrence of that particular cancer, with the highest risk considered to be during the first 5 years after remission. Clients who have had chemotherapy or radiation for any cancer are also at increased risk of developing cancer of any kind. Secondary cancers are especially common in children who had cancer.

Question 52

For any client, a fever over 101°F or urine output less than 30 mL per hour is a reason to notify the health care provider

TRUE OR FALSE

Answer 52

TRUE

Question 53

What to remember about Transurethral resection of the prostate

Answer 53

Transurethral resection of the prostate (TURP) is the most common surgical procedure to treat benign prostatic hyperplasia (BPH). Following surgery, monitor for deficient fluid volume that may result from bleeding, possible infection, increased pain, and TURP syndrome (a life-threatening condition that results from absorption of bladder irrigation fluid). Hemorrhage is the greatest danger following TURP. While pink-tinged urine with occasional clots is expected, the client should not have sanguinous drainage, as it suggests hemorrhage. Determining whether the client is bleeding will be difficult when the collection bag is full of urine, irrigation solution, and blood. The nurse is concerned when unmistakable, concentrated red blood is noted, indicating a site of hemorrhage. Decreased urine output can indicate hemorrhage, catheter blockage, or other complications.

Monitor vital signs. Maintain continuous bladder irrigation (CBI) and ensure drainage tubing and urinary bag are free of kinks and clots. Observe urine for color and adjust continuous irrigation to ensure urine is clear to light red or pink. After 1 or 2 days post-operatively, bleeding will slow or stop and the CBI can be discontinued. Monitor the client’s voiding after catheter removal.

Question 54

What is the purpose of continous bladder irrigation ?

Answer 54

Continuous bladder irrigation (CBI) is used to reduce the risk of clot formation and maintain indwelling urinary catheter (IUC) patency by continuously irrigating the bladder via a three‑way catheter.

It flushes sterile fluid through your catheter and into your bladder. Bladder irrigation helps remove and prevent blood clots in your bladder

Question 55

What is Epinephrine ?

Answer 55

Epinephrine is a vasopressor that is used to maintain cardiovascular function. Vasopressors act on the blood vessels and induce vasoconstriction to raise blood pressure.

It is used off-label to help maintain an adequate heart rate and rhythm.

Question 56

Life-threatening dysrhythmias result in ___________________________. ____________________ is the primary treatment for dysrhythmias. Following medication administration, assess the client for signs of increased perfusion, increased level of consciousness, and vital signs.

Answer 56

lowered cardiac output or the inability to maintain adequate perfusion; Antidysrhythmic medication adminstration

Question 57

A primary nursing intervention for pneumonia is promoting ________________________-.

Answer 57

alveolar expansion; When the client takes in a deep breath, the alveoli expand and the air can move around the mucus, helping to propel it out of the alveoli and up to the airway for expectoration.

Question 58

What to remember about Cholecystitis?

What kind of diet is needed ?

Answer 58

The gallbladder stores bile. Inflammation or stones change how the stored bile is released, causing it to be released directly into the intestines instead of when it is needed to digest fat. Bile in the intestines causes a laxative effect. Fat without bile is mostly undigested and causes diarrhea, as well. The client must limit fat intake to avoid significant gastrointestinal discomfort.

The client diagnosed with cholecystitis should consume a low-fat, low-carbohydrate, and high-protein diet.​

Cholecystitis is inflammation of the wall of the gallbladder. It is usually associated with obstruction related to the presence of gallstones or biliary sludge. However, it can occur alone as a result of fasting, prolonged parenteral nutrition, diabetes mellitus, infection, or serious illness. The gallbladder stores bile made by the liver. Bile helps digest fat. Bile moves from the gallbladder to the small intestine through the cystic duct and the common bile duct. Observe for indigestion, clay-colored stools, fever, jaundice, palpable gallbladder, dyspepsia, colicky pain in right upper quadrant of abdomen, and abdominal distention, which may indicate internal bleeding.

Question 59

On occasion, the nurse finds that an electric IV programmable infusion pump is not available, such as during an overwhelming community crisis. The_________________- for any infusion tubing is listed on the tubing label. Administering IV medications by gravity requires an IV pole and a tubing set with a roller clamp. The nurse adjusts the roller clamp in order to set the infusion at the appropriate rate, and the IV pole may need to be raised and lowered as well during this process. It is important to administer medications at an acceptable rate to avoid causing harm to the client.

Answer 59

drop factor

Question 60

Procedure for a client who is choking

Answer 60

The nurse should recognize the universal sign for choking: hands clutched to the throat.

The nurse should ask if the client can speak or cough. If the client can do either, the client has a partial airway obstruction. The client should be encouraged to cough to dislodge the foreign body.

Once a choking client has been identified, the nurse or bystander should immediately call for help (e.g., call 911 in the community). A trained first responder may perform abdominal thrusts (i.e., Heimlich maneuver). To perform the Heimlich maneuver on an adult client, the nurse should stand behind the client and place one foot slightly in front of the other foot for balance. Next, wrap arms around the client’s waist and tip the client slightly forward. Then, make a fist with one hand and position it slightly above the client’s navel. Grasp the fist with the other hand. Finally, press hard into the abdomen with a quick, upward thrust, as if trying to lift the person up. Perform six to ten abdominal thrusts until the blockage is dislodged or until the client loses consciousness.

For the conscious adult choking victim, assess the client’s cough effort and signs of poor air exchange (e.g., cyanosis or respiratory distress). If a complete airway obstruction is present, provide abdominal thrusts until the object is expelled or the victim becomes unresponsive. For the unconscious adult choking victim, activate the emergency response system. Initiate cardiopulmonary resuscitation (CPR), starting with compressions. Look for the object each time before giving breaths. Remove the object with fingers if it is visible and can be removed easily. However, never perform a blind finger sweep.

Question 61

A client who is unresponsive, not breathing, and has no heart beat requires immediate _____________________________.

Answer 61

cardiopulmonary resuscitation (CPR).

Nurses and other health care providers will be prepared to provide CPR. When providing chest compressions, proper technique is required to prevent injury to the ribs, lungs, and xiphoid process and to ensure effectiveness of the compression. The nurse should place the heel of one hand over the lower third of the client’s sternum, place the other hand directly on top of the other hand, straighten the arms, and compress the chest. Any deviation from this technique alters the effectiveness of resuscitation efforts.

Question 62

For the infant client, it is essential to instruct the parents to always mix a medication with formula or food

TRUE OR FALSE

Answer 62

FALSE

For the infant client, it is essential to instruct the parents to never mix a medication with formula or food unless specifically instructed to do so. This can alter the medication ’s action, the client might not consume the entire dose, or the client may begin refusing the food or formula.

Question 63

The cranial nerves IX and X control ___________________________. To test these nerves, the nurse will need something to touch the back of the client’s throat, such as a tongue depressor, and a flashlight to watch the _____________rise in the back of the throat when swallowing.

Answer 63

swallowing function and the gag reflex; uvula

Question 64

What is butorphanol tartrate ?

Answer 64

an opioid analgesic.

can produce the following central nervous system effects: cough suppression, miosis, nausea/vomiting, respiratory depression, and sedation. When providing care to a client who is prescribed any opioid analgesic, the nurse must monitor for respiratory depression as this can quickly escalate to a medical emergency (i.e., respiratory arrest) if not promptly treated. In the event of a butorphanol tartrate overdose manifested by respiratory depression, naloxone should be considered. Repeat dosing with naloxone may be required because butorphanol tartrate’s duration of action usually exceeds naloxone’s duration of action.