Question Trainer 1 Remediation Flashcards
1
Q
true or false
the type of stroke can be determined solely based on manifestations
A
FALSe
manifestations of different types of stroke are similar and therefore it is critical to determine the type of stroke occuring; the type cannot be determined solely based on manifestations and the correct and appropriate treatent for the stroke type must be initiated
2
Q
the type of stroke needs to be determined within a certain time frame after arrival in order for timely treatment to begin
TRUE OR FALSE
A
TRUE; Time is of the essence when providing care to a client who experiences an ischemic stroke, as thrombolytic therapy is only effective for a certain time frame once symptoms begin (4.5 to 6 hours). This is the priority assessment question, as thrombolytic therapy can restore circulation for this client.
3
Q
How is the type of stroke usually identified ?
A
Usually done using imaging such as a CT scan
4
Q
Different between bone marrow aspiration and biopsy
A
The two procedures are often done together. They differ in the specific content of the bone marrow they remove
Bone marrow has a fluid portion and a more solid portion. In bone marrow biopsy, your doctor uses a needle to withdraw a sample of the solid portion. In bone marrow aspiration, a needle is used to withdraw a sample of the fluid portion.
Risks include infection, bleeding, penetration of the breastbone which can cause heart or lung problems, or long lasting discomfort at the biopsy site.
The sternum may be used for bone marrow aspiration. However, there is not enough marrow available in the sternum for a biopsy.
The procedure can be done at the bedside or in the operating room
5
Q
Therapeutic Communication Do’s
A
Do respond to feeling tone.
Do provide information.
Do focus on the client.
Do use silence.
Do use presence.
6
Q
What is the prioroty assessment in the unconscious client ?
A
The airway, as increases in arterial carbon dioxide levels will increase intracranial pressure
7
Q
___________________communication often causes fatigue for the client diagnosed with MS.
A
Verbal
the client is taught to make important points first prior to the onset of fatigue.
8
Q
A
Impaired balance or coordination
9
Q
Enteral tube feedings should be administered if bowel sounds are absent.
TRue or false
A
FALSE
Feedings should not be administered if bowel sounds are absent
10
Q
For gastrointestinal tube feedings, we do not hang more solution that is required for a _________________ hour period
A
4
This is done to reduce the risk of bacterial growth
11
Q
The gastrostomy tube should be rotated 360 degrees daily to reduce the risk of skin irritation and breakdown.
TRUE OR FALSE
A
TRUE
12
Q
We should check for slight in-and-out movement of the gastrostomy tube.
TRUE OR FALSE
A
TRUE
A slight in-and-out movement indicates that the gastrostomy tube is not embedded in the wall of stomach
13
Q
a common and disabling condition following brain damage in which patients fail to be aware of items to one side of space. Neglect is most prominent and long-lasting after damage to the right hemisphere of the human brain, particularly following a stroke. Such individuals with right-sided brain damage often fail to be aware of objects to their left, demonstrating neglect of leftward items.
A
Unilateral neglect syndrome
14
Q
The client who is recovering from a stroke may have a short attention span or visual difficulties, making reading with comprehension a difficult task. The nurse should provide verbal instructions with _______________________.
A
short sentences.
15
Q
During DKA, osmotic diuresis occurs and the client is at significant risk for ___________________–
A
fluid volume deficit.
16
Q
decreased circulation is a _______________-for anti-embolism stockings
Venous thromboembolism is a ________________for anti-embolism stockings
A
contraindication; contraindication
17
Q
The best indication of peripheral arterial disease and circulation to extremities is to monitor the client’s _____________________-
A
pedal pulses
18
Q
Vital signs should be within ___________—of preprocedure values
A
20%
19
Q
Anesthesia nursing considerations
A
vital signs every 15-30 minutes
20
Q
An involuntary eye movement which may cause the eye to rapidly move from side to side, up and down, or in a circle, and may slightly blur vision
A
Nystagmus
21
Q
a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back.
A
hirsutism
22
Q
overgrowth of gum tissue around the teeth.
A
gingival hyperplasia
can be an adverse effect of phenytoin sodium
23
Q
Metoclopramide
A
antiemetic; cab be given 30 minutes before antineoplastic agents such as Cisplatin
24
Q
Expected findings for Rheumatoid arthritis
A
joint swelling, stiffness and pain
elevated ESR
anemia
joint deformities, muscle atrophy, and decreased range of motion in affected joints
positive rheumatoid factor
25
exacerbations of rheumatoid arthritis occur
during periods of physical or emotional stress and fatigue
26
rheumatoid arthritis weakens the \_\_\_\_\_\_\_\_\_\_\_\_, leading to dislocation and permanent deformity of the \_\_\_\_\_\_\_\_\_\_\_\_\_
joint
27
this is the speed at which RBC settle in well-mixed venous blood. Higher levels indicate inflammation
what are normal values ?
Erythrocyte sedimentation rate
males less than 50 yrs: less than 15 mm/hr
males greater than 50 years: less than 20 mm/hg
female less than 50 years: less than 25 mm/hr
females greater than 50 years: less than 30 mm/h
28
one contraindication of Etanercept to remember
active infection
Etanercept is an antiarthritic agent
29
Any heat source, including hot baths and electric blankets, will increase the absorption of medication through the skin
TRUE OR FALSE
TRUE
30
A fever increases absorption of medication through the skin
TRUE OR FALSE
TRUE
31
When providing care for a client diagnosed with acute kidney injury, it is important for the nurse to monitor circulation by reviewing the client's \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-, which is a good indicator of fluid volume.
urine specific gravity
32
this is a urine test that measures the ability of the kidneys to concentrate urine
what is the normal range
**Urine specific gravity**
**1.005-1.030**
a higher specific gravity reflects more concentrated urine
a lower specific gravity reflects a less concentrated urine (this could indicate renal disease or the kidney's inability to concentrate urine)
33
The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings for this client?
Hypotension, low back pain, fever, nausea/vomiting
34
The health care provider prescribes an increase in the parenteral nutrition (PN) infusion rate from 50 mL/hour to 100 mL/hour. The PN is infusing through a peripherally inserted central catheter (PICC) device. Which is the priority action for the nurse?
**Parenteral nutrition is hyperosmolar and will pull fluid into the intravascular space, thereby causing osmotic diuresis.** Fluid volume affects the ABCs (airway, breathing, circulation). Therefore, **monitoring urine output** is the priority nursing action.
35
this is the rapid emptying of the gastric contents into the small intestine that occurs following gastric resection
Dumping syndrome
36
Dumping syndrome symptoms
nausea/vomiting
feelings of abdominal fullness and abdominal cramping
diarrhea
palpitations & tachycardia
perspiration
weakness/dizziness
Borborygmi (loud gurgling sounds resulting from bowel hypermotility)
37
Client Education: Preventing Dumping Syndrome
avoid sugar, salt and milk
eat a high protein, high fat, **low carbohydrate diet**
**eat small meals and avoid consuming fluids with meals**
**lie down after meals**
take antispasmodic medications as prescribed to delay gastric emptying
38
During a urinary bladder catheter insertion, with a size 16 French catheter on an older adult male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take?
Stop the insertion and instruct the client to take deep breaths.
Instructing the client to take deep breaths will relax the urethral muscles and facilitate passage through the prostate gland
39
When drawing blood from a PICC line, what are appropriate guidelines.
discard 3 to 5 mL of blood prior to obtaining the sample in order to prevent contamination of the blood sample with IV fluids or medications.
A 10 mL syringe is recommended to reduce pressure on the lumen of the PICC line during the flush
Clean gloves are used when drawing blood from a PICC line
The push-pause technique reduces the risk of clot formation and damage to the PICC line.
40
The nurse expects how many ml of water in the water seal chamber of the chest tube
2 cm
41
\_\_\_\_\_\_\_\_\_\_\_\_\_\_-gloves are used for tracheostomy suctioning
Sterile
42
In order to ensure the client does not experience\_\_\_\_\_\_\_\_\_\_\_\_\_\_ during tracheostomy suctioning, the nurse \_\_\_\_\_\_\_\_\_\_\_\_\_the client before and after each time the airway is entered for suctioning.
hypoxia; hyperoxygenates
43
Which position is ideal for tracheostomy suctioning?
**A semi-Fowler,** not high-Fowler, **position is ideal for this client during tracheostomy suctioning.**
44
Elevating the head of the bed will allow for a \_\_\_\_\_\_\_\_\_\_\_\_-
more open airway.
45
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is the earliest indication of poor cardiac output.
A change in LOC and/or alertness
46
How to care for an evisceration following surgery?
Cover the area with sterile gauze soaked in normal saline
**immediately cover the site with a sterile dressing soaked with normal saline and contact the health care provider.**
47
The use of "why" questions is not therapeutic
TRUE OR FALSE
TRUE
48
The client with altered mental status is at risk for aspiration, TRUE OR FALSE
TRUE
49
The nurse provides care for a client who is prescribed assist-control mechanical ventilation with positive end-expiratory pressure (PEEP) of 5 cm H 2O. Which actions will the nurse include in the client's plan of care?
Changing client position every 2 hours to reduce risk of atelectasis, pneumonoia and skin breakdown
strict handwashing before suctioning to prevent VAP
Administering Pantoprazole (will decrease the risk of aspiration of gastric contents)
Elevate head of bed at least 30 degrees
oral care and teeth brusing should be done at least every 8 hours
50
dysphonia
muffled voice
51
Do all unemancipated minors presenting to the ED for treatment require guardian consent for treatment?
**NO**
Unemancipated minors may consent to medical treatment if they have specific medical conditions (i.e. pregnancy, pregnancy-related conditions, minor treatment for custodial child, sexually transmitted infection information and treatment, substance abuse treatment, and mental health treatment).
Depending on why the minor is seeking treatment, guardian consent may not be necessary and could breach HIPAA (Health Insurance Portability and Accountability Act) guidelines.
52
The nurse works on the medical surgical unit. The nurse-to-client ratio is 1:10. Which action does the nurse take first?
1. Document the situation in writing.
2. Refuse the client assignment.
3. Delegate tasks to the LPN/LVN.
4. Notify the nursing supervisor.
**Notify the nursing supervisor**
This is the priority action, as the nurse-to-client ratio is proportionately high. This action alerts the nursing supervisor of the situation so nurses can be "floated" from other departments, if available.
The nurse maintains responsibility for client outcomes. The problem is nurse-to-client ratio. Therefore, the nursing supervisor can provide more staffing, if needed.
**notifying the supervisor is the priority**. The nurse should provide the documentation to the nursing administrators, but **the documentation does not relieve the nurse of responsibility if clients suffer harm because of inattention**
53
Fetal heart tones cannot be heard with Doptone until \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_weeks gestation.
8-12
54
this is postpartum discharge from the uterus that consists of blood from the vessels of the placental site and debris from the decidua
Lochia
Lochia rubra - bright red discharge that occurs from day of birth to day 3
Lochia serosa- brownish pink discharge that occurs from days 4-10
Lochia Alba- white discharge that occurs from days 11-14
Discharge decreases daily in amount
55
The competent client has the right to make personal choices without interference.
TRUE OR FALSE
TRUE
56
The nurse completes documentation for a client and realizes the entry has been placed in the wrong client's medical record. Which action by the nurse is most appropriate
2.Draw a single line through each line of the incorrect entry and write a new note explaining what occurred.
Draw 1 line through the error, initial and date
57
The nurse provides care for an adolescent client reporting arm pain after a fall. The nurse notes bruising in multiple stages of healing. The nurse accesses the client's medical record and notes the client was treated twice last month for reported back pain after two separate falls. The client was treated two months ago for a perforated eardrum. Which action by the nurse is the priority?
Contact social services
The adolescent client's history suggests that there may be abuse. ***The law mandates that the nurse report known or suspected child abuse by collaborating with social services and law enforcement.*** Therefore, this is the priority action.
While the nurse should assess the client's anxiety level, a professional assessment of the client's situation takes priority over psychosocial nursing actions.
58
Individuals who have a BMI lower than \_\_\_\_\_\_\_\_\_\_\_\_\_\_--are at increased risk for problems associated with poor nutritional status.
18.5
**a low BMI is associated with higher mortality rate among hospitalized clients.**
59
Individuals who experience spousal \_\_\_\_\_\_\_\_\_\_\_\_\_\_often accept blame, become compliant, and feel helpless
abuse
60
Herpes Zoster is also known as \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
It is contagious to anyone who has not had __________________ or who is \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-
What kind of infection precautions do we take ?
Shingles; chickenpox; immunosuppressed
Contact precaution
61
The nurse must verify the client's \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_before administering medications
identity
62
Older adult clients need visual examinations every \_\_\_\_\_\_\_\_\_\_\_\_\_--years
1 to 2
63
safety and infection control : the priority is to prevent the spread of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
contamination
64
Restraints should be discontinued as soon as the client becomes
alert and oriented
65
A client with an endotracheal tube requires suctioning. How should it be done?
insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion
never suction longer than 10–15 seconds
2) use twirling motion when withdrawing catheter
suction is never applied when catheter is inserted
Hyperoxygenates the client before and after
66
attributing one’s thoughts or impulses to another
projection
67
shifting of emotion concerning person or object to another neutral or less dangerous person or object)
displacement
68
shifting of emotion concerning person or object to another neutral or less dangerous person or object)
sublimation
69
incorporation of someone else’s opinion as one’s own
internalization
70
attempt to make behavior appear to be the result of logical thinking
rationalization
71
excessive reasoning or logic used to avoid experiencing disturbing feelings
intellectualization
72
development of conscious attitudes and behavior patterns into opposite of what one really wants to do
reaction formation
73
something represents something else)
symbolization
74
By 6 months, the infant should be able to
sit with support
roll from back to abdomen
play peek a boo
75
tactile stimulation can cause _____________ in the patient with a spinal cord injury
autonomic dysreflexia
76
anytime time you get poor perfusion to the kidneys you are going to get ...............
flank pain
77
what is the outcome of giving fluids to someone with nausea?
vomiting
78
A competent client has the right to determine their own care. This is an important concept on the NCLEX.
TRUE OR FALSE
TRUE
79
when can you treat a minor without parental consent ?
STD, abuse situations, pregnancies, emergencies, mental health
80
an incident report goes into the clients medical record.
TRUE OR FALSE
FALSE
an incident report does **not go into the clients medical record**
81
When we have potential abuse – our priority is the \_\_\_\_\_\_\_\_\_\_\_\_\_\_-of our client. We are required by law to report the potential abuse.
physical safety
82
**A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure?**
1. Inserts the suction catheter 4 in into the tube. Applies suction for 30 seconds, using a twirling motion as the catheter is withdrawn.
2. Hyperoxygenates the client. Inserts the suction catheter into the tube, and suctions while removing the catheter in a back and forth motion.
3. Explains the procedure to the client. Inserts the catheter gently while applying suction, and withdraws using a twisting motion.
4. Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn.
1) catheter is inserted until resistance is met; never suction longer than 10–15 seconds
2) use twirling motion when withdrawing catheter
3) suction is never applied when catheter is inserted
4) CORRECT — **insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion**
83
What is the primary purpose of range of motion exercises ?
to assist someone in being able to carry out activities of daily living
84
Fetal Alcohol Syndrome - what to know
leading cause of mental deficiencies in children. **100% preventable**. Results from consuming high levels of alcohol in pregnancy. **There is no safe level of alcohol consumption during pregnancy**
Intellectual & Motor Deficiencies
Thin Upper Lip
Epicanthal Folds
Maxillary Hypoplasia
Small for Gestational Age
Microcephaly
hearing disorders
**We should swaddle infant at birth and decrease environmental stimuli.** We should administer sedatives to decrease symptoms of withdrawal. We should monitor infant's weight gain. We should promote nutritional intake.
85
True or false. The renal threshold for glucose is decreased in the elderly.
FALSE
The renal threshold for glucose is increased in the elderly.
The level at which urine starts to appear in the urine increases, leading to false-negative readings. This resluts in elevated blood glucose levels.
86
TRUE OR FALSE
For ultrasound, a client must drink fluid prior to test, have full bladder to assist in clarity of image.
What interferes with imaging ?
TRUE
Bone, gas, air, fluid interfere with imaging.
87
This is the removal of amniotic fluid for evaluation
Amniocentesis
Not performed earlier than 14 weeks
best performed between 15-20 weeks of pregnancy because amniotic fluid volume is addequate and man viable fetal vcells are present in the fluid by this time
88
fetal ultrasound detects the\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
size, growth patterns, and gestational age
89
Instructions in caring for the child with lice
an infestation of the hair and scalp with lice
transmitted by direct and indirect contact
hair should be combed daily with a nit comb. Should then be discarded or soaked in boiling water for 10 minutes
grooming items should not be shared
bedding and clothing used by the child should be changed daily, laundered in hot water with detergent and dried in a hot dryer for 20 minutes. This process should continue for 1 week
Child should not share clothing, headwear, brushes or combs
Furniture and carpets need to be vacuumned frequently
90
What position should the client receiving an enema be placed in ?
Sim's position
## Footnote
This allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution
91
Enema administration- for adults the tube should be inserted no more than _________ inches, _______ inches for the child and \_\_\_\_\_\_\_\_\_\_inche for the infant
3-4; 2-3; 1-1.5
92
This is the instillation of solution in the rectum and sigmoid colon in order to promote defecation by stimulating peristalsis
Enemas
93
Enemas should not be administered in the presence of
abdominal pain, nausea, vomiting or suspected appendicitis
94
Antipsychotic medications commonly produce\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ symptoms as side effects
extrapyramidal
95
inadequate airway clearance is the top priority for clients with a tracheostomy because \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**loss of the upper airway increases the amount and viscosity of secretions**
96
What is hypoparathyroidism?
The parathyroid glands secrete less parathyroid hormone in the blood and there are decreased serum calcium levels in the blood
The parathyroid glands are located posterior to the thyroid glands
97
What does parathyroid hormone do ?
It maintains serum calcium levels and serum phosphate levels
When calcium levels decrease, phosphate increases. There is an inverse relationship.
Decreased calcium levels lead to increased irritability of nerves & muscles
98
What will the nurse expect to observe in hypoparathyroidism?
basically the symptoms of hypocalcemia
Neuromuscular Irritability: Twitching
Increased Deep Tendon Reflexes
Tremors
Positive Chvosteks sign
Positive Trousseau's sign
Numbness & Tingling of Extremities
Disorentiation & Confusion
99
the lower the serum calcium, the greater the risk for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
seizures
100
Vitamin D enhances the absoprtion of __________ from the GI tract
calcium
101
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-is most important reason for fetal monitoring
fetal well-being
102
intellectually delayed client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent _________________ and \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
overdose and underdose
103
Predisposing factors for pregnancy induced hypertension
Large fetus
Older than 35 years, younger than 17 years
Primigravida
Multiple fetuses
Poor nutrition
history of diabetes, renal or vascular disease
Family History
104
Mild preeclampsia begins past the _____________ week of pregnancy
When assessing the client, the nurse will observe a blood pressure of greater than\_\_\_\_\_\_\_\_\_-
The client will also have 2+, 3+ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
20th; 140/90; proteinuria
105
Assessment for severe preeclampsia
BP \>160/110
4+ proteinuria
headache
epigastric pain
pulmonary edema
hyperreflexia
106
infection of the dermis and underlying hypodermis
Cellulitis
assessment notes **pain & tenderness, erythema & warmth, edema, fever**
107
The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication?
1. Inability to talk.
2. Loss of the gag reflex.
3. Inability to open the affected eye.
4. Corneal abrasion.
1) may occur, but nursing care cannot prevent it
2) may occur, but nursing care cannot prevent it
3) may occur, but nursing care cannot prevent it
**4) CORRECT — client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect the eye**
108
This cranial nerve controls movement of the face and taste sensation
Facial Nerve
Cranial Nerve VII
109
Instruct the clinet taking lithium to maintain a fluid intake of _________ glasses of water a day and an adequate _________ intake to prevent lithium toxicity
6-8; salt
110
Symptoms of lithium toxicity begin to appear when the serum lithium level is ________________ mEq/L
1.5-2
111
therapeutic lithium levels
0.6-1.2 mEq/L
112
early signs of lithoum toxicity
fine motor tremors
nausea & vomiting
diarrhea
113
This is when a portion of the stomach herniates through the diaphragm and into the thorax
Hiatal hernia
114
a full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn
TRUE OR FALSE
TRUE
This is why in a client with reflux food and fluids should be withheld just before going to bed
115
When are solid foods started in the infant ?
usually started between 4-5 months of age
infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast-fed infants may be started on solids even later
116
The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process?
Elderly adults engage in less activity and have decreased GI muscle tone.
**reduced gastrointestinal motility due to decreased muscle tone**, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, **adverse effect of medications**, emotional problems, **insufficient fluid intake**, and excessive dietary fat
117
This type of play is characteristic of an infant?
Solitary
118
This type of play is characteristic of a toddler ?
Parallel play
119
This type of play is characteristic of 4 year olds ?
Associative play
The child requires regular socialization with mates of similar age
120
What is Addison's disease?
This is the **hyposecretion of adrenal cortex hormones** (glucocorticoids & mineralocorticoids) from the adrenal gland, resulting in deficiency of the corticosteroid hormones. The condition is fatal if left untreated
121
The abrupt withdrawal of corticosteroids can lead to acute ___________ disease
Addison's
122
Decreased glucocorticoids lead to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Decreased mineralocorticoids (like aldosterone) lead to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Decreased androgens lead to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
decreased stress & immune response
decreased sodium & water retention
decreased male sex characteristics
123
An Addisonian crisis can be caused by
stress, infection, trauma, surgeryor abrupt withdrawal of exogenous corticosteroid use
124
Signs and Symptoms of Addisonian Crisis
Remember the 5’S & 3 H’s
**Super low blood pressure** (nothing will bring it up)
**Sudden pain in stomach, back, and legs**
Syncope (going unconscious)
**Shock**
Severe vomiting, diarrhea and headache
**Hyponatremia**
**Hyperkalemia**
**Hypoglycemia**
125
assessment of someone in Addisonian Crisis
severe headache
severe abdominal, leg, or lower back pain
generalized weakness
irritability and confusion
**severe hypotension**
**shock**
126
Adrenal crisis in a nutshell is extremely low \_\_\_\_\_\_\_\_\_\_\_\_levels.
CORTISOL
127
Key Players in Adrenal Crisis:
**Adrenal Cortex: produces CORTISOL**
Pituitary Gland (anterior): regulates CORTISOL production by releasing ACTH (adrenocorticotropic hormone)…when this is released it causes the adrenal cortex to release cortisol.
CORTISOL: a steroid hormone which is a glucocorticoid know as the “STRESS Hormone” . **This helps the body deal with stress such as illness or injury by increasing blood glucose though glucose metabolism**, breaking down fats, proteins, and carbs, and regulating electrolytes.
128
Nursing management of Adrenal Crisis
Administer some cortisol STAT via fastest route which is IV!!
Most commonly prescribed is Solu-Cortef **“hydrocortisone”**, along with IV fluids which will help replenish sodium and glucose (D5NS).
Start on PO glucocorticoids and mineralocorticoid:**For replacing cortisol: ex: prednisone, hydrocortisone**
Education: patient to report if they are having stress such as illness, surgery, or extra stress in life…… will need to increase dosage, take medication exactly as prescribed….don’t stop abruptly without consulting with md.
For replacing aldosterone: **Fludrocortisone aka Florinef**
Education: consuming enough salt..may need extra salt
Watch sodium, potassium and glucose levels and ensure clean environment to prevent infection
129
For those with Addison's disase, ____________________ will need to be increased during times of stress
corticosteroid replacement
130
Addison's disease symptoms
lethargy, fatigue, and muscle weakness
gastrointestinal disturbances
weight loss
menstrual changes in women; impotence in men
hypoglycemia, hyponatremia
hyperkalemia; hypercalcemia
hypotension
hyperpigmentation of skin (bronzed) with primary disease
131
What is the fourth stage of labor ?
***This is the period 1-4 hours after birth and the delivery of the placenta***
The blood pressure returns to prelabor level
The pulse is slightly lower than during labor
**The fundus remains contracted, in the midline, 1 or 2 fingerbreadths below the umbilicus**
**Perform maternal assessments every 15 minutes for 1 hour, every 30 minutes for 1 hour and hourly for 2 hours**
**Provide warm blankets**
**apply ice packs to the perineum**
**massage the uterus if needed; teach mother to also**
**provide breast feeding support as needed**
132
Regarding Postoperative cataract patients - sudden changes in \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_increase the intraocular pressure and put pressure on the suture line
position, constipation, vomiting, stooping, or bending over
Post operative cataract patients will be instructed to bend from the knees to pick things up, avoid straining and heavy lifting
sleep on the unaffected side (decreases pain and swelling when elevated)
133
dyspepsia
indigestion
134
Which information does the nurse recognize as being the most pertinent to the diagnosis of cholecystitis?
## Footnote
1. Flatulence.
2. Nausea and vomiting.
3. Right upper abdominal pain.
4. Dyspepsia.
Right upper adbominal pain
135
Symptoms of alcohol withdrawal
Tremors
anxiety
N/V
irritability
insombia
tachycardia
Elevated Temperature
Nocturnal leg cramps
early signs of alcohol withdrawal peak after 24-48 hours and then rapidly dissapear, unless the withdrawal progresses to alcohol withdrawl delirium. This state of delirium usuall peaks 48-72 hours after cessation or reduction of intake (**watch for diaphoresis, disorientation with fluctuating levels of consciousness, hallucinations & delusions, tachycardia & hypertension)**
136
pituitary dwarfism assessment
height below normal, **body proportions normal,** none/tooth development retarded, sexual maturity delayed, skin fine and smooth, features delicate (appear younger than chronological age)
137
Mannitol is what kind of medication ?
Osmotic Diuretic- t**hese increase osmotic pressure of the glomerular filtrate, inhibiting reabsorption of water & electrolytes**
They are used for oliguria and to prevent kidney failure, decrease ICP, and decrease intraocular pressure in clients with narrow angle glaucoma.
Monitor for vital signs & electrolyte imbalances
138
The nurse knows that according to Erikson’s stages of psychosocial development, which developmental stage best represent a 50-year-old client?
1. Integrity versus despair and disgust.
2. Generativity versus stagnation.
3. Intimacy versus isolation.
4. Identity versus role diffusion.
2.Generativity versus stagnation.
139
The long-term use of ceftriaxone sodium, a cephalosporin, can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended
TRUE OR FALSE
TRUE
140
This is a hypothyroid state resulting from hyposecretion of thyroid hormines and characterized by a decreased rate in body metabolism
hypothyroidism
141
This rare but serious disorder results from persistently low thyroid production
It cab be precipitated by acute illness, rapid withdrawal or thyroid medication, anesthesia or surgery, hypothermia, or the use of sedatives and opioid analgesics
Myxedema Coma
142
hypothyroidism symptoms
Let the condition’s name help you: **everything is going to be LOW and SLOW due to the body working at a very slow metabolism rate**
Weight Gain
Unable to tolerate cold
Possible goiter from constant thyroid stimulation to get the thyroid gland to produce T3 and T4 MOST COMMON SIGN IN HASHIMOTO’S
Extremely tired and fatigued
Slow heart rate
Thinning and brittle hair
Depression
Constipation
Memory loss
Myxedema: swelling of the skin (eyes and face) that gives it a waxy appearance
Dry skin
Joint, muscle pain
Menstrual problems (irregular or heavy periods)
\*\*\*early signs are feeling tired and fatigue…then as hypothyroidism progresses the patient starts to exhibit other symptoms
143
The client with hypothyroidism should avoid these medication classes because of increased sensitivity- they may precipitate myxedema coma.
Sedatives & Opioid analgesics
144
What is the Rinne Test ?
The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard.
when the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should still hear a sound
client should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction
145
What is the Weber test ?
The stem of a vibrating tuning fork is held in the middle of the forehead, and the client's hearing is assessed in both ears.
determines whether the client has a conductive or sensorineural hearing loss
146
Clomiphene Citrate
clomiphene citrate induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum
147
What is the most effective method of reducing infection ?
good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients
148
Being NPO inhibits normal blood glucose control
TRUE OR FALSE
TRUE
149
The nurse knows that cortisol is responsible for which action?
Converting proteins and fat into glucose.
150
This substance regulates the calcium metabolism.
parathyroid hormone
151
This substance prepares the body for fight or flight
Epinephrine
152
This substance enhances musculoskeletal activity
norepinephrine
153
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ are a false belief that public events or people are directly related to the individual
**delusions of reference**
154
a strongly held belief that is not validated by reality
delusion
155
Mood altering drugs like \_\_\_\_\_\_\_\_\_\_\_\_\_\_--are most often used intravenously and are most often associated with an increased risk for HIV infection
narcotics
156
How many extra calories a day does the nurse advise the clients to consume to support breastfeeding?
milk production requires **an increase of 500 calories per day**
157
This is an examination of the upper GI tract under flouroscopy after the client drinks barium sulfate. What is this diagnostic procedure called ?
Barium swallow
**Withhold foods and fluids for 8 hours prior to the test**
infant should be NPO 3 hours prior to the procedure
158
symptoms of allergic reaction to blood transfusion
occurs immediately or within 24 hours
Mild- urticaria, itching, flushing
Anaphylaxis- **hypotension, dyspnea, decreased oxygen saturation, flushing**
159
What is the purpose of a pacemaker ?
It is a temporary or permanent device that provides electrical stimulation and maintains the heart rate when the clients intrinsic pacemaker fails to provide a perfusing rhythm
## Footnote
**It increases the cardiac output**
160
What instructions should be given to the client before plasma cholesterol screening ?
only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results
normal diet should be eaten the week before the test
no alcohol intake
161
The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler?
1. Milk.
2. Water.
3. Orange juice.
4. Fruit punch.
**MILK**
milk contains calcium; ***calcium binds to lead and inhibits its absorption***
162
Physical symptoms of lead poisoning
irritability
sleepiness
nausea/vomiting, abdominal pain, poor appetite
constipation
decreased activity
increased ICP - seizures & motor dysfunction
163
What are the stages of grief ?
Denial
Anger
Bargaining
Depression
Acceptance
164
What is the purpose of a pyelogram ?
**The health care provider is able to examine the urinary tract by x-ray.**
***It evaluates kidney function through X-rays of entire urinary tract***
165
Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best?
1. "SIDS will provide you with this opportunity."
2. "SHARE will provide you with this opportunity."
3. "RESOLVE will provide you with this opportunity."
4. "CANDLELIGHTERS will provide you with this opportunity."
1) support group for parents who have had an infant die from sudden infant death syndrome
2) **CORRECT — SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage**
3) support group for infertile clients
4) support group for families who have lost a child to cancer
166
Which action is the best way for the nurse to assess the fluid balance of an elderly client?
1. Assess the client’s blood pressure.
2. Check the client’s tissue turgor.
3. Determine if the client is thirsty.
4. Maintain an accurate intake and output.
Strategy: Determine how each answer relates to hydration.
1) may be elevated because of age-related hypertension
2) not accurate because of changes in skin elasticity due to the aging process
3) not reliable indicator; may have diminished sensation of thirst
4) CORRECT—best indicator of fluid status
167
Nephrotic syndrome is a kidney disorder characterized by
**massive proteinuria, hypoalbuminemia and edema**
168
What is Colostomy irrigation ?
This is an enema givent through the stoma to stimulate bowel emptying
Irrigation is performed by instilling 500-1000 mL of lukewarm tap water through the stoma and allowing the water and stool to drain into a collection bag
Perform irrigation at about the same time each day
perform irrigation preferably 1 hour after a meal
to enhance effectiveness of the irrigation, massage the abdomen gently
**Avoid frequent irrigations, which can lead to loss of fluids and electrolytes**
catheter should never be inserted more than 4 inches into the stoma
169
the loss of purposeful movement in the absence of motor or sensory impairment
Apraxia
170
the repetition of a particular response (such as a word, phrase, or gesture) regardless of the absence or cessation of a stimulus. It is usually caused by a brain injury or other organic disorder.
Perseveration
171
Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information?
allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure
172
Fractured hip assessment
**Leg shortened, adducted and externally rotated**
173
paresis
a condition of muscular weakness caused by nerve damage or disease; partial paralysis.
