Version 1 Flashcards
A resident of a long-term care facility, who has moderate dementia, is having
difficulty eating in the dining room. The client becomes frustrated when dropping
utensils on the floor and then refuses to eat. What action should the nurse
implement?
ANSWER- Encourage finger foods, distraction, speak
therapeutically
2 days after admission from alcohol withdrawal what should the nurse do?
ANSWER- Monitor HR and BP
which action should the nurse implement first for a client experiencing alcohol
withdrawal? -
ANSWER- prepare the environment to prevent self injury: self
A patient won't take oral meds that is going through alcohol withdrawal. The
nurse
starts giving saline lock per alcohol protocol and thiamine. What do you tell them
that
it will help with recovery? -
ANSWER- Thiamine will replenish alcohol effects on
the body (something to do with iron)
A client comes in after being in a car accident and is experiencing alcohol
withdrawal,
magnesium level of 1.1, cardiac dysrhythmias. What would you give first? -
magnesium
Patient having to get treated for benzodiazepine and methadone overdose. What do
you use? -
narcan
When preparing to administer a domestic violence screening tool to a female
client,
which statement should the nurse provide?
ANSWER- all clients are screened for
domestic abuse because it is common in our society
a mental health care worker caring for a client with escalating aggressive behavior.
What action by the mental healthcare worker wards immediate interventions? -
ANSWER- -attempting to physically restrain patient
Violence handling
ANSWER- - Engage in dialogue to prevent escalation,
intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for meds,
be consistent
a 30 year old sales manager tells the nurse "i am thinking about a job change.
i don't feel like i am living
up to my potential." which of maslows developmental stages is the sales
manager attempting to achieve
- ANSWER- self actualization:
A client is admitted to the mental health unit and reports taking extra anti anxiety
medication because, “I’m so stressed out. I just want to go to sleep.” The RN
should
plan one-on-one observation of the client based on which statement? -
“I don’t want to walk. Nothing matters anymore.”
What is the most important goal for a client diagnosed with major depression who
has
been receiving an antidepressant medication for two weeks
NSWER- not
attempt to commit suicide
The nurse is obtaining the medical histories of new clients at a community-based
primary care clinic. Which individual has the highest risk for experiencing elder
abuse? -
A 78 year old female on a fixed income who lives with her
relatives
Who is most prone to being abused (elder abuse)? -
ANSWER- Females over 75
living with their families.
While caring for an older client, the RN observes multiple bruises in Over the
client’s legs, arms, back, and gluteal areas. When the RN suspects elder abuse.
What action should the RN take?
ANSWER- Measure and document size, shape
and color of the bruised areas.
Grief priority
Priority should be based on SHOCK!
When checking a third grader’s height and weight the school nurse notes that these
measurements have not changed in the last year. The child is currently taking daily
vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder
(ADHD). Which intervention should the nurse implement?
ANSWER- Refer
child to the family healthcare provider
A middle school male student was recently diagnosed with Attention-Deficit
Hyperactivity Disorder (ADHD) and is having trouble with his grades. He is
referred to the school nurse by the teacher because he continues to have learning
problems. Which action should the school nurse take?
ANSWER- * Refer the
child to the school counselor for educational testing
A female client with obsessive compulsive personality disorder is admitted to the
hospital for a cardiac catheterization. The afternoon before the procedure, the client
begins to keep detailed notes of the nursing care she is receiving, and reports her
findings to the RN at bedtime. What action should the nurse implement?
ANSWER- Encourage the client to express her feelings regarding the upcoming
procedure.
When preparing to administer a domestic violence screening tool to a female
client, which statement should the nurse provide
ANSWER- all clients are
screened for domestic abuse because it is common in our society
A woman is being abused by her husband, the abuse is escalating. What would the
nurse ask first?
NSWER- Do you have a plan in place when you are not safe?
(SAFETY!!!)
You’re having a one on one session and nurse begins to get angry at patient. -
ANSWER- terminate the session before the feelings escalate
A nurse is preparing a client for the termination phase of the nurse-client
relationship. The nurse prepares to implement which nursing task appropriate for
this phase?
ANSWER- Making appropriate referrals
Which action should the nurse implement during the termination phase of the
nurse-client relationship? -
ANSWER- Help summarize accomplishments
Which features are prominent in anorexia nervosa? -
ANSWER- Amenorrhea for 3
cycles; Perfectionism; Powerlessness; Rigid food rituals
After receiving treatment for anorexia, a student asks the school nurse
for permission to work in the school cafeteria as part of the school’s
work study program. What action should the nurse take?
ANSWER- Recommend
assignment to the receptionist’s office.
Bizarre social behavior
assess physical needs, suicide risk, ensure
safety at all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
Which assessment finding should indicate to the nurse that a client with arterial
HTN is experiencing a cardiac complication?
ANSWER- Shortness of breath on
exertion
When discussing recent onset of feelings of sadness and depression in a client with
hypothyroidism, the nurse should inform the client that these feelings are
ANSWER- Most likely related to low thyroid hormone levels and will improve
with treatment.
Diverticulosis signs and symptoms
ANSWER- LLQ abdominal pain
(descending/sigmoid colon)
Bloating/Gas
Fever
Nausea/Vomiting
Constipation alt. w/ diarrhea
Anorexia
A patient is ordered by the physician to take allopurinol (Zyloprim) for treatment
of gout. You’ve provided education to the patient about this medication. Which
statement by the patient requires you to re-educate them about this medication?
ANSWER- “This medication will help relieve the inflammation and pain during an
acute attack”
Allopurinol
ANSWER- -take after meals
- avoid alcohol
- purine-rich foods (red meat/shellfish/fructose drinks)
- increase fluids
- reduce stress
DM poor compliance
ANSWER- Check feet
Check visual acuity
Check sensation
During discharge teaching, the nurse discusses the parameters for weight
monitoring with a client who was recently diagnosed with heart failure (HF).
Which information is most important for the client to acknowledge -
ANSWERReport
weight gain of 2 pounds (0.9kg) in 24 hours
A male pt calls the clinic and complains because he can’t tie his shoes? What
should the nurse do next?
ANSWER- Ask if the pt has gained weight in the past
few days
Osteoarthritis exercise
ANSWER- Aquatic exercise—improves function,
decreases pain
Remind client that excessive use of the involved joint aggravates pain and may
accelerate degeneration
The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis.
Which factor in this client’s history is a contributor to osteoarthritis? -
ANSWERLong
distance runner since high school.
A client with a small bowel obstruction is experiencing frequent vomiting. Which
instructions are most important for the nurse to provide to the UAP who is
completing morning care for this client?
ANSWER- Maintain a quiet
environment
The nurse is caring for a client with a small bowel obstruction. The client is
vomiting foul smelling fecal-like material. Which action should the nurse
implement? -
ANSWER- Give IV fluids with electrolytes.
The nurse is assessing a client with a small bowel obstruction who was
hospitalized 24 hours ago. Which assessment finding should the nurse report
immediately to the healthcare provider? -
ANSWER- Rebound tenderness in the
upper quadrants
The nurse is developing the plan of care for a client with pneumonia and includes
the nursing diagnosis of “Ineffective airway clearance related to thick pulmonary
secretions.” Which intervention is most important for the nurse to include in the
client’s plan of care?
ANSWER- Increase fluid intake to 3,000 ml/daily
Pneumonia Treatment/Prevention
ANSWER- oxygen therapy, hydration, bed
rest, positioning to facilitate breathing, deep breathing, humidified air, chest
physiotherapy, suctioning prn,
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen
with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the
patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and
an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse
observes the patient resting with closed eyes, pink coloration, a respiratory rate of
12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is
correct?
ANSWER- Decrease the oxygen to 2 L/min to improve respiratory rate
What are the nutritional needs of this client throughout recovery?
ANSWERAcute
phase: NPO, IV fluids
* Recovery phase: no fiber or foods that irritate the bowel
* Maintenance phase: high-fiber diet with bulk-forming laxatives
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis.
Which nursing intervention has the highest priority
- ANSWER- Place the client
on NPO status.
A nurse is caring for a client who has heart failure and has been taking digoxin
0.25 mg daily. The client refuses breakfast and reports nausea. Which of the
following actions should the nurse take first?
ANSWER- Check the client’s vital
signs.
The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with
congestive heart failure. Which intervention should the nurse implement prior to
administering the digoxin? -
ANSWER- Assess the serum potassium level
A 77-year-old female client is admitted to the hospital. She is confused and has had
no appetite for several days. She has been nauseated and vomited several times
prior to admission. She is currently complaining of a headache. Her pulse rate is 43
beats/min. The nurse is most concerned about the client’s history related to what
medication?
ANSWER- Digitalis (Lanoxin)
The nurse is administering a dose of digoxin to a patient with heart failure (HF).
The nurse would become concerned with the possibility of digitalis toxicity if the
patient reported which symptom?
ANSWER- Anorexia, nausea, vomiting,
blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity
IV fluids hypertonic
ANSWER- Hypertonic solutions exert an osmotic pressure
greater than that of the ECF.
When normal saline solution or lactated Ringer solution contains 5% dextrose, the
total osmolality exceeds that of the ECF
Saline 3% or 5%
3% NaCl
5% Nacl
D10W
‘D20W
D50W
D5LR
Rheumatoid arthritis pain
ANSWER- movement causes pain, rather than
relieving pain.
Rheumatoid arthritis occurs bilaterally.
E. Morning stiffness
F. Bilateral inflammation of joints
PUD NGT
ANSWER- During surgery stomach contents are drained by NG tube
- Confirmation that obstruction is the cause of pt discomfort us done by assessing
the amount of of fluid aspirated a residual of >400 mL indicated obstruction
prostatic hyperplasia
ANSWER- Decreased force in the stream of urine is an
early symptom of benign prostatic hyperplasia
- urgency
- nocturia
- hesitancy
- decreased/intermittent stream
- incomplete emptying
- less than 50-100mL’s
Assessment: palpate the bladder
BPH - don’t give antihistamines - do not give decongestant, anticholinergics,
antidepressants
Type I DM tight control
ANSWER- glucose checks at home
- A1C should be 4-6%
*** LESS THAN 7%
Which intervention should the nurse include in a long-term plan of care for a client
with Chronic Obstructive Pulmonary Disease (COPD)?
ANSWER- Reduce risks
factors for infection
A 55-year-old male client has been admitted to the hospital with a medical
diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is
the most significant in the development of this client’s COPD
ANSWER- The
client smokes 1 to 2 packs of cigarettes per day.
IBD - peritonitis
ANSWER- - Fluid, colloid, and electrolyte replacement is the
major focus
- Antibiotic therapy
The mother of a child recently diagnosed with asthma asks the nurse how to help
protect her child from having asthmatic attacks. To avoid triggers for asthmatic
attacks, which instructions should the nurse provide the mother? (Select all that
apply)
ANSWER- Close car windows and use air conditioner
Avoid sudden changes in temperature
Keep away from pets with long hair
Stay indoors when grass is being cut
Ulcerative colitis bloody diarrhea
ANSWER- Patients with ulcerative colitis may
experience as many as 10-20 liquid, bloody stools per day
Arterial insufficiency diabetic
ANSWER- arterial insufficiency symptoms
-weak pedal pulses
-shiny and cool skin
-intermittent claudication
- aching/cramping
- induced fatigue
Which of the following instructions should the nurse include in the teaching plan
for a client who is experiencing gastroesophageal reflux disease (GERD)? -
ANSWER- The nurse should instruct the client to not lie down for about 2 hours
after eating to prevent reflux
Minimize symptoms by wearing loose and comfortable clothes
Pre op labs which is abnormal
ANSWER- WBC count higher than 5,000-
10,000/mm3 = possible infection
Seizure unconscious pat
ANSWER- Make sure suction is available
While monitoring a client during a seizure, which interventions should the nurse
implement? (Select all that apply)
ANSWER- a. Move obstacle away from client
b. Monitor physical movements
d. Observe for a patent airway
e. Record the duration of the seizure
A pt is preparing for discharge after lithotripsy. Which intervention should
the nurse include in the client’s postoperative discharge instructions?
ANSWERmonitor
urinary stream for decrease in urinary output
A patient returns to the medical-surgical unit after having extracorporeal shock
wave lithotripsy (ESWL). What is an appropriate nursing intervention for the
postprocedural care of this patient?
ANSWER- Strain the urine to monitor the
passage of stone fragments
General anesthesia - post anesthesia car
ANSWER- systolic under 90 =
immediately reportable unless baseline!!
Thrombocytopenia labs -
ANSWER- under 50,000 /LOW PLATELET COUNT
normal PT/PTT
prolonged Bleeding time
Thrombocytopenia: Low platelet count
Bleeding and petechiae usually do not occur with platelet counts greater than
50,000/mm3, although excessive bleeding can follow surgery or other trauma.
When the platelet count drops to less than 20,000/mm3, petechiae can appear,
along with nasal and gingival bleeding, excessive menstrual bleeding, and
excessive bleeding after surgery or dental extractions. When the platelet count is
less than 5000/mm3, spontaneous, potentially fatal central nervous system or GI
hemorrhage can occur
Sickle cell first sign of crisis
ANSWER- pain
- fatigue
- swollen hands and feet
- dehydration
**give oxygen, fluids, pain med, infection prevention
A child with possible Duchenne muscular dystrophy ( MD) undergoes an
electromyogram (EMG). Following the procedure, the child’s parents tell the nurse
that the child is complaining of sore muscle. How should the nurse respond?
ANSWER- Offer reassurance that muscle soreness following this procedures is
temporary and does not indicate a problem
The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, “How
can our son have this disease? We are wondering if we should have any more
children.” What information should the nurse provide to parents?
ANSWERThis
is an inherited X-linked recessive disorder, which primarily affects male
children in the family
A 4-year-old boy was recently diagnosed with Duchenne muscular dystrophy
(DMD). Which characteristic of the disease is most important for the nurse to
focus on during the initial teaching?
ANSWER- Lower legs become
progressively weaker, causing waddling, unsteady gait
Duchenne muscular dystrophy
- ANSWER- Duchenne muscular dystrophy appears
in early childhood (ages 3 to 5 years) (children appear normal at birth until signs
and symptoms of the disease manifest).
By the age of 9 to 11 years old, the child loses the ability to walk independently.
Life expectancy generally in the third decade
Febrile seizures teaching
ANSWER- febrile seizures: reassure parents febrile
seizures will go away
use seizure precautions, call 911 if lasts more than 5 minutes
