Capstone exam 2

Question 1

Babinski Sign

Answer 1

When you stroke the bottom of the foot from the heel upward. The big toe bends back and the other toes spread out. Indicates CNS Disorder

Question 2

Serum Ammonia Level

Answer 2

10-80mcg
High=severe liver disease

Question 3

Mild anemia

Answer 3

Palpitations, dyspnea, mild fatigue. HGB 10-12

Question 4

Moderate Anemia

Answer 4

Increased palpitations, fatigue, dyspnea. HGB 6-10

Question 5

Severe Anemia

Answer 5

Tachycardia, anorexia, PICA, Pallor, Bone pain, Impaired thoughts, HGB below 6

Question 6

Anemia Teaching

Answer 6

Dietary changes, Alternate rest and activity, Increase protein, B vitamins, Folic Acid, Iron, Vitamin C, Vitamin E, Blood transfusion, Erythropoietin, Oxygen therapy

Question 7

Glasgow Coma Scale

Answer 7

Best score 15. Less than 8 severe head injury or coma, 9-12 Moderate head injury, Mild 13-15

Question 8

Post craniotomy Interventions

Answer 8

Monitor vital signs, airway, Neuro status, pain, surgical site, fluid and electrolyte

Question 9

EMG

Answer 9

Evaluates condition of muscles and nerves that control them. No smoking 3hrs before exam, bath or shower yo remove oils from skin, wear comfy nonobstructive clothing, low risk, client may have soreness where test was performed.

Question 10

Variable Decelerations
Early Decelerations
Accelerations
Late Decelerations

Answer 10

Cord Compression
Head Compression
Oxygen good
Placental Insufficiency

Question 11

Brudzinski’s sign

Answer 11

Severe neck stiffness causes patients hips and knees to flex when neck is flexed. Indicates meningitis

Question 12

Biophysical profile

Answer 12

Combines non stress test with ultrasound

Question 13

Chorioamnionitis

Answer 13

Intraamniotic infection, acute inflammation of membranes due to polymicrobial bacterial infection in the setting of membrane rupture

Question 14

Amniotic fluid embolism

Answer 14

Catastrophic complication, amniotic fluids, fetal cells, hair, other debris enter into maternal pulmonary circulation causing cardiovascular collapse.

Question 15

Isosorbide mononitrate

Answer 15

Used to prevent chest pain
Side effects: Headache, dizziness, lightheadedness, nausea, flushing. Take first thing in the AM. Headaches are a sign the med is working. Dont take with viagra or cialis

Question 16

Carbamezapine

Answer 16

Tx epilepsy, trigeminal neuralgia, may cause steven johnson syndrome, or toxic epidermal necrolysis. Wait 14 days after stopping to take MAO

Question 17

Calcitonin

Answer 17

Tx bone problems (pagets disease, osteoporosis) and to reduce high blood levels of calcium. Injectable causes flushing of face, hands, and feet several mins after admin. Pruritus, tingling of palms and soles, increased diuresis.

Question 18

Pt with HF taking furosemide and digoxin develops muscle cramps, N/V, and anxiety. What order would the nurse expect.

Answer 18

Give supplemental K+

Question 19

Lab value to report for DIC

Answer 19

Fibrinogen of 85

Question 20

Multiple PVCs

Answer 20

indicate low potassium or low oxygen

Question 21

MI Ekg findings

Answer 21

ST elevation, Abnormal Q wave, T wave inversion

Question 22

CKD Symptoms

Answer 22

Decreased GFR, Azotemia, Increased BUN, Oliguria

Question 23

Signs of Hypermagnesemia

Answer 23

Diminished DTR, Tall T waves, Decreased St elevation, bradycardia.

Question 24

Lasix causes

Answer 24

Metabolic Alkalosis

Question 25

Warfarin is prescribed for

Answer 25

Patients with Afib

Question 26

COPD

Answer 26

Respiratory Acidosis

Question 27

Respiratory acidosis and pnuemonia

Answer 27

Overproduction of hydrogen ions

Question 28

Signs of acute respiratory acidosis

Answer 28

Lethargy, hypotension, Fatigue, decreased perfusion, impaired memory and cognition

Question 29

Respiratory acidosis

Answer 29

Client with rib fracture

Question 30

Adverse reaction to carbamazepine

Answer 30

WBC of 3000

Question 31

Positive Brudzinski's sign

Answer 31

Patient passively flexes the hip and knees in response to neck flexion and reports pain in the vertebral column

Question 32

Child is unable to flex leg when the thigh is flexed anteriorly at the hip. suspect

Answer 32

meningitis

Question 33

Signs of meningitis in CSF

Answer 33

Cloudy CSF, Elevated protein, Decreased glucose levels

Question 34

Guillain Barre

Answer 34

Observe respiratory rate and effort

Question 35

Guillain Barre pt reports they cant move their legs and feel tingling above waistline

Answer 35

Bring ECG monitor and Intubation tray

Question 36

Person most at risk for Guillain Barre

Answer 36

Respiratory or gastro infection over the past month

Question 37

Tonic clonic seizure turns cyanotic

Answer 37

Continue to monitor

Question 38

Actions for a seizure

Answer 38

Loosen restrictive clothing, Remove pillow and raise padded side rails, turn to side with head flexed forward

Question 39

Additional teaching about GERD is needed if pt says

Answer 39

I eat small meals and have a bedtime snack

Question 40

Frequent complication of ileostomy

Answer 40

Fluid and electrolyte imbalance

Question 41

Healthy Stoma

Answer 41

Red and moist

Question 42

Additional Teaching for goiter and possible hyperthyroidism

Answer 42

Checks BP in one arm Palpates neck to assess thyroid size orders saline drops for bulging eyes offers warm blankets for cold feet

Question 43

ECG changes in hypocalcemia

Answer 43

QT prolongation ST segment lengthened

Question 44

DKA patient being weened off insulin reports they are lightheaded and sweaty

Answer 44

obtain glucose reading

Question 45

Before and oral glucose tolerance test

Answer 45

Avoid smoking before test several blood samples will be obtained Fast 8 hours before test

Question 46

Take levothyroxine on

Answer 46

an empty stomach

Question 47

Dont do these with a patient with a goiter

Answer 47

warm blankets for feet, palpate goiter

Question 48

A form of glucose should be taken if pt has

Answer 48

shakiness, palpitations, lightheadedness

Question 49

Stoma diversion that creates the greatest risk for skin breakdown

Answer 49

Ileostomy

Question 50

How to drain flatus from one piece drainable ostomy pouch

Answer 50

Open the bottom of the pouch

Question 51

Empty a colostomy pouch when

Answer 51

its 1/3 to 1/2 full

Question 52

EMG test

Answer 52

evaluate muscle weakness discontinue muscle relaxants before procedure ask if they take herbal supplements before test