Exam 1

Question 1

Erickson stage for adolescence

Answer 1

identity vs. role confusion

tires integrating many roles into a self image under role model and peer pressure

Question 2

Erickson stage for young adult

Answer 2

intimacy vs. isolation

learns to make personal commitment to another as spouse, parent, or partner

Question 3

Erickson stage for middle age adult

Answer 3

generativity vs. stagnation

seeks satisfaction through productivity in career, family, and civic interests

Question 4

Erickson stage for older adult

Answer 4

integrity vs. despair

reviews life accomplishments, deals with loss and preparation for death

Question 5

Maslow’s hierarchy

Answer 5

1) physiological needs
2) safety and security
3) love and belongingness
4) self esteem
5) self actualization

Question 6

who does patient education before discharge?

Answer 6

nurse

Question 7

who assesses patient?

Answer 7

nurse

Question 8

who holds accountability for delegation?

Answer 8

nurse

Question 9

dehydration - excess or deficit?

Answer 9

extracellular fluid volume deficit

Question 10

who is at risk for dehydration? why?

Answer 10

elderly - not enough intake, altered cognition, lack of thirst, diuretics, trouble swallowing, mobility

Question 11

most common measure of I&O?

Answer 11

body weight

Question 12

average I&O per day?

Answer 12

1500-2000ml

Question 13

expected output for patients with catheters?

Answer 13

30ml/hr (or more)

Question 14

output defined as oliguria for patients with catheters?

Answer 14

less than 20ml/hr

Question 15

changes in vital signs for dehydration

Answer 15

low systolic BP, weak pulse, increased HR, increased temp, orthostatic hypotension, flat jugular veins

Question 16

clinical manifestations of dehydration

Answer 16

dry mucous membranes, decreased skin turgor, sunken eyes, muscle weakness, constipation, restlessness, HA, hallucinations, coma

Question 17

diagnostic findings for dehydration

Answer 17

increased sodium, increased BUN, normal creatinine, increased glucose, increased hematocrit

Question 18

plasma osmolality

Answer 18

=2x plasma Na

assesses state of body’s water balance

Question 19

oral fluid restoration equation

Answer 19

100ml/kg for first 10kg
50ml/kg for second 10kg
15ml/kg for remaining kg

Question 20

which types of patients should you pay special attention to when it comes to fluid overload?

Answer 20

renal, cardiac, liver, and pulmonary

Question 21

which serum level should you pay close attention to with fluid volume excess/deficit?

Answer 21

sodium

Question 22

fluid overload

Answer 22

extracellular fluid volume excess (hypervolemia)

Question 23

top 2 reasons for fluid overload?

Answer 23

heart failure and lack of output

Question 24

clinical manifestations of fluid overload

Answer 24

lung involvement (can’t sleep laying down, cough, SOB, crackles)
decreased O2, anxiety, increased CO2, pleural effusion
cardiac involvement (jugular vein distention, bounding pulse, extra S3 heart sound)
dependent edema, weight gain
cerebral involvement (restlessness, confusion, lethargy, seizures, coma)

Question 25

diagnostic findings for fluid overload

Answer 25

decreased Na, decreased hematocrit, plasma osmolality <8

Question 26

tx for fluid overload

Answer 26

restrict Na, diuretics, cardiac issues (ACE, ARB, beta blockers)

Question 27

diuretics

Answer 27

lasix (stronger, need K supp) hctz (first choice, weaker) aldactone (holds K)

Question 28

where do you check for edema r/t fluid overload?

Answer 28

sacrum and ankle

Question 29

third spacing

Answer 29

accumulation of fluid in the interstitial space caused by inflammation, protein malnutrition, altered lymph can cause hypovolemia because fluid isn't in system

Question 30

clinical manifestations of third spacing

Answer 30

starts with restlessness | hypovolemia, pallor, cold limbs, weak rapid pulse, hypotension, oliguria, decreased LOC, no change in body weight

Question 31

tx for third spacing

Answer 31

replace fluid, watch for overload, stabilize problem (pull fluid off), measure circumference of limb or abdominal girth, monitor I&O

Question 32

hyponatremia

Answer 32

<135mEq/L | most common fluid overload

Question 33

clinical manifestations of hyponatremia

Answer 33

HA, apprehension, restlessness, confusion, seizures, brain herniation, decreased BP, weak thready pulse, tachycardia

Question 34

tx for hyponatremia

Answer 34

restrict fluids | <115 - 3% NaCl; monitor carefully

Question 35

hypernatremia

Answer 35

>145mEq/L | usually associated with water loss or sodium gain

Question 36

clinical manifestations of hypernatremia

Answer 36

polyuria then oliguria, anorexia, weakness and restlessness, cardiac involvement

Question 37

tx for hypernatremia

Answer 37

oral fluid replacement, IV hypotonic sol 0.2 or 0.45 NaCl or D5W, watch for cerebral edema

Question 38

hypokalemia

Answer 38

<3.5mEq/L commonly seen in older adult cause: malnourishment, bulimic, vomiting, diarrhea, NG suction w/o replacement, meds (lasix, hctz, cathartics, digoxin), increased Na levels, renal losses

Question 39

why do you monitor the heart with K problems?

Answer 39

potassium imbalances can lead to ventricular dysrhythmias and/or cardiac arrest

Question 40

clinical manifestations of hypokalemia

Answer 40

abnormal EKG (prominent U), slow weakened pulse, constipation, anorexia, muscle weakness

Question 41

tx of hypokalemia

Answer 41

restore 40-60mEq/day, PO replacement for mild/mod, IV K diluted in IV fluids given slowly for severe foods - oranges, bananas, tomatoes, potatoes

Question 42

hyperkalemia

Answer 42

>5mEq/L | cause: renal failure, meds, salt substitutes

Question 43

clinical manifestations of hyperkalemia

Answer 43

nerve and muscle excitability, cardiac with K >6-7 (tachycardia, vent dysrhythmias, peaked T)

Question 44

tx of hyperkalemia

Answer 44

dietary restriction, IV saline, IV lasix, IV calcium gluconate and IV insulin (severe), kayexelate enema (IV insulin puts K into cells and stops dysrhythmias)

Question 45

hypercalcemia

Answer 45

>10.2mg/dl cause: hyperparathyroidism, malignancy tx: isotonic saline, promote excretion, hydrate, lasix

Question 46

hypocalcemia

Answer 46

``` s sign (tetany) tx: PO or IV replacement ```

Question 47

hyperphosphatemia

Answer 47

>4.4mg/dl cause: renal failure tx: treat underlying cause, decrease milk products, hydrate

Question 48

hypophosphatemia

Answer 48

<2.4mg/dl cause: malnourishment, alcoholism, fasting tx: PO or IV supplement

Question 49

hypermagnesium

Answer 49

>2.5mEq/L cause: renal failure, adrenal insuff tx: prevention, dialysis, IV calcium chloride or calcium gluconate

Question 50

hypomagnesium

Answer 50

<1.5mEq/L cause: starvation tx: PO supp, IV mag sulfate

Question 51

allen's test

Answer 51

assesses arterial blood flow of the hand

Question 52

IV blood administration

Answer 52

``` Y tubing w/ blood and normal saline 14-20 gauge tubing 2 RNs or RN+LPN check blood stay w/ pt for 15min after infusion monitor for occlusion (usually r/t positioning), infiltration (white/pale, swelling of fluid), infection (redness, swelling, warmth) clear dressing to monitor site ```

Question 53

sodium range

Answer 53

135-145

Question 54

potassium range

Answer 54

3.5-5

Question 55

calcium range

Answer 55

8.6-10.2

Question 56

phosphate range

Answer 56

2.4-4.4

Question 57

magnesium range

Answer 57

1.5-2.5

Question 58

pH range

Answer 58

7.35-7.45

Question 59

CO2 range

Answer 59

35-45

Question 60

HCO3 range

Answer 60

22-26