Weakness 2 Flashcards
1
Q
Mother brings infant complaining of vomiting and diarrhea to ER that’s been
breastfeeding and introducing formula
A
ANSWER- Ask what kind of water are
you mixing with formula
2
Q
what should a patient with cystic fibrosis know ?
A
- take pancreatic enzyme supplements(pancrelipase) with meals
- eat a high fat/high calorie diet
- will need to have a sweat chloride test
- Chest physiotherapy(before meals or several hours after eating to prevent
vomiting) with postural drainage
3
Q
A 17-year-old male student with cystic fibrosis talks with the school nurse about
his disease and wonders how it will affect getting married and having children.
Which relevant information would the nurse include in this discussion? -
A
NSWER- He is likely to have infertility problems and further evaluation
4
Q
what should be assessed in adults for hydrocephalus?
What should be assessed in infants for hydocephalus?
tx?
A
- Changes in LOC
- seizures
- decline in academics
- personality changes
- widen stature
- “sunset eyes”
- High pitched cry
- difficult to eat
- Shunt placement (p-shunt)
what
5
Q
what is a risk factor for slipped femoral capital epiphysis (SCFE)
A
- Obesity
- African American, Hispanic
- Male
6
Q
What are the interventions for scoliosis post- op
A
- Log roll patient for five days
- body needs to stay in alignment
- neuro assessment
- pain control
- body jacket (several months)
- assist with ambulation
7
Q
what is 24- hour jaundice?
A
yellowing of the eyes
- yellowing of skin
- high bilirubin
- put pressure on bridge of nose of forehead or sternum to identify
- occurs in the first 24 hours of life or extends beyond 7 days
8
Q
A one-day-old neonate develops a cephalhematoma. The nurse should closely
assess the neonate for which common complication?
A
jaundice
9
Q
What are nursing interventions for Hemophilia
A
- frequent BP
- Rectal suppositories
- Temps
- Aspirin
10
Q
A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing
around when a blood specimen is obtained.The child’s color becomes blue and
respiratory rate increases to 44 bpm.Which of the following actions would the
nurse do first?
A
knee to chest position
11
Q
During a follow up clinical visit a mother tells the nurse that her 5 month old son
who had surgical correction for tetralogy of fallot has rapid breathing, often takes a
long time to eat, and requires frequent rest periods. The infant is not crying while
being held and his growth is in the expected range. Which intervention should the
nurse implement?
A
ANSWER- Auscultate heart and lungs while infant is held
12
Q
What acid imbalance would you expect from a pt that has chronic kidney disease
A
metabolic acidosis
13
Q
what are assessment findings for a patient with chronic kidney disease
A
- fruity breath
- headache
- high bicarb levels
14
Q
metabolic alkalosis (high HcO3)
Metabolic acidosis ( low HCO3)
A
respiratory acidosis compensation
- respiratory alkalosis compensation
- kussmaul respirations
15
Q
Pulmonary edema first action - getting out of bed
A
place patient in high fowlers, feet hanging over the edge of the bed.
- auscultate lung sounds to check for dyspnea
- frothy sputum
16
Q
The nurse is caring for several clients on a telemetry unit. Which client should the
nurse assess first? The client who is demonstrating? -
A
ANSWER- Normal sinus
rhythm and complaining of chest pain
17
Q
normal sinus rhythm
A
P wave always IN front
P:QRS ratio 1:1
60-100 bpm
PR interval 0.12-0.2
U WAVE AFTER T= ABNOMRAL
18
Q
Diabetes insipidus -
A
ANSWER- Dry Inside
diabetes insipidus (DI) = makes you want to SIP water
Diabetes insipidus - dysuria, dysphagia, low urine specifity gravity, wgt loss, NA+
is high, high blood sugar
-Caused by a deficiency of production of ADH or a decreased renal response to
ADH.
-Clinical Manifestations: Polydipsia and Polyuria.
-Diagnostic Studies: Water deprivation test (pt deprived of water for 8-12 hrs and
then given desmopressin acetate subcut or nasally), Measure level of ADH after an
analog of ADH is given
19
Q
Signs and symptoms of glaucoma
A
loss of peripheral vision
halo around lights
reddened sclera
mild aching
headache
** tonometry diagnose between the two (open and closed angle)
IOP pressure - 30mmhg is glaucoma
20
Q
what needs to be assessed for Guillian barre
A
- AIRWAY
-SWALLOWING - impaired mobility related to paralysis
-ask if had a cold or flu in last month - paralysis of ocular facial and orophyngeal muscles
21
Q
cva expressive aphasia communication
A
ask yes or no questions
pictures
22
Q
cardiomyopathy care plan
A
MEDICATIONS: digoxin, diuretics, antidysrhythmic antihypertensive medications
SURGERY: septal myectomy, septal ablation, implanted devices (CRT, ICD,
LVAD, pacemaker), heart transplant
GOAL: decrease heart workload
ACTIVE RANGE OF MOTION WORKING UP TO GET INTO CHAIR
Signs and symptoms of cardiomyopathy
SOB
- activity intolerance
- fatigue
- cardiac palpitations
23
Q
what should you check when assessing for compartment syndrome
A
6 P’s?
Pain
Pressure
Paresthesia
Pallor
Paralysis
Pulselessness
24
Q
A client sustains a complex comminuted fracture of the tibia with soft tissue
injuries after being hit by a car while riding a bicycle. Surgical placement of an
external fixator is performed to maintain the bone in alignment. Postoperatively it
is most essential for the nurse to?
A
ANSWER- Perform a neurovascular
assessment of both lower extremities
25
One day following an open reduction and internal fixation of a compound fracture
of the leg, a male client complains of “a tingly sensation” in his left foot. The nurse
determines the client’s left pedal pulses are diminished. Based on these findings,
what is the client’s greatest risk? -
ANSWER- Neurovascular and circulation
compromise related to compartment syndrome
26
The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention
ANSWERDeep
unrelenting pain in the right arm --> compartment syndrome
27
Stroke broca’s area
ANSWER- Stroke in Broca’s area of left cerebral cortex
Answer: Listen patiently
- expressive aphasia usually occurs
-paralyzed on right side
28
patient has Broca’s aphasia. Which lobe of the brain does the nurse anticipate to
have been affected by a stroke?
ANSWER- The frontal lobe of the brain is related
to reasoning, planning, parts of speech, movement, emotions, and problem solving
29
A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test
result is most indicative of acute pancreatitis
ANSWER- Serum amylase
30
Acute pancreatitis assessment
- History
- ETOH abuse
- Severe LUQ pain
-tachy
- restless
- decrease bowel
- jaundice
- grey turner or Cullen signs
- increase serum amylase/lipase or WBC
- hyperlipidemia
30
What is the nursing care for cirrhosis?
- Soft bristle toothbrush
- no alcohol
- low sodium diet
- electric razor
- high fowler position to help breathing
31
A female pt was in an MVC and admitted with a fractured L femur. Nurse
assessment include diminished pulses. What should the nurse do next? SATA
ANSWER- Verify pedal pulses with a Doppler
Monitor L leg for pain, pulselessness, pallor,paralysis
Evaluate the app of the splint to the L leg
31
Pt with Addison’s has started taking hydrocortisone in a divided dose. What should
the nurse do next?
monitor pt's glucose
32
If Hypoglycemia occurs during Addison’s crisis, what should the nurse do?
administer iv glucose
33
What are signs and symptoms of Addison's crisis
hypoglycemia
- weakness
- fatigue
-severe hypotension
- nausea/vomiting
- dehydration
- dysrhythmias
- shock
34
What are side effects of chemo therapy?
Nausea vomiting, hair loss, loss of appetite, sores in mouth (24-48 hours can be
delayed up to one week.
bone marrow suppression
* Alopecia
* Weight gain or loss
* Anorexia
* Fatigue
* Decline infunctional status
* Mucositis
* “Chemo” Brain
35
The nurse formulates the nursing diagnosis of Urinary retention related to
sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention
should the nurse implement?
ANSWER- Teach the client techniques of
intermittent self-catheterization
36
What is the first step of meningitis?
-Blood test
- broad spectrum antibiotics (penicillin- ampicillin) and cephalosporin
- Corticosteroids
37
What is the priority care for a patient with meningitis
- droplet precautions
-Private room
-cultures right away (detects resistance)
-broad spectrum antibiotic given after blood draw to decrease the risk of altering
results
-Keep room dark with low stimuli
38
The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse
would plan which of the following as a priority action?
place on cardiac monitor
39
The client hemodialyzed suddenly becomes short of breath and complains of chest
pain. The client is tachycardic, pale and anxious. The nurse suspects air embolism.
The priority action for the nurse is to
ANSWER- discontinue dialysis and notify
the physician
40
A nurse is caring for a client who has Cushing’s syndrome. Which of the following
clinical manifestations should the nurse expect to observe? (Select all that apply.
ANSWER- 1) Buffalo hump
2) Purple striations
3) Moon face
41
The nurse is developing a plan of care for a client with Cushing’s syndrome. The
nurse documents a client problem of excess fluid volume. Which nursing actions
should be included in the care plan for this client? Select all that apply.
ANSWER- Answer: Monitor daily weight.
Monitor intake and output.
Assess extremities for edema
42
The home health care nurse is caring for a client with cancer who is complaining of
acute pain. The most appropriate determination of the client’s pain should include
which assessment?
ANSWER- The client’s pain rating
43
A female client who has breast cancer with metastasis to the liver and spine is
admitted with constant, severe pain despite around-the-clock use of oxycodone
(Percodan) and amitriptyline (Elavil) for pain control at home. During the
admission assessment, which information is most important for the nurse to
obtain?
NSWER- Sensory pattern, area, intensity, and nature of the pain
44
A client is admitted to the hospital with intractable pain. What instruction should
the nurse provide the UAP who is assisting with a bed bath?
ANSWER- Take
measures to promote as much comfort as possible
45
Two clients with polydipsia and polyuria arrived at the hospital. Both were having
similar symptoms but were diagnosed with different types of diabetes insipidus.
Which assessment finding helped to differentiate the diagnosis?
Answer: Urine Osmolarity
46
A client has a history of GERD. Why should the nurse monitor the client for
clinical manifestation of heart disease?
Esophageal pain may imitate the symptoms of a heart attack
47
A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes
about self-care. What is the primary long-term goal this nurse and client should
agree on?
Maintaining normoglycemia
48
The nurse is caring for a client before, during and immediately after surgery.
Which type of care is provided to the client?
Care that supports homeostatic regulation
49
A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection.
The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and
is in the 10th percentile for both height and weight. What is the priority nursing
intervention?
perform postural drainage
50
A nurse is planning to teach a school-aged child with newly diagnosed type 1
diabetes about self-care. After an assessment of what the child knows about
diabetes, what is the next nursing intervention?
Developing a sequence of goals with the child and parent
51
The nurse concludes that a client with glaucoma needs education when the client
makes which statement?
“It is dangerous for me to use sedatives.”
Sedatives have no effect on intraocular pressure
52
A mother reports feeding her infant immediately before arriving in the emergency
department. After completing the assessment, the nurse reports which finding
immediately to the primary healthcare provider because it likely indicated pyloric
stenosis?
Peristaltic waves that transverse the epigastrium
53
The registered nurse is teaching a student nurse the points to be included while
educating a client on cortisol replacement therapy about self-management. Which
statement provided by the student nurse indicates the need for further teaching
“I will advise the client to take the medication before meals.”
54
A client with stage 3 Alzheimer’s disease is living with his son and daughter-inlaw.
The visiting nurse is educating the family about the progression of the illness,
including “sundown syndrome,” and is assisting with care planning and comfort
measures. Which statement by the daughter-in-law reflects that the teaching has
been effective?
“We will have locks placed at the top of all the outside doors.”
Rationale:
Placing locks at the top of the doors is an important safety intervention. The term
“sundown syndrome” refers to behaviors that become more pronounced in the
evening. Clients with late stage dementia are prone to wandering, especially at
night.
55
A client with long-term alcohol addiction is admitted to the emergency department.
Which medications should the nurse anticipate the healthcare provider will
prescribe for this client?
Diazepam.
Multivitamins.
Thiamine (vitamin B1).
Rationale:
Alcohol withdrawal delirium usually peaks 48-72 hours since last consumption of
alcohol. The diazepam has sedative and anticonvulsant properties. Thiamine and
multivitamins are usually given to help with nutritional and malabsorption
deficiencies common in clients with alcohol addiction
56
what is the best diet for a patient with diarrhea?
Brat
Bananas, rice, applesauce, and toast.
NO MILK/ DAIRY
NO GREASY FOODS
Pedialyte
57
A client with stage 2 Alzheimer’s disease is being cared for at home by the spouse.
The client’s spouse tells the nurse about the emotional difficulties involved in
providing fulltime care at home. Which self-care activity is most important for the
nurse to recommend to the spouse?
Periodic times of respite from caregiving.
Rationale:
Caregiver role strain may be attributed to many different factors. The nurse must
become familiar with this diagnosis in order to accurately assess the caregiver and
offer effective interventions. One important recommendation is to have the
caregiver incorporate periodic breaks as part of the daily routine to relieve stress.
The nurse should contact the client’s manager and provide the client’s caregiver a
list of agencies offering “Respite Care”.
58
The nurse and the treatment team establish a weekly weight gain goal for a client
with anorexia nervosa. The client agrees to the goal, but continues to engage in
vigorous exercise before the weight gain goal has been met. Which statement by
the nurse is most effective in this situation?
“According to our agreement, no exercising is permitted until you have reached
your goal.”
Rationale:
Clients must be held accountable for behaviors that are not consistent with
treatment plan goals. The nurse is correct to remind client about the previously
established weight gain goals and to state that exercise should be limited (or not
permitted) until the weekly goal has been achieved.
59
Which behaviors indicate that the treatment plan for a client in alcohol
rehabilitation has been effective?
Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has
spoken with employer about returning to work.
Rationale: The statement “one day at a time” reflects the Alcoholics Anonymous
(AA) philosophy. AA promotes a 12-step program that has been successful in
helping individuals who desire to stop drinking and abusing substances.
Individuals learn about sobriety and responsibility through the support of other
members.
60
A client is admitted due to alcohol intoxication and injuries sustained in a fall. The
client appears anxious, agitated, and diaphoretic. Vital signs include a pulse of 140
and a blood pressure of 170/98. Delirium is suspected due to the client’s claim that
bugs are crawling on the bed. Which medication should the nurse expect will be
administered to the client?
Chlordiazepoxide (Librium).
Rationale: The information provided indicates that the client is experiencing
alcohol withdrawal, and is therefore at an increased risk for seizures.
Chlordiazepoxide (Librium) raises the seizure threshold to reduce the risk of
convulsions.
61
A client is undergoing treatment for schizophrenia. Which outcome provides
evidence that the client’s negative symptoms are improving?
Participates in music therapy and states that he enjoys playing the drums.
Rationale: An inability to experience pleasure and a desire to remain isolated are
examples of negative symptoms exhibited by clients with schizophrenia. By
participating in therapy and expressing enjoyment, the client shows a decrease in
negative symptoms and evidence that the treatment is being effective
62
The emergency department nurse is providing care for a rape victim. Which action
represents an essential element of care for this client?
Providing nonjudgmental care.
Rationale: The nurse’s attitude can have an important therapeutic effect on the
victim of rape. Displays of shock, horror, disgust, or disbelief can increase anxiety
and shame. When providing care for a rape victim, it is essential to maintain a
nonjudgemental attitude, and to let the client talk while listening attentively
63
A newborn yellow abdomen and chest
Assess bilirubin level
64
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal
bleeding after the IV Pitocin is infused. When notifying the healthcare provider of
the condition, what information is most important for the nurse to provide?
maternal bp
65
A 36-week primigravida is admitted to labor and delivery with severe abdominal
pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch.
The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120
beats/minute. What action should the nurse implement first?
get written consent for emergency c section
66
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration.
The nurse determines that the increased respiratory rate is a compensatory
mechanism for wich acid base alteration?
met acid
67
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after
spontaneous rupture of the membranes, the nurse notes several sudden decreases in
the fetal heart rate with quick return to baseline, with and without contractions.
Based on this fetal heart rate pattern, which intervention is best for the nurse to
implement?
Place the client in a slight Trendelenburg position.
The goal is to relieve pressure on the umbilical cord, and placing the client in a
slight Trendelenburg position is most likely to relieve that pressure. The FHR
pattern is indicative of a variable fetal heart rate deceleration, which is typically
caused by cord compression and can occur with or without contractions.
68
The nurse calls a client who is 4 days postpartum to follow up about her transition
with her newborn son at home. The woman tells the nurse, “I don’t know what is
wrong. I love my son, but I feel so let down. I seem to cry for no reason!” Which
adjustment phase should the nurse determine the client is experiencing
Postpartum blues
During the postpartum period, when serum hormone levels fall, women are
emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth postpartum day.
The taking-in phase is the period following birth when the mother focuses on her
own psychological needs; typically, this period lasts for 24 hours. Crying is not a
maladaptive attachment response. It indicates a normal physical and emotional
response. The letting-go phase is when the mother sees the child as a separate
individual.
69
The Total bilirubin of a 36-hour, breastfeeding newborn is 14mg/dL. Based on this
finding, Which intervention should the nurse implement?
encourage to breastfeed frequently
70
A multigravida client arrives at the labor and delivery unit and tell the nurse that
her “bag of water” has broken. The nurse identifies the presence of meconium fluid
on the perineum and determines the fetal heart rate is between 140 to 150 bpm.
What action should the nurse implement next?
Complete a sterile vaginal exam.
A vaginal exam should be preformed after the rupture of membranes to determine
the presence of a prolapsed cord.
71
A woman who gave birth 48 hours ago is bottle feeding her infant. During
assessment, the nurse determines that both breasts are swollen, warm, and tender
upon palpation. What action should the nurse take?
Apply cold compress to both breast for comfort
72
When explaining “postpartum blues” to a client who is one day postpartum, which
symptoms should the nurse include in the teaching plan?(Select all that apply)
-Mood swings
-Tearfulness
73
risk factor for abruptio placentae
htn
74
A client with obsessive-compulsive personality disorder is admitted for
laparascopic surgery of the gallbladder. What is the nurse likely to observe in the
client prior to surgery?
Client keeps detailed notes of everything that is said by the nurse about the
procedure and the postoperative instructions.
Rationale: OCD is characterized by an occupation with control. Patients are very
perfectionistic and rigid in their behavior and thought patterns. Taking detailed
notes of everything being said is an attempt to regain control in a stressful
situation.
75
A client is experiencing symptoms of alcohol withdrawal. During which interval is
the client most likely to develop a seizure?
12 to 48 hours after the last drink.
Rationale: The risk for seizures is highest 12 to 48 hours after the last drink
76
A client with schizophrenia suddenly becomes very anxious and says that an evil
alien is trying to get him. What should the nurse do at this time?
Relocate the client to the assigned room and suggest doing a puzzle together.
Rationale: the nurse should distract an anxious client with a non-threatening
activity in a low stimuli environment. Solving a puzzle together in the client’s room
will help reduce anxiety
77
A client with an anxiety disorder is having trouble completing work because
emails need to be reread several times before sending to ensure nothing
inappropriate is written. Which disorder is this client most likely experiencing?
Obsessive-compulsive disorder (OCD).
Rationale: client with OCD present with a combination of repetitive thoughts and
specific fears (obsession), as well as stereotyped, ritualized behavior (compulsions)
that are used to reduce that fear
78
