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Carla is teaching a group of middleschool students about osteoporosis and bone health. Which statement, if made bya student, demonstrates that further teaching is needed about osteoporosis?
a. my grandmother has osteoporosis. ill suggest weight-bearing exercises
B/ Ill tell my mother to stop smoking to prevent primary osteoporosis
C. i need to drink more milk to prevent osteo.
d. why do I need to learn this? it wont matter when im 45
Once an alteration in body image isidentified, the primary nurse for Jeff develops a plan of care. Which outcomeis expected?
A. the client will have a positive internal picture of himself most of the time.
B. the client will verbalize his feelings about how others regard him
C. the client will demonstrate adjustments to changes in his health status
Sierra has developed osteomyelitis inher right leg. Her primary physician needs to determine whether herosteomyelitis is acute or chronic. Which symptoms indicate an acute episode ofosteomyelitis?
A. fever, erythema of affected area, and tenderness to touch
B. ulceration of the skin, fever, and localized pain
C. sinus tract formation, drainage and erythema
D. localized pain, ulceration of the skin, and constant bone pain
Sierra's primary nurse is developingher plan of care in caring for her osteomyelitis. Which nursing interventionshould be performed first?
A. assess temperature
B. medicate for severe pain
C. assess for pain
D medicate for infection
The physician has written the following ordersfor a child with Duchenne muscular dystrophy hospitalized for a respiratoryinfection. The nurse should question which order?
A, strict bedrest
B. physical therapy
C. antibiotic therapy
D. passive ROM
Kyle is a 17-year-old boy admitted to theemergency department following a stab wound to his abdomen while involved in aschoolyard fight. Once stabilized, the client is admitted to the generalmedical-surgical unit. Which nursing intervention should be done first?
A. assess skin temp and color
B. medicate for pain
C. assess urine output
D. assess vital signs
Following an automobile accident, aclient is admitted with possible abdominal trauma. All of the following ordersare written by the physician. Which of the orders will the nurse implementfirst?
A. take the client for computed tomography of the abdomen
B. insert ng tube and connect to intermittent suction
C. start IV and infuse saline at 200mL/hr
The RN working on the medical-surgicalunit has just received report about the following four clients. Which clientwill the RN assess first?
A. a client who has returned to the unit after a colon resection with a new colostomy stoma, which is dark pink
B. a client who has been admitted following a motor vehicle accident and has exxhymoses on both flanks
C. a client w/pneumonia who has abdominal distention and markedly decreased bowel tones
D. client w/familial adenomatous polyposos who is scheduled for a colonoscopy
Lisa has a history of portalhypertension. She has begun to manifest signs of hematemesis, and has just lostconsciousness. Which nursing interventions should be performed first?
A. monitor vital signs, especially b/p
B. assess for other signs of hemorrhage
C. administer IV fluids
D. use a soft toothbrush for oral care
As Mark begins his career in nursing,he is counseled upon ways to prevent contracting hepatitis. Which remarkindicates the need for further teaching?
A. I should use standard precautions with each and every client
B. i shoudl receive the hepatitis B vaccine in 3 dosages
C. I should use standard precautions in knownw infected clients
D. i shoudl avoid using needles when needleless systems are presents
The nursing team consists of an RN, twoLPNs/LVNs, and three CNAs. The RN should care for which of the followingclients?
A. an obtunded client with alcoholic encephalopathy requiring a blood draw
B. a client with hepatitis C requiring a dressing change
C. A client on lactulose with diarrhea
D. a client w/end-stage alcoholic cirrhosis requiring instruction about a low-protein diet
An LPN from the oncology unit"floats" to the renal inpatient unit where you are the nurse manager.Which client would be best to assign to the LPN?
A. a 43y/o client with MS who requires intermittent straight cath.
B. 44 y/o type 2 diabetic client who is scheduled for IV urography
C. 18y/o client with acute pain due to renal calculi who is receiving IV morphine sulfate
D. 76y/o client with renal insufficiency who is having a renal biopsy this afternoon
The charge nurse is making client assignmentsfor the day shift. Which of these clients would be most appropriate to assignto a nursing assistant?
A. 34y.o diabetic client who has just returned from having arenal arteriogram
B.76y.o with a ureteral stricture who is scheduled for a renal ultrasound
C 24y.o who is NPO for a possible cystoscopy and cystourethroscopy
D. 56y.o with chronic glomerulonephritis who is having a renal biopsy
The RN is caring for a client who has justreturned from having a renal artery arteriogram. All of the followinginterventions are ordered. Which action should the nurse take first?
A. obtain BUN and creatinine
B> insert retention catheter
C. take pulse and b/p
D infuse normal saline at 100mL/hr
The RN is caring for a diabetic client who hasbeen NPO for IV urography. When the client returns to the nursing unit, all ofthe following interventions are ordered. Which one will the nurse accomplishfirst?
A. reg. insulin, 12 units sub.
B. 1200 calorie diabetic diet as tolerated
C. .45% normal saline infusion at 125mL/hr
D. senokot tabs, 3 today
Which of the following clients is at highestrisk for developing renal failure associated with diabetes?
A. 30y.o client with type 1 diabetes and hypertension controlled by meoprolol
B. 42y.o client with type 1 and HbA1c of 3.5%
C. 50y.o with type 2 diabetes who is obese
D. 63y.o with type 1 and retinopathy
You have just received report from theemergency department on a client with diabetic ketoacidosis. As you prepare forher admission on your medical unit, which of the following interventions do youanticipate will be given the highest priority?
a. urine ketone checks every hour
B. infuse 3 to 5L of normal saline
C. continuous IV infusion of reg. insulin
D. glucagon 1mg IV
A 10 year-old diabetic tells the school nursethat he has some early signs of hypoglycemia. The nurse recommends that thechild:
a. Take an extra injection of regular insulin
b. Drink a glass of orange juice
c. Skip the next insulin dose
d. Start exercising
An adolescent with diabetes has had severalepisodes demonstrating a lack of diabetic control. The nurse is reviewingtechniques for checking the control of diabetes. The nurse states to theadolescent, "The best way to maintain control or your disease is to:
A. check your urine glucose three times a week
B. check your glycosolated hemoglobin every 3 months and then every 6 months when stable
C. check your blood glucose at least twice a day and the clycosolated hemoglobin every month
D. check your blood glucose daily as long as you feel well
A 12 year-old boy was just diagnosed with type1 diabetes. As the nurse teaches him about insulin injections, he asks why hecan't take the diabetic pills like his aunt takes. What would be the bestresponse by the nurse?
A you will be able to take the pills when you reach adulthood
B. you have a different type of diabetes where the pills wont work
C. we have to test you to see if you can take the diabetic pills
D. you might be able to alternate taking the pills and insulin
The charge nurse on the medicalsurgical unit is making client assignments for the shift. Which of thefollowing clients will be most appropriate to assign to a nursing assistant?
A. 22y.o client with possible pituitary adenoma who has just arrived on the nursing unit
B. 34y.o client with cushing's syndrome who requires orthostatic b/p assessment
C. 50y.o client with exophthalmos who has many questions about endocrine function testing
D. 52 y.o with acromegaly who is scheduled for a growth hormone suppression test
A mother of a 4 month-old tells the nurse thather child has been diagnosed with hypothyroidism. The nurse notes which of thefollowing symptoms that is NOT consistent with this diagnosis?
A, high pitched cry
B. prolonged jaundice at birth
C. described as a good baby
A 2 month-old infant arrives at the pediatricclinic. Upon assessment, the baby exhibits the following characteristics. Whichcharacteristic does the nurse relate to a diagnosis of congenitalhypothyroidism?
a. Open fontanels
You have just received report on the endocrineunit. Which client should you see first?
A.The20-year-old newly diagnosed type 1 diabetic client complaining of polydipsiaand fatigue
B 30y.o type 1 diabetic client with continuous sub. insulin pump who just reported that her insulin pump is beeping "occlusion"
C. 40 y.o type 2 client with a blood glucose of 400mg/dL who is feelig nauseated
D. 6-y.o with type 2 witha b/p of 150/90
All of the following diagnosticinformation is obtained for a client admitted with a possible pituitarydisorder. Which information has the most immediate implications for theclient’s care?
a. Blood glucose 125 mg/dL
b. Blood urea nitrogen 40 mg/dL
c. Serum potassium 5.2 mEq/L
d. Serum sodium 110 mEq/L
lFiberoptic tube is insertedinto a joint for direct visualization or to remove cartilage or bone fragmentsin the joint that cause pain....flex the knee
lSwelling and tenderness
lErythema & heat
lUlceration(major difference btwn acute and chronic osteomyelitis is ULCERATION)
¡Reduce and immobilize fracturevia direct visualization and realignment of the bone with pins, screws, rods orprostheses
¡Percutaneous pins and wiresattached to a rigid external frame
¡Bone chips from client (iliaccrest) or cadaver packed and wired to end of bone to facilitate bone growth.
-Replacement of severely damaged hip, usuallyfrom arthritis or femoral neck fractures, with artificial joint
Yourpatient has just returned from a scope procedure to obtain a biopsy of hisgastric mucosa. Which of the following assessments would be a priority?
nBackward flow (reflux) of gastrointestinalcontents into the esophagus
nProtrusion of the stomach through theesophageal hiatus of the diaphragm into the thorax
nHelicobacterpylori, Escherichia coli can cause gastritis, NSAID, & ETOH
nSymptoms includeepigastric pain, anorexia, N & V
nAutoimmunity, H. pylori,ETOH, stressful lifestyle and smoking
nTwo types (A & B)
nVague symptoms which mayinclude epigastric pain, anorexia, N & V, pernicious anemia.
nAt risk for hemorrhage
nErosion of the mucosal liningof the stomach or duodenum to the point at which the epithelium is exposed togastric acid and pepsin (autodigestion)
nNasogastric tube management
nInsure patency to avoidabdominal distention
nSecure to prevent dislodgement
nSecretions may include a scantamount of blood for the first 12-24 hours
Irritable BowelSyndrome (IBS)
nPhysically obstructed due tofactors outside of the intestine (adhesions or hernias) or by blockages in theintestinal lumen (tumors, inflammation or fecal impactions)
nNeuromuscular disturbance(also known as a paralytic ileus)
nPatientmore at risk that have had abdominal surgery, always assess for bowel soundsand make sure patient ambulates
nAcute inflammation of abdominal cavity
nCaused by bacteria entering sterile cavity
unknown etiology characterizedby remissions and exacerbations (flare-ups).
nCramping, abdominal pain,loose stools containing blood and mucus, poor absorption of vital nutrients,and thickening of the colon wall can result.
nPrimarily affects young people(15-25) and is more common in females
nIdiopathic inflammatorydisease of the small intestine and the colon, or both
nIncreased resistance orobstruction to flow of blood through portal vein
nAffects spleen, esophagus,stomach, intestines, abdomen and rectum
nThin walled esophageal veinsbecome distended from increased pressure
nFluid accumulation inperitoneal cavity
nCaused from portalhypertension
nInflammation of thegallbladder, lasts 2-3 days
nMost often caused bygallstones
nSerious inflammatory processof pancreas
A clienthad a cast applied 2 hours ago for a fractured left femur. All of the followingfindings are suggestive of the possibility of compartment syndrome except:
Cystography and Cystourethrography
nInstilling dye into bladder via urethralcatheter
nMonitoring for infection
Renal Arteriography (Angiography)
nInject dye into femoral artery
ncheck dressing and pulses
nbedrest 4-6 hours nothing by mouth
nInflammation of bladder
nUsually infection frombacteria
nCatheters most common causefor UTIs in hospitalsCan lead to urospesis
nPresence of calculi (stones) in the urinarytract
nHistory of urologic stones
nExtracorporeal shock wave lithotripsy usessound, laser, or dry shock wave energy to break the stone into small fragments.
Key Features of Chronic Pyelonephritis
nUsually secondary to urinary tract anomaly,obstruction or reflux disease
nInability to conserve sodium
nDecreased concentrating ability
nTendency to develop hyperkalemia and acidosis
nThickening in the nephron blood vessels,resulting in narrowing of the vessel lumen
nOccurs with all types of hypertension,atherosclerois, and diabetes mellitus (leads to diabetic nephropathy)
ndropin urine output/NA level is higher, but of so much fluid it delutes the numberof NA called delutional hyponutrienium…this is difference btwn acute andchronic renal failure
Chronic Renal Failure
nDysfunction of the PosteriorPituitary GlandDeficiency of antidiuretic hormone (ADH) also known asvasopressin
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) manifestations
qHeadache, weakness, anorexia,muscle cramps and weight gain
nFluid volume excess: heart will work harder
qCrackles in the lungs
qDistended neck veins (bed at 45 degree angel)
qTaut skin (edema)
nbuffalo hump, enlarged trunk,acne, muscle wasting, weakness, emotional liability (causedby steroid drug)
nHirsutism, clitoralhypertrophy, and male pattern balding in women
nExcessive production thyroid hormones
nNormal feedback system has failed
nProducing state of hypermetabolism increasing sympathetic nervous systemactivity
Grave’s Disease (mostcommon cause of hyperthyroidism)
nAutoimmune antibodies thatmimic TSH, stimulates hypersecretion of thyroid hormones
nOccurs if hyperthyroidism ispoorly controlled, untreated or if the individual is stressed
nMedical emergency with a highmortality rate due to the increase in body metabolism, vasometabolicrate extremely high!
Maintain a patent airway
-Monitor for dysrhythmias
-Medications to decrease temperature (Tylenol, Motrin), decrease SNS activity
-Blood glucose with coverage
-O2 as needed
nIncreased in sleeping time
nGeneralized weakness,anorexia, muscle aches
nCourse features, puffy face,hands and feet
nUnintentional weight gain
nEdema around eyes and face
nThick tongue, husky voice
nRisk for constipation
nOverall muscle movement slow
nDecreased cardiac output
-decreased blood pressure
nCardiacmuscle becomes flabby and the chamber size increases, augments an alreadydepressed cardiac output
nParathyroid glands: calcium (more calcium so problems with clots) and phosphatebalance
nHyperglycemia secondary toproblems with insulin secretion or insulin resistance
nIncrease risk for infections
nControlled by exogenousinsulin
nRisk for DKA and insulin coma
nIncreased risk for infections
nControlled by diet and oralantidiabetic medications, later may require insulin
nRisk for HHNK
-Build up of excessive acids; body’s attempt to rid
-Breath smells “fruity”
-Cardiovascular—MI, CAD, Heart Failure, angina
Damage to small arteries and veins (Neuropathy), kidneys: major form from diabetes
-Eye and Vision Problems
nSkin cool, clammy
nAnxiety, irritable, confusion,blurred vision
nGeneral weakness, seizures
nCan be a result of too muchinsulin, or omission of a meal
nTreat with glucose source (15gof Carbohydrates)
nBiggestmistreatment in hospital is when person takes insulin but goes down for aprocedure before eating
nHot, dry, skin
nAbsence of diaphoresis
nAlert to coma
nNausea and vomiting, abdominalpain (with DKA)
nTreat with oral hypoglycemics,insulin
üRapid-acting (Humalog, lispro)
üOnset 15 minutes; Peaks .5-1.5 hours, Remainsin body 2-6 hours
üCan inject right before meal, Packaged inpurple-topped vial
üShort Acting (Humulin R, regular)
üOnset ½ to 1hour, peaks 2-3 hours, Remains in body 3-10 hours
üInject ½ to 45 minutes before meals
üOnset 2-4 hours, Peaks 4-12 hours, Remains inbody 10-20 hours
üFrequently mixed with regular
üMaybe given twice a day
üLong acting (Ultralente)
üOnset 6-10 hours, Peaks 8-20 hours, remainsin body 18-24 hours
üNot used a often
üLong acting (Lantus)
üDuration 24 hour
Signs and symptoms of SIADShyponatremia include
You not a patient has a nursingdiagnosis of Peripheral Neurovascular Dysfunction involving both feet, which ofthe following assessmentas would support this diagnosis?
States, I can not feel my feetanymore
–Abnormal, sudden,excessive, uncontrolled electrical discharge of neurons within the brain; mayresult in alteration in consciousness, motor or sensory ability, and/orbehavior
–Chronic disorderwith recurrent, unprovoked seizures
– may be caused byabnormality in electrical neuronal activity, and/or imbalance ofneurotransmitters
•Tonic: stiffens up, experience some type of ora
•Colonic: jerky, spasmodic movement, no recollection ofmovement/seizure
•Not so high level functioning
•marching seizure, can involve a side of the body
•Primary oridiopathic epilepsy
•results from anunderlying brain lesion, most commonly a tumor or trauma
–Prolongedseizures lasting more than 5 minutes or repeated seizures over the course of 30minutes
–Risks include common viral illnesses (i.e., mumps,measles, and herpes)Resolves without treatment
–Risks include bacterial infections (strep) orURI (otitis media)
–High mortality rate, 25%
–Reduce medication dose.
–Change medications or frequency ofadministration.
–Take “drug holiday,” especially in the use oflevodopa therapy.
•Chronic,progressive, degenerative disease that accounts for 60% of dementias occurringin people older than 65 years of age
•Risk with in first hour after injury due toloss of autonomic function
•This condition is characterized by thefollowing below the level of injury:
–Lift extremity it drops, noreflexes and no resistance
–Loss of reflex activity below the level ofthe lesion
•Chronic autoimmune disease affecting themyelin sheath and conduction pathway of the CNS
Amyotrophic Lateral Sclerosis
•Known as Lou Gehrig’s disease, a progressiveand degenerative disease that involves the motor system (affects thoracic and up, main difference is respiratory issues***)
•An acute autoimmune disorder
–Destruction ofmyelin sheaths
–Muscle weaknessand paralysis
•Autoimmunedisease that produces severe muscle weakness.
•characterized byperiods of exacerbation and remission.
•Primarily in musclesinnervated by cranial nerves **ON EXAM, as wellas in skeletal and respiratory muscles.(changes infacial muscle movement, difficulty swallowing, affects sholders and up)
• an exacerbation of the myasthenic symptomscaused by undermedication with anticholinesterases
–Priority for nursing management is tomaintain adequate respiratory function.
–Cholinesterase inhibiting drugs ineffectiveduring crisis and cause increase in secretions
•acute exacerbation of muscle weakness causedby overmedication with cholinergic (anticholinesterase) drugs
–Muscle twitching to the point of respiratorycompromise
–Priority to maintain respiratory function
–Symptoms improve with anticholinergicmedications (atropine)
•A disruption in the normal blood supply tothe brain may lead to death after a few minutes.
•The brain is unable to store oxygen orglucose and must receive a constant flow of blood to function.
•Ischemic strokes/Thrombotic strokes
•Narrowing of arteries, that isdelivering O2 to the brain has a TIA (See below)
•Transient ischemic attack and reversibleischemic neurologic deficit
•resulting from ruptured aneurysm,arteriovenous malformation (space occupying lesion)
Client isadmitted with a stroke on neurologic assessment, nurse notes that the clientsarms wrists and finger have become flexed there is internal rotation andplantar flexion of the legs what would the nurse’s best action
A. determin client's advance directive status
B. repotision client to prevent contractures
C. document findings only
D. notify physicia
Glasgow Coma Scale
The nurse is assessing a client withtraumatic brain injury, the nurse knows what the ealiest signs of decreased LOCinclused all of the following except
A memory loss
B. glascow coma scale of <7
Ofthe following clients, which one should the nurse assess first after takingreport?
A. 85 y.o client with a subdural hematoma who is scheduled for repeat computed tomography scan that evening with a current glascow score of 13
B. 71 y.o client with a history of transient ischemic attacks scheduled for a carotid endarterectomy the following day
c. 45y.o client with breast cancer and brain metastatic disease who is receiving chemo.
D. 23 y.o client with a history of closed head injury who is suddenly vomiting and has a glasgow score decreased from 14 to 12
Ofthe following clients, which one would not be appropriate to assign to a newgraduate RN who is working independently on the medical-surgical unit in asmall hospital?
A. 24y.o pregnant woman with a history of myasthenia gravis who has been admitted for cholecystitis
B. 39y.o client diagnosed with tic douloureux and admitted for pain control with IV fluids
C. 48y.o admitted from the ER with descending Guillain-Barre syndrome
D. 61y.o with pancreatic cancer who is admitted for pain control related to peripheral neuropathy
Ofthe following nursing diagnoses that are pertinent to the client withmyasthenia gravis, which is of priority?
a.Impaired Verbal Communication related to muscle weakness
b.Self-Care Deficit related to fatigue and muscle weaknessc. Risk for Ineffective Breathing Patternrelated to muscle weakness
Youare working with a nursing assistant when caring for a gentleman withGuillain-Barré syndrome. When turning the client to assess his skin, you notethe client is having difficulty breathing. Of the following, which would beappropriate to have the nursing assistant do to assist you in managing thisscenario?
A. place an endo. tube into the client's airway
b. notify the physician of the client's deterioration
C. place the client supine and place an oral airway
D. go to the nurses' station and get anothe rRN
Youare the RN caring for a client on a rehabilitation unit for spinal cord–injuredclients. Your client has had a complete injury to T6. Suddenly you noticeflushing of the face and chest and the client complains of a severe headache.Blood pressure is elevated and the heart rate slow. Your first interventionshould be which of the following?
A. check for fecal impaction
B. straight-cath the client
C. help the client sit up
D. loosen the client's tight clothing
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