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HURST Psychiatric Nursing 2023 correctly solved.docx
Depression: Signs/Symptoms -loss of interest in life's activities -negative view of the world -anhedonia -usually related to loss -poor kept appearanc... [Show More] e Depression Signs/Symptoms: What is anhedonia? loss of pleasure in usually pleasurable things 00:12 01:10 Depression Signs/Symptoms: In mild depression there is _____________ while there is ______________ in severe depression weight gain; weight loss Depression Signs/Symptoms: There are crying spells with ________________ and no more tears with ___________________ mild to moderate depression; severe depression Depression Signs/Symptoms: It is commons for client's to experience sleep disturbances Depression Signs/Symptoms: These clients have slow thoughts so we need to speak slowly to them and use the therapeutic communication technique of silence (give them time to process) Depression Signs/Symptoms: Clients who are depressed can have ___________________ and _________________ delusions; hallucinations Depression Treatment: They may need help with their self-care Depression Treatment: Prevent _________________ because _______________________ makes the client feel better isolation; interacting with others Depression Treatment: Help them experience accomplishments Depression Treatment: Be careful with _______________ as they may make the client _________________ compliments; feel worse Depression Treatment: If severely depressed, ________________________________ may be the best thing you can do. It's a _______________________________ sitting with client and making no demands; self-esteem thing 00:00 01:10 Depression Treatment: As they feel better, encourage them to _____________________. Let the client know that _________________________________________ describe their feelings; you understand they are in pain and feel powerless Depression Treatment: Help them set accomplishable goals Depression Treatment: If they are capable, activities such as _________________________________________ will help with depression walking, running, weight lifting Depression Treatment: Assess for suicide risk Depression Treatment: As depression lifts, what happens to suicide risk? the risk goes up Depression Treatment: Observe clients when they start taking antidepressants because their risk for suicide just went up (increase in SSRIs and energy) Depression Treatment: A sudden change in mood towards the better may indicate that the client has made the decision to kill themselves Depression Treatment: Culturally, ____________________ have a higher suicide rate American Indians Depression Treatment: ___________ clients are particularly at risk for suicide Elderly Depression Treatment: ______________________ tend to be very successful because they generally use ______________________ Elderly men; very lethal methods Depression Treatment: When assessing suicide risk, ask clients 3 very important questions 1. do they have a plan? 2. what is the plan? 3. how lethal is the plan? Depression Treatment: When assessing suicide risk, determine if they ____________________ and if they have ever ____________________ have access to the plan; attempted suicide before Depression Treatment: When assessing suicide risk, watch for things like -isolating themselves -writing a will -collecting harmful objects -giving away their belongings Depression Treatment: Suicide interventions include -direct, closed ended statements -providing a safe environment -safe-proofing the room -getting a signed contract to postpone suicide Depression Treatment: A signed contract post poning suicide is done in hope that the client will develop coping mechanisms during this time Mania: One pole is __________ and the other is ________________ mania; depression Mania: Signs/Symptoms -continuous high -labile emotions (periods of extremes) -flight of ideas -delusions -constant motor activity -no inhibitions -altered sleep patterns -poor judgment -manipulation Mania: Delusions are just a false idea Mania: Types of delusions can include -delusions of grandeur (ex. client thinks they are Jesus) -delusions of persecution Mania: Constant motor activity leads to exhaustion Mania: Lack of inhibition can include -inappropriate dress -hyper-sexual behaviors (an attention-seeking mechanism) Mania: Manipulation makes these clients feel secure and powerful Mania Treatment: Decrease the stimuli Mania Treatment: Don't ___________ or __________________ argue; try to reason Mania Treatment: Do you talk a lot about the delusion? no Mania Treatment: Let the client know you ____________________________, but that you ___________________ accept that they need the belief or delusion; do not believe it Mania Treatment: Look for the underlying need in the delusion Mania Treatment: The underlying need with delusions of persecution is the need to feel safe Mania Treatment: The underlying need with delusions of grandeur is the need to feel good about self Mania Treatment: Set ___________ and be ______________ limits; consistent Mania Treatment: They feel most secure in one-on-one relationships Mania Treatment: Remove hazards (no cigarettes-1 or 2 then monitor) Mania Treatment: Stay with the client as anxiety increases Mania Treatment: These clients need a structured schedule Mania Treatment: Provide _______________ to replace _____________________________ activity; non-purposeful activity Mania Treatment: Supply __________________ because they are _________________________ finger foods; too busy to stop and eat Mania Treatment: Walk with client during meals Mania Treatment: Don't forget about ________________ because this client can become ____________________________________ fluids; dangerously dehydrated Mania Treatment: Make sure dignity is maintained Mania Treatment: ECT treatment can induce a tonic clonic seizure Mania Treatment: ECT treatment is used for clients with severe depression Mania Treatment: Prior to ECT treatment, what needs to happen? -client needs to be NPO -client needs to void -atropine is given (prevent aspiration) -consent is signed -succinylcholine (Anectine) is given (relax muscles) Mania Treatment: ECT treatments are given in a series of treatments depending on the client's response Mania Treatment: Following ECT treatment, what must be done? -position client on side (prevent aspiration) -stay with the client -reorient them repeatedly -return to day-to-day activities ASAP Mania Treatment: What is expected post ECT treatment? temporary memory loss IMPORTANT TO REMEMBER: With psych patients, get people involved and active!! Schizophrenia: Signs/Symptoms -focus is inward (they create their own world) -inappropriate affect, flat affect, or blunted affect -disorganized thoughts (looseness of associations) -ineffective communication skills -concrete thinking (don't say "clean your plate") -religiosity -delusions -hallucinations Schizophrenia: What is one of their biggest problems? communication Schizophrenia: What specific communication problems do they have? -echolalia -neologism -word salads Schizophrenia: What is echolalia? hearing a word and repeating it Schizophrenia: What is neologism? making up new words that have special meaning to the client, but NOT to the nurse Schizophrenia: What should you do when client expresses neologism? seek clarification (ex. I don't understand) Schizophrenia: With neologism, what do these words mean? nothing Schizophrenia: What are the most common hallucinations that these clients have? auditory Schizophrenia: Treatment includes -decreasing stimuli -frequent observation -frequent orientation -reality based conversation -observing for hallucinations Schizophrenia Treatment: When observing, make sure you don't look suspicious (physically go in the room-no peeking) Schizophrenia Treatment: With frequent orientation, it's important to remember that although client may know person, place, and time, delusions may still occur Schizophrenia Treatment: When observing for hallucinations, make sure you warn them before touching them Schizophrenia Treatment: When observing for hallucinations, make sure you don't refer to the voices as "they" because this makes the hallucinations seem real Schizophrenia Treatment: Pertaining to hallucinations, let the client know that you do NOT share the perception Schizophrenia Treatment: Hallucinations are connected to times of anxiety Schizophrenia Treatment: Get these patients involved in an activity Schizophrenia Treatment: Elevate the head of the bed Schizophrenia Treatment: Turn off the TV Schizophrenia Treatment: You should offer reassurance because the client is frightened Schizophrenia Treatment: The nurse should observe for command hallucinations, these are auditory hallucinations that command the client to hurt themselves or others Schizophrenia Treatment: Command hallucinations are often frightening for the client and can signal a psychiatric emergency Paranoid Personality Disorder: Signs/Symptoms -always suspicious for no reason -distrust of others -can't explain away their delusions or false beliefs -pathologic jealousy -hypersensitive to comments or actions -can't relax -no humor -unemotional -abnormal anger response, responds w/rage when provoked Paranoid Personality Disorder: Treatment includes -being reliable (do what you say to build trust!) -being honest -consistent nurses and brief visits -being matter-of-fact -respecting personal space -being careful with touch -don't mix medications -may need to give sealed foods -restraints [Show Less]
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HURST Renal question and answer rated A+
Where do most burns occur? At home How often should smoke detector batteries be changed? every 6-12 months 00:41 01:10 Flammable items ... [Show More] should be kept at least how far from heat sources? 3 feet The water heat device should be set no higher than 120 degrees fahrenheit Why does plasma seep out into the tissue after a burn? Increased capillary permeability When does the majority of plasma seepage occur? first 24 hours (worry about shock!) Why does the pulse increase after a burn? compensation; every time there is a FVD, the pulse will increase Why does the cardiac output decrease after a burn? there is less volume to pump out Why does the urine output decrease after a burn? kidneys are either trying to hold on to fluid or they aren't being perfused adequately Why is epinephrine secreted after a burn? because epi and norepi make you peripherally vasoconstrict, blood is shunted to the vital organs With a normal BP of 120/80, anytime the systolic BP drops below ______, the client will not have adequate organ perfusion; this can be very DANGEROUS 90 Why are ADH and aldosterone secreted after a burn? to retain sodium and water with aldosterone and retain water with ADH; this will increase blood volume 00:02 01:10 Rule of 9's: Head and Neck 9% Rule of 9's: Trunk (Front and Back) 36% total - front 18% and back 18% Rule of 9's: Arm 9% each Rule of 9's: Leg 18% each Rule of 9's: Genitalia 1% Partial thickness burns are also known as first and second degree burns Full thickness burns are also known as third and fourth degree burns If a burn is located on the face, neck, or chest there could be interference with breathing Burns: Risk Factors -heart, lung, or kidney disease -pre-existing diabetes or PVD can affect healing of foot or leg burns -other injuries that occurred when client was burned -higher mortality in very old and very young Why is there a higher mortality among the very old and very young with burns? -skin is very thin and they have less SQ fat -the burn can go deeper and cause more complications -body surface area is less in the very young Burns: Treatment Stop burning process -wrap client in blanket to stop (absent flames do not guarantee this) -cool water can stop -NO more than 10 minutes (can cause extensive heat loss) -remove jewelry because swelling will occur -remove non-adherent clothing and cover burns with clean, dry cloth What does a blanket do when stopping the burning process? help hold in body heat and keep out germs What is the number one cause of death with burns? inhalation injury inhalation injuries are usually caused by inhaling carbon monoxide OR hydrogen cyanide Normally, oxygen binds with hemoglobin Carbon monoxide ____________ __________ ______________ than oxygen; therefore travels much faster; it gets to the hemoglobin first and binds Is oxygen able to bind after carbon monoxide has? no The client becomes ____________ from carbon monoxide poisoning hypoxic Carbon Monoxide Poisoning: Treatment 100% oxygen Why will 100% oxygen help treat carbon monoxide poisoning? placing more O2 in the race to increase probability that O2 will bind before CO Hydrogen Cyanide: Treament 100% oxygen -an antidote may be given at the hospital It would be important to determine if the burn occurred in ________________________________________ an open or closed space If someone is burned in a closed space, they will have inhaled ___________ carbon monoxide and/or hydrogen cyanide so, more; the risk for complications is increased When you see a client with burns to the neck/face/chest, you should focus on their airway What might the primary healthcare provider do prophylactically? intubation (the airway can swell and close off) Indications of inhalation injury -singed nose hair -singed facial hair -soot on face -coughing up secretions with dark specks -difficult swallowing -wheezing -blisters found on the oral/pharyngeal mucosa -hoarseness -substernal/intercostal retractions and stridor are bad signs Is there more death with upper or lower body burns? upper because of the effects on the airway If a burn client's respirations are shallow what are they retaining? CO2 Which acid base imbalance will burn client with shallow respirations have? Respiratory acidosis One of the most important aspects of burn management is fluid replacement We are giving large volumes of fluid so the client will need at least 2 large bore IVs What fluids will be used for fluid replacement? crystalloids (LR) and colloids (albumin) Why is it important to know what time the burn occurred? because fluid replacement therapy (for the first 24 hours) is based on the time the injury occurred, not when the treatment was started Common Rule for fluid replacement therapy calculate the total amount of fluid needed for the first 24 hrs and then give half of the amount during the first 8 hours To calculate the fluid replacement properly, you must know the client's weight (in kg) and the TBSA affected If the client is restless, it could suggest three problems 1. inadequate fluid replacement 2. pain 3. hypoxia 1. inadequate fluid replacement 2. pain 3. hypoxia Which is the nurse's priority? hypoxia American Burn Association Fluid Requirement Formula (2-4mL of LR) X (body weight in kg) X (% of TBSA burned) = total fluid requirement for first 24 hrs after burn *4mLs used for electrical burns to prevent renal damage How much fluid is given per 8 hours? 1st 8 hours: 1/2 total volume 2nd 8 hours: 1/4 total volume 3rd 8 hours: 1/4 total volume Would you select a client's weight or their urine output to determine if their fluid volume is adequate? urine output Urinary output needs to be a minimum of 0.5 to 1 mL/kg/hr which is usually at least 30-50 mL/hr in an adult What is the urinary output goal in client's with electrical injuries? 75-100 mL/hr What is the required urinary output for children? 1mL/kg/hr Albumin is administered ___________ first 24 hours after; capillary permeability normal Albumin does what holds onto fluids in the vascular space What does albumin do to the vascular volume? increases it What does albumin do to kidney perfusion increases it What does albumin do to blood pressure? increases it What does albumin do to cardiac output? increases it Albumin helps correct a ___________ because we are putting more fluid in the _____________ ________________ FVD; vascular space When you start giving a client albumin, the vascular volume will increase What will happen to the workload of the heart when giving albumin? increase (more volume to pump) Albumin ALERT: If you stress the heart too much the client could go into FVE Albumin ALERT: if FVE occurs, what will happen to the cardiac output? it will decrease What is a measurement you could take hourly to ensure that an infusion is not overloading the client? CVP When giving a narcotic, especially IV, what is the most important reassessment you must make? respirations Why are IV pain meds preferred over IM with burns? IV meds act quickly [Show Less]
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Gastrointestinal Content Post Test- HURST question and answer already solved
The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect? Awake, a... [Show More] lert, and oriented reporting diffuse abdominal pain rated 9/10. Skin warm and dry. Cullen's sign noted. Abdomen rigid with guarding. Temperature 101 degrees F (38.3 degrees C), BP 96/64, HR 102, RR 26. Choose One 1. Cirrhosis 2. Pancreatitis 3. Peptic ulcer 4. Ulcerative colitis 2 Rationale 2. Correct: These s/s point to pancreatitis. Look at the big clues: Cullen's sign, rigid abdomen with guarding, and fever. 1. Incorrect: What are the classic s/s of cirrhosis that are different from pancreatitis? Firm, nodular liver, dyspepsia, change in bowel habits, splenomegaly, acites. 3. Incorrect: Peptic ulcers typically do not present with severe pain, but with a burning pain in the mid-epigastric area and back. Dyspepsia is common as well, but no bruising around the flank area or umbilicus. 4. Incorrect: Ulcerative colitis presents with diarrhea, rectal bleeding, vomiting, weight loss, cramping, rebound tenderness and fever. The nurse is educating a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include? Select All That Apply 1. Removes old RBCs from the body. 2. Produces clotting factors. 3. Detoxifies the body. 4. Releases digestive enzymes. 5. Breaks down medications. 2, 3, 5 Rationale 2., 3., & 5. Correct: Three of the four functions are listed: the liver produces clotting factors, detoxifies the body, and breaks down medications. It also synthesizes albumin. 1. Incorrect: The spleen, not the liver, removes old RBCs from the body. 4. Incorrect: The exocrine function of the pancreas releases digestive enzymes into the small intestine. What is the most important action for the nurse to take prior to a client having a liver biopsy? Choose One 1. Make certain the consent has been signed. 2. Obtain vital signs. 3. Check clotting study results. 4. Position client supine with right arm above head. 3 Rationale 3. Correct: This is a priority question. All actions should be done by the nurse, however, the nurse better check the clotting study results. The client could hemorrhage if the clotting factors are too messed up. 1. Incorrect: Yes, the consent must be signed, but what is more life saving? Checking the clotting factor results. 2. Incorrect: Yes, the nurse will need to obtain pre-procedure vital signs. However, the procedure may not be done if the clotting study results are bad. 4. Incorrect: Yes, the client will need to be positioned so that the primary healthcare provider has access to the liver. But again, this is not the priority. What signs/symptoms would lead the nurse to suspect that a client diagnosed with cirrhosis may be developing hepatic coma? Select All That Apply 1. Asterixis 2. Fetor 3. Grey Turner's sign 4. Hyperactive reflexes 5. Squiggly handwriting 1, 2, 5 Rationale 1., 2., & 5. Correct: Signs and symptoms that a client diagnosed with cirrhosis is getting worse and headed for hepatic coma include asterixis, fetor, and handwriting changes. 3. Incorrect: Grey Turner's sign is seen with pancreatitis. 4. Incorrect: With hepatic coma, the client is full of toxins, so reflexes will be decreased. The family of a client being treated for bleeding esophageal varices asks the nurse why the client is receiving octreotide. How should the nurse respond? Choose One 1. "Octreotide is an antibiotic given to decrease the risk of developing an infection." 2. "Taking this medication forms a protective barrier over the varices to prevent bleeding recurrence." 3. "Octreotide helps eliminate ammonia from the body." 4. "This medication lowers the pressure in the liver, so bleeding stops." 4 Rationale 4. Correct: Octreotide is a synthetic hormone that selectively inhibits the release of vasodilating hormones in the internal organs. By doing this it decreases blood flow to the liver. When you decrease blood flow to the liver, the pressure in the liver lowers. Less volume, less pressure. So, bleeding should stop. 1. Incorrect:Octreotide is not an antibiotic. 2. Incorrect: You might be thinking of sucralfate, which forms a barrier over an ulcer so acid can't get on the ulcer. 3. Incorrect: No, lactulose decreases ammonia. A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents? Select All That Apply 1. Miotic inhibitor 2. Serotonin antagonist 3. H2 antagonist 4. Acetylsalicyclic acid 5. Proton pump inhibitor 3, 5 Rationale 3., & 5. Correct: H2 antagonist or receptor blockers are used to decrease excess stomach acid seen with ulcers. Antisecretory agents like proton pump inhibitors are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids. Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori. 1. Incorrect: Mitotic inhibitors are chemotherapeutic agents that are indicated for the treatment of malignancies and cancerous cells. They are most often used in combination chemotherapy regimens to enhance the overall cytotoxic effect. 2. Incorrect: Serotonin antagonists are antiemetic agents that are indicated for the treatment of nausea and vomiting. Serotonin antagonists block the serotonin receptor sites located throughout the body responsible for the mediation of nausea and vomiting. 4. Incorrect: Acetylsalicylic acid is a non narcotic analgesic that inhibits the cox-2 protective mechanisms to the gastric mucosa. This could make the ulcer worse. Clients are advised to avoid the use of NSAIDs and acetylsalicylic acid due to increased bleeding potential. The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select All That Apply 1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating. 6. Lie down on left side after eating. 1, 2, 3, 4, 6 Rationale 1., 2, 3, 4., & 6. Correct: Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. After eating, the client should lie down on the left side to keep food in the stomach longer. 5. Incorrect: Sitting up after a meal is counterproductive, since this will increase the speed of food through the digestive tract. Therefore, clients are encouraged to lie down on the left side following meals to slow the processing of food. What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis? Select All That Apply 1. Abdominal cramping 2. Hematemesis 3. Diarrhea 4. Fever 5. Rebound tenderness 6. Rectal bleeding 1, 3, 4, 5, 6 Rationale 1., 3., 4., 5., & 6. Correct: Ulcerative colitis is an ulcerative inflammatory bowel disease in the large intestines. Common s/s include abdominal cramping, diarrhea, fever, rebound tenderness, and rectal bleeding. 2. Incorrect: Hematemesis is seen with upper GI bleeding. A client returns to the room post appendectomy. In what position should the nurse place the client? Choose One 1. Sims' 2. Prone 3. Semi-fowler's 4. Right lateral 3 Rationale 3. Correct: After any major abdominal surgery, the position of choice is to elevate the head of the bed 35-45 degrees. This will decrease pressure on the abdomen and suture line. 1. Incorrect: Sims' is a semi-prone position where the client assumes a posture halfway between lateral and prone. This is used for clients who need their airway protected. 2. Incorrect: Prone is not recommended. This will put more pressure on the suture line and abdomen. 4. Incorrect: Slightly side lying would be okay if the head of the bed was elevated to decrease abdominal and suture line pressure. The best position is semi-fowler's immediately post op. What interventions should the nurse include when caring for a client who is receiving total parenteral nutrition (TPN)? Select All That Apply 1. Change tubing and filter every 48 hours. 2. Monitor IV drip rate hourly. 3. Compare new bag with prescription prior to infusing. 4. Weigh weekly. 5. Cover TPN with dark bag. 6. Check urine for protein. 3, 5 Rationale 3., & 5. Correct: Remember safety and that TPN is a medication. You must make sure that what is in the bag is what was prescribed, so double check the bag against the prescription. Cover the IV bag with a dark bag to prevent chemical breakdown. 1. Incorrect: The IV tubing and filter must be changed with each new bag. Remember: A bag cannot hang more than 24 hours. 2. Incorrect: TPN must be placed on an IV pump. Relying on calculating to maintain a drip rate is dangerous. The client could get too much TPN too fast without having it on a pump at the prescribed rate per hour. This is a safety issue. 4. Incorrect: The client should be weighed daily. We want to make sure the client is not losing weight while on TPN. They should be maintaining or gaining weight. 6. Incorrect: Monitor urine for glucose and ketones. The only way protein will be in the urine is if the kidneys are damaged. [Show Less]
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NCLEX Practice Questions HURST (Adult Health) rated A+
A male client diagnosed with primary hyperaldosteronism is receiving spironolactone. Which potential side effect should the nurse educate the client regard... [Show More] ing? Select all that apply 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia 4. Hypernatremia 5. Hypokalemia 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia The nurse is preparing discharge teaching for a client diagnosed with peripheral vascular disease (PVD). Which teaching points should the nurse include about foot and leg care? Select all that apply 1. Wear soft cotton socks 2. Avoid hot whirlpools 3. Rub feet dry 4. Wash feet every other day 5. Clear pathways in house 1. Wear soft cotton socks 2. Avoid hot whirlpools 5. Clear pathways in house 00:03 01:10 The nurse is caring for a client diagnosed with Guillain-Barre' Syndrome. What assessment finding would the nurse expect see in this client? Select all that apply 1. Areflexia 2. Dysphagia 3. Hemiplegia 4. Orthostatic hypotension 5. Hypertonia 1. Areflexia 2. Dysphagia 4. Orthostatic hypotension A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible. 2. Wrap each digit individually to prevent webbing. The edrophonium (Tensilon) test has been prescribed for a client. Which statement by the client would indicate to the nurse that the client understands this test? 1. "This medication will be given to me as an IM injection immediately after my muscles are tired." 2. "This test will determine if I have multiple sclerosis." 3. "The test is positive if my muscles do not get stronger after injection with this medication." 4. "I will be asked to perform a repetitive movement to test my muscles." 4. "I will be asked to perform a repetitive movement to test my muscles." A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological 3. Airway What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? 1. Notify the primary healthcare provider 2. Monitor for paresthesia in the fingers and hands 3. Insert an indwelling urinary catheter 4. Assist the client with performing passive range of motion 1. Notify the primary healthcare provider A client reports excruciating paroxysmal facial pain occurring after feeling a cool breeze and drinking cold beverages. Based on this client's reports, what disorder does the nurse suspect? 1. Bell's palsy 2. Submucous cleft palate 3. Trigeminal neuralgia 4. Temporomandibular joint disorder (TMD) 3. Trigeminal neuralgia The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular 1. Renal A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider. 4. Notify the primary healthcare provider. What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? Select all that apply 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry. 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor What should the nurse include in the teaching plan for a client who has iron deficiency anemia? Select all that apply 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water. 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 4. Educate about ferrous sulfate supplement. 00:03 01:10 What should the nurse tell a 68 year old client who states that they have started experiencing tremors? 1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors." "We need to let your primary health care provider know because it may indicate a problem." A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis, and a 10 pound weight loss over the past month. The primary healthcare provider orders an antiemetic and daily mouthwashes. When the home care nurse evaluates the client one week later, what change described by the client would best indicate improvement? 1. Eating three meals daily. 2. Weight gain of two pounds. 3. No further mouth pain. 4. Improved skin turgor. 2. Weight gain of two pounds. The homecare nurse is visiting a client to assess the response to new medications ordered for benign prostatic hyperplasia (BPH). What symptoms reported by the client would indicate to the nurse the medications are not working? Select all that apply 1. Bladder pain 2. Fever with chills 3. Urinary frequency 4. Terminal dribbling 5. Nighttime sweats 1. Bladder pain 3. Urinary frequency 4. Terminal dribbling A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse? 1. “I feel like food gets stuck in my throat when I eat.” 2. “I have a hard time brushing my teeth properly.” 3. “My fingers burn when I go outside in the winter.” 4. “I get short of breath whenever I exercise.” 1. "I feel like food gets stuck in my throat when I eat." When explaining to caregivers how to reduce the risk of falls in their elderly parent, the nurse should educate about which measure? Select all that apply 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown. 3. Prevent respiratory complications. Following escharotomy of a circumferential burn to the arm, which assessment is the best indicator when evaluating the effectiveness of this procedure? 1. Decreased pain in the extremity 2. Prompt capillary refill < 2 seconds after blanching 3. Bleeding at the site of the incision 4. Ability of the client to wiggle his/her fingers 2. Prompt capillary refill < 2 seconds after blanching For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm 1. Urine output of 860 mL / 24 hours. A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates. 2. Protein must be limited because of elevated ammonia levels. The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse’s suspicions? Select all that apply 1. Diarrhea 2. Increased urination 3. Dilated pupils 4. Tachycardia 5. Nausea and vomiting 1. Diarrhea 2. Increased urination 5. Nausea and vomiting A client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding by the nurse is most significant? 1. Ventricular fibrillation 2. Ventricular tachycardia 3. 2nd degree AV block 4. Atrial fibrillation 1. Ventricular fibrillation A client with a deep partial-thickness burn to the right forearm has returned from surgery with a skin graft to the burned area. Which graft site intervention would the nurse implement within the first 24 hours? 1. Monitor temperature every 12 hours. 2. Position arm to prevent pressure to the graft site. 3. Prepare to change the 1st dressing within 24 hours. 4. Perform passive range of motion exercises to the right arm. 2. Position arm to prevent pressure to the graft site. What interventions should the nurse include when teaching a client how to prevent and treat fungal infections of the feet? Select all that apply 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe. Which assessment finding by the nurse is most indicative of fluid volume overload? 1. Client has pitting edema in lower extremities. 2. Client’s blood pressure is 120/80. 3. Client's CVP measurement is 6 mmHg. 4. Weight gain of 1.5 pounds (0.68 kg) in one day. 1. Client has pitting edema in lower extremities. An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. “Don’t be afraid because I will not let you fall.” 2. “Your doctor says you must walk twice today.” 3. “I’ll get another nurse to help so you won’t fall.” 4. “What worries you most about getting out of bed?” 4. "What worries you most about getting out of bed?" Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client’s level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse’s first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm. 1. Administer 100% oxygen per mask. Following nasal surgery, the nurse suspects a client has developed diabetes insipidus. The nurse knows what laboratory results provide evidence of diabetes insipidus? Select all that apply 1. White blood cells of 9,500 mm3 (9.5 x 10^9/L) 2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) 5. Glucose of 100 mg/dL (5.6 mmol/L) 2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) Two days after a client has a chest tube inserted, the nurse notes constant bubbling in the water seal chamber. What action should the nurse take? 1. Do nothing since this is normal. 2. Decrease the amount of suction. 3. Replace CDU unit with another one. 4. Notify primary healthcare provider. 4. Notify primary healthcare provider. The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased. 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. [Show Less]
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HURST Maternity Nursing question and answer correctly solved
What is the name of the hormone that induces amenorrhea? progesterone Progesterone makes your temperature increase after ovulation Signs/Sy... [Show More] mptoms of Pregnancy: Presumptive signs include -amenorrhea -N/V -urinary frequency -breast tenderness Signs/Symptoms of Pregnancy - Presumptive Signs: What can be one of the first signs of pregnancy? urinary frequency amenorrhea N/V breast tenderness Signs/Symptoms of Pregnancy - Presumptive Signs: Why is breast tenderness is presumptive sign of pregnancy? because of the excess hormones in the body Probable signs of pregnancy include... -positive pregnancy test -Goodell's sign -Chadwick's sign -Hegar's sign -uterine enlargement -Braxton Hicks contractions -pigmentation changes of skin Signs/Symptoms of Pregnancy - Probable Signs: A positive pregnancy test is based on the presence of hCG levels Signs/Symptoms of Pregnancy - Probable Signs: There are other conditions that can increase hCG levels like hydatidiform (molar pregnancy) or some other medications Signs/Symptoms of Pregnancy - Probable Signs: What is hydatidiform (molar pregnancy)? benign neoplasm of grape-like vesicles that can become malignant If a hydatidiform (molar pregnancy) is not malignant a D & C is required with close follow-up for 6 months to 1 year Probable Signs: What is Goodell's sign? softening of the cervix during the second month Probable Signs: What is Chadwick's sign? bluish color of the vaginal mucosa and cervix during the 4th week d/t vasocongestion Probable Signs: What is Hegar's sign? softening of the lower uterine segment during the 2nd/3rd month Probable Signs: Braxton Hicks contractions occur when and for what purpose? they occur throughout pregnancy and move blood through the placenta Probable Signs: What skin pigmentation changes occur? -linea nigra -facial chloasma -abdomen striae -darkening of the areola Positive signs of pregnancy include -fetal hearbeat -fetal movement -ultrasound Signs/Symptoms of Pregnancy - Positive Signs: Fetal heartbeat can be heard with a doppler weeks 10 to 12 Positive Signs: Fetal heartbeat can be heard with a fetoscope weeks 17 to 20 Pregnancy Terms: Terms include -gravidity -parity -viability -TPAL Pregnancy Terms: What is gravidity? the number of times someone has been pregnant Pregnancy Terms: What is parity? the number of pregnancies in which the fetus reaches 20 weeks Pregnancy Terms: What is viability? when an infant has the ability to live outside the uterus Pregnancy Terms: The age of viability is 24 weeks; anything less is NOT considered viable Pregnancy Terms - TPAL: What does this acronym stand for? T - term P - preterm A - abortion (includes spontaneous and elective) L - living children Pregnancy Terms - TPAL: Bleeding, cramping, backache...think miscarriage Pregnancy Terms - TPAL: With an imminent miscarriage, the _________________ will begin to drop hCG level Pregnancy Terms - TPAL: Most miscarriages occur before 20 weeks Pregnancy Terms - Naegle's Rule for the EDD: Steps to calculate 1. find the first day of the LMP 2. add 7 days 3. subtract 3 months 4. add 1 year Pregnancy Terms - Naegle's Rule for the EDD: This rule is only accurate plus or minus 2 weeks Trimesters of Pregnancy - First Trimester: This trimester is weeks 1 through 13 First Trimester - Client Education/Teaching: During this trimester it is important to teach the client about -nutrition -weight gain -prenatal vitamin supplements -exercise -danger signs and potential complication of maternity -common discomforts -medications -smoking -primary healthcare provider visits -ultrasounds First Trimester - Client Education/Teaching: Increase protein intake to 60 grams per day (40-45 is normal) First Trimester - Client Education/Teaching: Regarding culture, consider nutritional influences such as -hot vs cold foods -Kosher foods -fasting First Trimester - Client Education/Teaching: The client should expect to gain ___________________ pounds in the first trimester and will also be dependent on what the _______________________ is 1 to 4; starting BMI First Trimester - Client Education/Teaching: What are the biggest complaints with iron? constipation and GI upset First Trimester - Client Education/Teaching: Always take iron with __________ and why? vitamin C because it prevents GI upset and enhances absorption First Trimester - Client Education/Teaching: Folic acid prevents neural tube defects First Trimester - Client Education/Teaching: What is the daily dose of folic acid? 400 mcg/day First Trimester - Client Education/Teaching: What are some iron-rich foods? -liver -spinach -lentils -raisins -fortified cereal -dark chocolate -dried fruit First Trimester - Client Education/Teaching: Regarding exercise, NO _____________ high impact exercise First Trimester - Client Education/Teaching: What are the best exercises to do? walking and swimming First Trimester - Client Education/Teaching: NO heavy exercise program, but can continue regular exercise program First Trimester - Client Education/Teaching: When exercising, you do NOT want your heart rate to get above 140 First Trimester - Client Education/Teaching: If the HR goes over 140 bpm there will be decreased CO and decreased uterine perfusion First Trimester - Client Education/Teaching: We do not want these patients to get ________________ so NO ______________________ because these will _____________________________ and can cause __________________ overheated; hot tubs or heating blankets; increase body temperature; birth defects First Trimester - Client Education/Teaching: What are some danger signs and potential complications of maternity? -sudden gush of vaginal fluid -bleeding -persistent vomiting -severe H/A -abdominal pain -increased temps -edema -NO fetal movement First Trimester - Client Education/Teaching: What is the most common complaint associated with poor outcomes? no fetal movement First Trimester - Client Education/Teaching: What are common discomforts during this trimester? -constipation -ankle edema -N/V -breast tenderness -urinary frequency -tender gums -fatigue -heartburn -increased vaginal secretions -nasal congestion -varicose veins -hemorrhoids -backache -leg cramps First Trimester - Client Education/Teaching: What are you going to tell the pregnant person about taking medications? NO medication First Trimester - Client Education/Teaching: What is smoking during pregnancy associated with? -small for gestational age -low birth weight babies -cleft lip or palate -placental abruption First Trimester - Client Education/Teaching: The risk for placental abruption doubles with smoking First Trimester - Client Education/Teaching: How often should a pregnant client visit the primary healthcare provider during the first 28 weeks? once a month First Trimester - Client Education/Teaching: How often should a pregnant client visit the primary healthcare provider during weeks 28-36 weeks? every 2 weeks (twice a month) First Trimester - Client Education/Teaching: How often should a pregnant client visit the primary healthcare provider after 36 weeks? weekly until delivery First Trimester - Client Education/Teaching: Before an ultrasound, what will you ask the client to do? drink water First Trimester - Client Education/Teaching: Why do you have the client drink water before an ultrasound? to distend the bladder and push the uterus up closer to the abdominal surface because it makes an easier to get a good picture First Trimester - Client Education/Teaching: With an ultrasound before a procedure what do you have the client do? void Second Trimester - Client Education/Teaching: What is the recommended calorie increase during this time? 300 calories per day Second Trimester - Client Education/Teaching: If the client is an adolescent they can increase their calories by 500 a day Second Trimester - Weight Gain: What is the expected weight gain during this trimester? in general, 1 lb Second Trimester - Weight Gain: This is variable depending on the woman's BMI pre-pregnancy Second Trimester: Should the client still be experiencing nausea and vomiting? no Second Trimester: Should the client still be experiencing breast tenderness? yes Second Trimester: Should the client still be experiencing urinary frequency? no, because the uterus rises and relieves pressure on the bladder Second Trimester: What is quickening and when does it happen? fetal movement around 16-20 weeks Second Trimester - Fetal Heart Rate: What should the fetal heart rate be during the second trimester? 110-160 Second Trimester - Fetal Heart Rate: If the fetal heart rate is less than 110 panic! Second Trimester - Kegel Exercise: The patient should do these frequently to strengthen the pubococcygeal muscles Second Trimester - Kegel Exercise: The pubococcygeal muscles help stop the urine flow Second Trimester - Kegel Exercise: The pubococcygeal muscles keep your uterus from falling out Third Trimester: This is weeks 27 through 40 Third Trimester: A pregnancy is considered term if it advances to 37 to 40 weeks Third Trimester - Assessment: What is the expected weight gain per week during this trimester? no more than a pound per week Third Trimester - Assessment: Monitor ______ and report ______________________ BP; any increases from the baseline Third Trimester - Assessment: Pre-eclampsia develops after 20 weeks gestation Third Trimester - Assessment: With the development of pre-eclampsia, the client will have -increased BP (160/110 or greater) -proteinuria -edema Third Trimester - Assessment: 2 or more pounds of weight gain in a week, watch closely and worry about possible pre-eclampsia Third Trimester - Assessment: The client with pre-eclampsia can have a seizure Third Trimester - Assessment: What is the drug of choice for severe pre-eclampsia? magnesium sulfate Third Trimester - Assessment: Magnesium sulfate is given ________, in __________________, and under _____________________ IV; hospital setting; close supervision Third Trimester - Assessment: Pre-eclampsia is defined as BP of 160/110 or greater that is documented 6 hours apart Third Trimester - Assessment: What does magnesium sulfate do? -acts like an anticonvulsant -sedates -vasodilates Third Trimester - Assessment: What is the difference between pre-eclampsia and eclampsia? the seizure Third Trimester - Assessment: It is called eclampsia when they have a seizure Third Trimester - Assessment: What should the fetal heart rate be during this trimester? 110-160 Third Trimester - Assessment: How is fetal position/presentation determined? Leopold ma [Show Less]
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HURST Review: Respiratory question and answer latest update
Penetrating Chest Trauma: This can be -hemothorax -pneumothorax -tension pneumothorax -open pneumothorax (sucking chest wound) Hemothorax/Pneumo... [Show More] thorax: This is when blood or air has accumulated in the pleural space and the lung has collapsed Hemothorax/Pneumothorax: Signs/Symptoms include -SOB -increased HR -diminished breath sounds on the affected side -less movement on the affected side -chest pain -cough -subQ emphysema Hemothorax/Pneumothorax Signs/Symptoms: What will should up on the x-ray? air or blood Hemothorax/Pneumothorax Signs/Symptoms: What is subcutaneous emphysema? air trapped in the tissue (usually neck, face, and chest) RULE: NEVER _________________ a penetrating object pull out Hemothorax/Pneumothorax: Treatment includes -thoracentesis -chest tube -daily chest x-ray Tension Pneumothorax: Can be caused by -trauma -too much PEEP -clamping a chest tube -insertion of central venous lines -taping an open pneumothorax on all 4 sides without an air valve Tension Pneumothorax: This occurs when pressure has built up in the chest/pleural space and has collapsed the lung which then causes mediastinal shift Tension Pneumothorax: What is mediastinal shift? when pressure pushes everything to the opposite side Tension Pneumothorax: Signs/Symptoms include -subQ emphysema -absence of breath sounds on one side -asymmetry of thorax -respiratory distress -cyanosis -distended neck veins, or JVD Tension Pneumothorax: JVD is a medical emergency and can be fatal as accumulating pressure compresses vessels leading to decreased venous return resulting in decreased CO Tension Pneumothorax: Treatment includes -large bore needle -treating the cause (chest tube will be inserted) Tension Pneumothorax Treatment: Large bore needle is placed into the _________________________ (by the primary healthcare provider) to _______________________________ 2nd intercostal space; allow excess air to escape Open Pneumothorax: AKA sucking chest wound Open Pneumothorax: This is an opening through the chest that allows air into the pleural space Open Pneumothorax: Treatment includes -have client inhale, Valsalva or hummmmmmm -place petroleum gauze over the area -have client sit up (if possible) to expand lungs Open Pneumothorax Treatment: Having the client inhale, Valsalva or hummmmmmm is done to increase the intra-thoracic pressure so no more outside air can get into the body Open Pneumothorax Treatment: When placing a piece of petroleum gauze over the area, tape down _______ sides and the _______________ acts like a ________________ or _______________ 3; 4th side; air vent; flutter valve Open Pneumothorax Treatment: While clients are to sit up, if able, to expand their lungs, trauma clients _______________ until _____________________________ stay flat; evaluated for other injuries Thoracic (Chest) Procedures: These include -thoracentesis -chest tubes Thoracic (Chest) Procedures - Thoracentesis: This is performed to remove fluid or air from the pleural space Thoracic (Chest) Procedures - Thoracentesis: It is used for analysis of lungs fluids to determine the cause of the effusion Thoracic (Chest) Procedures - Thoracentesis: The fluid obtained may be sent for culture or cancer cells Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure we must check for informed consent Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure the client must STOP any anticoagulant medications Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure we must obtain -baseline VS -oxygen saturation -pain level Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure be sure that a ___________________ has been performed CXR Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure positioning sit on the edge of bed, with feet supported, and lean over the bedside table Thoracic (Chest) Procedures - Thoracentesis: What if the client is not able to sit up pre-procedure? have them lie on the unaffected side with HOB at 45 degrees Thoracic (Chest) Procedures - Thoracentesis: During procedure the client must be very still; no coughing or deep breaths Thoracic (Chest) Procedures - Thoracentesis: During the procedure the ______________________ is being removed from ______________________ fluid/blood/exudate; the pleural space Thoracic (Chest) Procedures - Thoracentesis: During the procedure, as the fluid is being removed, the lung should reinflate Thoracic (Chest) Procedures - Thoracentesis: During the procedure we should be checking ___________________________________ and compare to VS, oxygen sats, pain level; baseline Thoracic (Chest) Procedures - Thoracentesis: Post-procedure another ______________ is taken CXR Thoracic (Chest) Procedures - Thoracentesis: Post-procedure monitor VS Thoracic (Chest) Procedures - Thoracentesis: Post-procedure we must listen to ___________________ for __________________ lungs; absent or reduced breath sounds on the affected side Thoracic (Chest) Procedures - Thoracentesis: Post-procedure we must check ___________________ and _________________ for bleeding puncture site; dressing Thoracic (Chest) Procedures - Thoracentesis: Post-procedure we must monitor for -subQ emphysema -infection -tension pneumothorax Thoracic (Chest) Procedures - Thoracentesis: Post-procedure we have the client turn, cough, and deep breathe Thoracic (Chest) Procedures - Chest Tubes: What has happened that the client needs a chest tube? the lung has collapsed Thoracic (Chest) Procedures - Chest Tubes: If the chest tube is placed in the upper anterior chest (2nd intercostal space) then it is for the removal of air Thoracic (Chest) Procedures - Chest Tubes: If the chest tube is placed laterally in the lower chest (8th or 9th intercostal space) then it is for drainage Thoracic (Chest) Procedures - Chest Tubes: Why is the tube placed in the upper chest for air removal and in the lower chest for removal of drainage? because air rises and drainage settles Thoracic (Chest) Procedures - Chest Tubes: The client can have both an upper and lower chest tube and they are _______________________ and attached to a ____________________ y-connected together; closed chest drainage unit (CDU) Thoracic (Chest) Procedures - Chest Tubes: The chest tube is ____________________ and an occlusive dressing is applied ______________________________ and then the chest tube is connected to _______________________ sutured to the chest wall; around the chest tube exit site; a closed chest drainage unit Thoracic (Chest) Procedures - Chest Tubes: What is the purpose of the CDU? it is to restore the normal vacuum pressure in the pleural space Thoracic (Chest) Procedures - Chest Tubes: How does the CDU restore the normal vacuum pressure in the pleural space? by removing all air and fluid in a closed 1-way system until the problem is corrected Thoracic (Chest) Procedures - Chest Tubes: What are the 3 chambers of the CDU? 1. drainage collection chamber 2. water seal chamber 3. suction control chamber Thoracic (Chest) Procedures - Chest Tubes: The chest tube connects to a ____________________ that leads to the _____________________ 6 foot connection tube; drainage collection chamber Thoracic (Chest) Procedures - Chest Tubes: What if the drainage collection chamber fills up? get a new CDU (rarely have to change) Thoracic (Chest) Procedures - Chest Tubes: What is the purpose of the water seal chamber? to promote 1-way flow out of the pleural space which will prevent air from moving back up the system and into the pleural space Thoracic (Chest) Procedures - Chest Tubes: The drainage chamber and water seal chamber are connected by a small tube that allows the drainage to remain in the first chamber and the air to go down into the water of the water seal chamber Thoracic (Chest) Procedures - Chest Tubes: The water seal chamber contains ____________________ which acts as a ___________________. In other words, we are ______________________ 2 cm of water; one-way valve; preventing backflow Thoracic (Chest) Procedures - Chest Tubes: You may see ________________ in the water seal chamber when the client ________________________________________ (normal) bubbling; coughs, sneezes, or exhales Thoracic (Chest) Procedures - Chest Tubes: You will see a slight ____________________________ in the water seal tube as the client __________________ rise and fall; breathes Thoracic (Chest) Procedures - Chest Tubes: The slight rise and fall seen in the water seal tube as the client breathes is called ________________ and is _______________ tildaling; normal Thoracic (Chest) Procedures - Chest Tubes: If tidaling stops, it usually means that the lung has re-expanded Thoracic (Chest) Procedures - Chest Tubes: If the client needs suction to remove air and fluid, the suction control chamber does what? controls the amount of suction applied Thoracic (Chest) Procedures - Chest Tubes: Sterile water is placed in the suction control chamber up to the ___________________ which is the _____________________ 20 cm line; usual prescribed amount Thoracic (Chest) Procedures - Chest Tubes: Turn on the wall vacuum suction until you have slow, gentle, continuous bubbling Thoracic (Chest) Procedures - Chest Tubes: If a dry suction system is used, ___________________________ and therefore, water is not needed to regulate the pressure; has no bubbling Thoracic (Chest) Procedures - Chest Tubes: A _________ is used to set the negative pressure dial Thoracic (Chest) Procedures - Chest Tubes: Increasing the vacuum wall suction will NOT increase the pressure Management of Closed Chest Drainage System: Assess dressing; it must be kept tight and intact Management of Closed Chest Drainage System: Listen for breath sounds in _______________________ and monitor for ______________________ both lungs; breathing difficulty Management of Closed Chest Drainage System: Monitor ____________________ and report anything below ___________ pulse oximetry; 90% Management of Closed Chest Drainage System: Palpate chest tube insertion site for __________________ because this could indicate ________________________________ subQ emphysema; poor tube placement Management of Closed Chest Drainage System: Record chest drainage every _______________ for 24 hours and then every _____________________ hour; 8 hours Management of Closed Chest Drainage System: Notify primary healthcare provider of _____________ of drainage or greater in 1 hour 200 mL Management of Closed Chest Drainage System: Notify primary healthcare provider of ____________ or greater any hour after the 1st hour 100 mL Management of Closed Chest Drainage System: Notify primary healthcare provider of change in color, like yellow to bright red Management of Closed Chest Drainage System: Have client ______________________________ and use an __________________________ deep breathe, cough; incentive spirometer Management of Closed Chest Drainage System: Watch for ______________________________ because they could develop an __________________ at insertion site fever, increased WBCs, and drain [Show Less]
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HURST REVIEW: MANAGEMENT OF CARE question and answer rated A+
As a new nurse, you cannot provide safe care to your clients if you don't know how to -manage care -assign care -supervise care -prioritize care ... [Show More] The judgments you make in management situations have to be based on med-surg knowledge If you don't understand disease processes, you cannot set priorities of care or determine which staff member would be best to take care of the client You MUST know your _______________________, and then you can move on to ________________________ core content; management decisions Assignments include the routine care, activities, and procedures that are within the authorized scope of practice of the RN, LPN/LVN, or part of the routine functions of the UAP Assignment is the sharing of routine work that each staff member is responsible for during a given shift or work period The assigned tasks should be part of the course work taught in the basic educational program of the staff member Delegation is allowing a specific task to be performed that is not routinely performed and is BEYOND the traditional role of the individual to which the nursing activity skill, or procedure is delegated The key is that the staff member who is delegated the task has received additional training or education and has validated competency to perform the delegated task You can delegate the responsibility of the task, but you cannot delegate the ultimate accountability The RN is accountable for ALL aspects of nursing care that are being provided including the choices you make about who is considered competent to perform each task What are the 5 rights of delegation? 1. right person 2. right circumstances 3. right task 4. right direction/communication 5. right supervision and evaluation/feedback The Right Task: What is the traditional role of the UAP? UAP is an umbrella term that NCSBN defines as any unlicensed personnel trained to function in a supportive nursing role, regardless of the title The Right Task: What type of clients can the RN delegate to the UAP? -perform tasks on STABLE clients in uncomplicated situations -routine, simple, repetitive, common activites that do NOT require nursing judgment The Right Task: Examples of tasks that the UAP can perform? -hygiene -feeding -I&O -routine vital signs -ambulation EVERYDAY THINGS! The Right Task: Can a UAP take VS ona client receiving IV Dopamine? no, because it requires nursing judgment The Right Task: Can the UAP provide a total bed bath and dress the client? yes The Right Task: Can the UAP serve meals and assist with eating? yes The Right Task: Can the UAP obtain a urine specimen from a catheter? no, this is a sterile procedure The Right Task: Can the UAP turn the client every 2 hours and provide skin care? yes The Right Task: Can the UAP assist the client to the bathroom with a walker? yes The Right Task: Can the UAP perform a fleet enema? no, because this is a medicated procedure The Right Task: Can the UAP answer the client's call light? yes The Right Task: Can the UAP clean and sanitize the client's room? yes The Right Task: Can the UAP change the linen on a totally bedridden client? yes The Right Task: Can the UAP provide mouth care and denture cleansing? yes The Right Task: UAPs CAN'T do medications The Right Task: What tasks can the LPN perform? -data collection -NO assessment -updating client data -NO evaluation (involves assessment) -NO admission hx The Right Task: The RN NEVER delegates or assigns tasks that involve assessment The Right Task: The LPN can assist the RN in data collection, but that is NOT assessment in the NCLEX world The Right Task: After the initial assessment, the LPN updates client data The Right Task: Can the LPN evaluate the client to determine if a goal has been met? no The Right Task: The LPN cannot do any form of _____________________, because _________________________________ evaluation; evaluation involves assessment, and we NEVER assign or delegate assessment or judgment The Right Task: Who must do the admission history? the RN [Show Less]
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Hurst – Gastrointestinal question and answer 100% correct
What is pancreatitis Auto-digestion of the pancreas What are the two separate functions of the pancreas? Endocrine - insulin Exocrine - digestive... [Show More] enzymes What are the two types of pancreatitis 1. Acute: #1 Cause = Alcohol #2 Cause = Gallbaldder Disease 2. Chronic: #1 Cause = Alcohol Parts of the pancreas a. Pancreatic Duct - travels through pancreas b. Digestive Enzymes - Inactive while in pancreas until they get to the small intestines c. Scar Tissue - forms in pancreatic duct by alcoholism which causes scar tissue and occludes duct d. Gallstones Enzymes get tired of waiting and activate while in the pancreas - so they start eating the pancreas Note: if any part of the GI system gets sick - other parts of the GI can get sick as well. Blank S/S of Pancreatitis a. #1 Pain - increases with eating b. Abdominal distention/ascites (losing protein rich fluids like enzymes and blood into the abdomen) c. Abdominal mass - swollen pancreas d. Rigid board-like abdomen (guarding or bleeding - developed pancreatitis) e. Bruising around umbilical area known as Cullen's sign Bruising in flank (side) area known as Gray Turner's sign f. Fever (inflammation) g. NV h. Jaundice - liver is involved i. Hypotension = bleeding or ascites What is ascites? Buildup of fluid in the space between the lining of the abdomen and abdominal organs Pancreatitis Lab Values Amylase: 45-200 U/L (dye) Lipase: 0-110 U/L - most specific to pancreatitis AST: 8-40 U/L ALT: 10-30 U.L Hemoglobin: 12-18 (male 14-18; female 12-16) Hematocrit: 38-54% (male 40-54%; female 38-47%) What is most specific in diagnosing pancreatitis? Lipase Dx: Serum lipase and amylase are.... Digestive enzymes and they are not supposed to be in the blood stream Dx: WBC's Blood sugar ALT, AST-liver enzymes PT, PTT Serium bilirubin H/H (hemoglobin & hematocrit) Dx: WBC's - elevated Blood sugar - elevated - could be a diabetic forever now ALT, AST - liver enzymes - elevated - if liver is messed up, #1 thing to worry about is bleeding PT, PTT - longer - for blood to clot Serium bilirubin - elevated H/H - (hemoglobin & hematocrit) increases or decreases (not at the same time) Why down? Bleeding Why up? Dehydrated Tx of Pancreatitis - Goal: Control Pain 1. Decrease gastric secretions by: ___________, NGT to suction, bed rest (decreases stomach secretions). NPO Want the stomach empty and dry. Testing Strategy - Pancreas Client = Keep stomach empty and dry 2. What pain medications are given? PCA narcotics: morphine sulfate (Morphine) hydromorphone (Dilaudid) Fentanyl patches (Duragesic) 3. Steriods, why? Reduce inflammation Long-term can get diabetes, Cushing's 4. Anticholinergics, why are they given? Name them. Dry secretions. Benztropine (Cogentin) Diphenoxylate/Atropine (Lonox) 5. What is given to decrease stomach acids? Pantoprazole (Protonix) - Proton pump inhibitor Ranitidine HCI (Zantac) - H2 receptor antagonist Famotidine (Pepcid) - H2 receptor antagonist Antacids - work really quick H2 Receptor Antagonist H2 are histamines that are released that cause inflammation in the stomach H2 receptor antagonists turns down the volume of HCL acid production 6. Maintain fluid and electrolyte balance. Blank 7. Maintain nutritional status - ease into a diet (TPN maybe) 8. Insulin, Why? Pancrease is sick - can't release insulin TPN Steroids - cause BS to increase Last 3 treatments: Daily weights Eliminate alcohol Refer to AA if this is the cause [Show Less]
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Cardiac Content Post Test- HURST question and answered correctly
The nurse performs a rapid assessment on a client who states, "I feel really sick and my heart is beating so fast." What signs and symptoms would indicate ... [Show More] to the nurse that the client's cardiac output is inadequate? Select All That Apply 1. CVP 5 mm Hg. 2. Moist skin. 3. Urinary output 150 mL over 4 hours. 4. Weak radial pulses. 5. BP 90/50, HR 200, RR 22. 6. Mild chest discomfort. 2, 4, 5, 6 Rationale 2, 4, 5, & 6. Correct: When cardiac output is inadequate, the vital organs are not being perfused properly. Skin will be cool and clammy (moist) because the skin is not being perfused. Radial pulses will be weak and thready, because less blood is pumping through the arteries. Less volume means less pressure, so BP is low. The heart rate is too fast, so blood does not have time to get in the ventricles before it is contracting again which decreases cardiac output. Less blood is being pumped to the body. Chest pain means oxygenated blood is not reaching the heart muscle. 1. Incorrect: Normal CVP is 2-6 mmHg, so this is a normal finding. 3. Incorrect: Normal urinary output (UOP) should be at least 30 mL per hour. This client's UOP was 150 mL over 4 hours (50 mL per hour). So no concern here. The nurse is caring for a client post cardiac catheterization that was performed via the right femoral artery. What assessment finding in the right lower extremity would be of concern to the nurse? Choose One 1. Right pedal pulse 2+/4+. 2. Capillary refill 2 seconds. 3. Erythema. 4. Slight oozing of blood. 4 Rationale 4. Correct: The number 1 complication is bleeding. So slight oozing of blood is a problem. Assume the Worse! This is bleeding and you must do something. 1. Incorrect: 2+/4+ is a normal pulse amplitude. We worry about 1+. 2. Incorrect: This is a normal capillary refill. Remember, we want color to return within 2 seconds. 3. Incorrect: Erythema is redness of the skin or mucous membranes, caused by an increased blood flow in superficial capillaries. We are worried about decreased blood flow which would be evidenced by pallor. A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? 2, 3 Rationale 2. & 3. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low, indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds. 1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall or the condition could deteriorate while ambulating. 4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs. 5. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100% per nonrebreather mask. Start with the least amount of oxygen that could relieve symptoms. The nurse has informed a client diagnosed with heart failure about the treatment plan, including prescriptions for an ACE inhibitor and a 2 gm sodium diet. Which statement by the client would indicate to the nurse that the client understands the treatment plan? Select All That Apply 1. "I plan to elevate the head of my bed on concrete blocks so I can sleep better." 2. Instead of using salt, I should use a salt substitute to season my food." 3. "It is important that I weigh myself weekly to monitor for weight gain." 4. "I need to eat foods high in potassium while taking an ACE inhibitor." 5. "A low sodium diet will help decrease swelling in my legs." 1, 5 Rationale 1., & 5. Correct: Lying flat when a client has heart failure will cause excess fluid, which has pooled in the extremities while up, to move into the thorax and back up into the lungs. This is why the client can breathe better when the head of the bed is elevated. A low sodium diet decreases fluid retention which decreases preload, the amount of fluid entering the right side of the heart. So, yes, a low sodium diet can help decrease dependent edema. 2. Incorrect: Salt substitutes are high in potassium and can be dangerous when taking an ACE inhibitor. ACE inhibitors block aldosterone, which causes the body to lose sodium and water and retain potassium. 3. Incorrect: The client should weigh self daily, not weekly, and report a weight gain of more than 2-3 pounds (1-2 kg). 4. Incorrect: This client needs to eat food low in potassium since ACE inhibitors cause the retention of potassium. The nurse is teaching a group of clients in cardiac rehabilitation how blood flows through the heart. What information should the nurse include? Select All That Apply 1. Deoxygenated blood enters the heart through the pulmonary vein. 2. Blood flows from the right atrium through the mitral valve to the right ventricle. 3. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. 4. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle. 5. The right ventricle pumps the blood out through the aorta to the body. 3, 4 Rationale 3., & 4. Correct: These are true statements. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle. 1. Incorrect: Deoxygenated blood comes from the body to the heart via the superior and inferior vena cava. 2. Incorrect: Blood flows from the right atrium through the tricuspid valve to the right ventricle. 5. Incorrect: The left ventricle pumps the blood out through the aorta to the body. The nurse is providing teaching to a group of clients newly diagnosed with chronic stable angina. What points should the nurse include? Select All That Apply 1. Wait 1/2-1 hour after eating to exercise. 2. Attend classes such as guided imagery to reduce stress. 3. Temperature extremes can precipitate an angina attack. 4. Gradually increase weightlifting training to improve cardiac output. 5. Eat a low fat, low fiber diet to lose weight. 6. Medications prescribed to prevent angina work by increasing the workload of the heart. 2, 3 Rationale 2., & 3. Correct: We want to teach clients who have angina to do whatever they can to decrease the workload of the heart. Stress can increase the workload on the heart, so learning ways to decrease or deal with stess is a positive step. This can be done through guided imagery or music therapy. Temperature extremes can precipitate an attack, so the client should dress warmly in cold weather and be cautious out in extremely hot weather. 1. Incorrect: The client should wait at least 2 hours after eating to exercise. During this time, more blood is going to the digestive system. We don't want the heart to have to compete with the gut. 4. Incorrect: Weightlifting will increase the workload of the heart. We don't want to increase the workload of the heart in a client with a cardiac issue. 5. Incorrect: Losing weight is often beneficial for the cardiac client, so we advise them to decrease calorie consumption and maintain a low fat, high fiber diet. 6. Incorrect: We want to decrease the workload of the heart, not increase it. Medications prescribed to prevent angina work to decrease the workload of the heart. A 70 year old female client reports an occasional choking sensation over the past 12 hours. What additional symptoms reported by the client would indicate to the nurse that the client may be having a myocardial infarction? Select All That Apply 1. Unusual fatigue. 2. Indigestion. 3. Aching jaw. 4. Feeling faint 5. Pain between the shoulder blades. 6. Left arm paresthesia. 1, 2, 3, 4, 5 Rationale 1., 2., 3., 4., & 5. Correct: Look at the hints - elderly, female, choking sensation. Women often present with GI signs and symptoms, epigastric complaints, or pain between the shoulders, aching jaw, or choking sensation. The triad of symptoms: feeling of fullness in the abdomen, unusual fatigue, and an inability to "catch one's breath". Remember that the elderly may just faint or only have SOB. 6. Incorrect: Left arm paresthesia sounds more like a stroke rather than an MI. The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which finding best indicates that bumetanide is having a therapeutic effect? Choose One 1. Apical pulse 108/irregular. 2. Foamy sputum. 3. Urine output 175 mL for one hour. 4. Respiratory rate 28/min Su 3 Rationale 3. Correct: Bumetanide is a diuretic that can be given IVP or continuous IV to provide rapid fluid removal. We know the medication is working because we have a good hourly urinary output. 1. Incorrect: The heart rate is still too fast and irregular. As excess fluid is removed, the heart rate should come down to a regular rate. 2. Incorrect: Pulmonary edema will cause the client to have a productive cough with pink, frothy (foamy) sputum. The presence of foamy sputum does not indicate that the medication has been effective. 4. Incorrect: The respiratory rate is too fast, so the pulmonary edema has not resolved. As fluid is pulled off the body, the respiratory rate should decrease. The nurse is assessing a client one hour post coronary artery bypass graft surgery (CABG). Based on the assessment data, what action should the nurse take? Client increasingly more difficult to arouse. Skin cool/damp. Distended neck veins. Lungs clear bilaterally. Heart sounds distant. CVP 8 mm Hg. BP 90/60. Choose One 1. Administer stat dose of clopidogrel. 2. Notify cath lab to prepare for angioplasty. 3. Set up for a central catheter line. 4. Prepare for immediate pericardiocentesis. 4 Rationale 4. Correct:The assessment findings point to cardiac tamponade, which is an emergency situation. Did you pick up on the classic s/s of this? Here we see the decreasing level of consciousness and evidence of poor perfusion from decreased cardiac output, distended neck veins from the backward pressure, muffled lung sounds from the fluid collection around the heart, increasing CVP, and the narrowing pulse pressure as the heart is being compressed. Treatment involves a pericardiocentesis to remove blood that has formed around the heart. The primary healthcare provider will insert a needle into the pericardial space to remove the fluid. 1. Incorrect: Clopidogrel is an anti-platelet medication that will not correct cardiac tamponade. 2. Incorrect: If the client were re-occluding, then the client would go to the cath lab or back to surgery. This is not the problem indicated by the signs/symptoms. 3. Incorrect: A central line is not going to correct cardiac tamponade. Immediate removal of the fluid compressing the heart is needed. The nurse is educating a client newly diagnosed with chronic stable angina about Nitroglycerin SL. What points should the nurse include? Select All That Apply 1. Nitroglycerin increased blood flow to the heart. 2. Take one nitroglycerin every five minutes until pain stops. 3. Sit or lie down when taking nitroglycerin. 4. The most common side effect is a headache. 5. Keep nitroglycerin in a clear, plastic bottle. 1, 3, 4 Rationale 1, 3, & 4. Correct: Nitroglycerin dilates the coronary arteries to allow more oxygen to get to the heart muscle. Because nitroglycerin also dilates all arteries and veins, the client's BP will drop. So they could faint. To prevent this, they should sit or lie down when taking the nitro. The most common side effect is that the client will get a headache. It is not life threatening, but advise the client that this will occur. 2. Incorrect: One Nitroglycerin can be taken SL every five minutes up to three doses. If pain is not relieved, the EMS should be activated. The client may be having an MI rather than angina. 5. Incorrect: Nitroglycerin should be stored in a dark, glass bottle so that it does not lose its potency. [Show Less]
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HURST Review: Neuro graded A+
Neurological Assessment includes -client's current condition -Glasgow Coma Scale -pupillary changes -hand grips/leg lifts/pushing strength of feet -Ba... [Show More] binski reflex Neurological Assessment of Client's Current Condition - Onset: It's important to know when the symptoms started Neurological Assessment of Client's Current Condition - Onset: Ask them _______________________________ and what ____________________________ when was the onset; symptoms did the client have intially Neurological Assessment of Client's Current Condition - Description of Symptoms: Have them describe Neurological Assessment of Client's Current Condition - Description of Symptoms: Know the ________________, how __________________________, and how _______________ location; long the symptoms have persisted; severe Neurological Assessment of Client's Current Condition - Associated Factors: Determine if there were any __________________________________ associated with the symptoms triggers or aggravating factors Neurological Assessment of Client's Current Condition - Associated Factors: Ask them "did anything ________________________ the symptoms?" help relieve Neurological Assessment of Client's Current Condition - Overall Appearance: Note the client's general appearance and behavior Neurological Assessment of Client's Current Condition - Overall Appearance: Observe if there are any ______________________________ of a ____________________________ deficit? obvious signs; neurological (speech slur? drooping side of face?) Neurological Assessment of Client's Current Condition - Degree of Consciousness: What is the MOST important aspect of the neuro exam? assessment of the client's mental status, including LOC Neurological Assessment of Client's Current Condition - Degree of Consciousness: Mental status includes -awareness of surroundings and alertness -orientation to person, place, and time -memory: both short-term and long-term Neurological Assessment of Client's Current Condition - Degree of Consciousness: The most sensitive indicator of neuro status is LOC Neurological Assessment of Client's Current Condition - Degree of Consciousness: A change in LOC may be the first sign that there is a problem Neurological Assessment - Glasgow Coma Scale: This scale is used to assess the LOC in a client who already has altered consciousness or has the potential of altered consciousness Neurological Assessment - Glasgow Coma Scale: This scale is used primarily in the ED or ICU Neurological Assessment - Glasgow Coma Scale: The definition of this scale is a scale that measures the degree of LOC Neurological Assessment - Glasgow Coma Scale: 3 responses of this scale 1. eye opening 2. motor response 3. verbal response Neurological Assessment - Glasgow Coma Scale: RULE - we like a high number ranging from 13 to 15 Neurological Assessment - Glasgow Coma Scale: What is always #1 with neurological assessment? LOC [Show Less]
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