RN ATI CAPSTONE
PROCTORED
COMPREHENSIVE
ASSESSMENT 2019 B /ATI
COMPREHENSIVE 2019
QUESTIONS AND
CORRECT DETAILED
ANSWERS |GRADED A+
A
... [Show More] nurse is caring for a client who had abdominal surgery 24 hours ago. Whic of the following actions is the nurse’s priority?
a. Assess fluid intake every 24 hours
b. Ambulate three times a day
c. Assist with deep breathing and coughing
(this is the nurses priority because ABCs which reduces the risk for postoperative pneumonia)
d. Monitor the incision site for findings of infection
A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client is an example of altruism?
a. “I have experienced physical discomfort when intimate with my partner since my diagnosis”
Conversion. Conversion is the development of physical manifestations in response to anxiety.
b. “I wish other women would stop socializing with my partner”
Projection. Projection is blaming others for unacceptable thoughts and feelings.
c. “I told my doctor that I would like to start a support group for other women who are sick in my community”
(this is the correct response because altruism is reaching out and helping others)
d. “I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness”
Splitting. Splitting is the inability to integrate negative and positive attributes of the self or others.
A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?
a. Assess the client’s IV site every 8 hours
Important to monitor this every 4 hr
b. Check the client’s WBC count every 48 hours
Important to monitor this every 24 hr
c. Monitor the client’s mouth every 8 hours
Monitor the client’s mouth at least every 8 hr for manifestations of an infection, such as sores or lesions
d. Change the client’s IV tubing every 48 hours
Change the IV tubing every 24 hr for client who has immunosuppression
A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks.
Which of the following instructions should the nurse include in the teaching?
a. Adjust the crutches for support as needed
A HCP should measure crutches for the client. Clients should not perform their own adjustments to the crutches. Use of improperly fitting crutches increases the risk of injury from falls. b. Use a three-point gait
A three-point crutch gait allows the client to be mobile without bearing weight on the affected extremity
c. Wear leather soled shoes
The client should wear rubber-soled shoes when using crutches. The client who wears leathersoled shoes has an increased risk of slipping and falling.
d. Advance the affected leg first when walking upstairs
When walking upstairs, the client should advance the unaffected leg first. When walking downstairs, the client should advance the crutches and the affected leg first and then follow with the unaffected leg.
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?
a. Radial vein of the inner arm
This site will have adequate subcutaneous tissue
b. Great saphenous vein of the leg
This can interfere with the performance of ADLs
c. Dorsal plexus vein of the foot
Veins and vessels in extremities are fragile in older adult clients
d. Basilic vein of the hand
Older adults can have skin that tears easily and can also experience a decreasein subcutaneous tissue in locations such as hands
A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
a. Perform gastrostomy feedings through a client’s established gastrostomy
tubeThe nurse should delegate providing gastrostomy feedings through the client’s established gastrostomy tube to an AP because this task is within the AP’s range of function
b. Determine if the PRN pain medication administered 30 min ago has helped
RN
c. Provide instructions about client care to a family member over the telephone
RN
d. Teach a client how to measure their own blood pressure
RN
A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
a. I will administer aspirin to my child to treat pain or fever
b. I will record an average of three readings from my child’s peak expiratory flow meter
Parent should record highest of three readings rather than average
c. I will place carpet in my child’s bedroom to control allergens
d. I will make sure my child receives a yearly influenza immunization
Type 1 diabetes is a contraindiciation for receiving cold therapy. A client who has type 1 diabetes can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Ice can further impair circulation.
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy.
Which of the following instructions should the nurse include in the teaching?
a. Check the functioning of oxygen equipment once each week
This should be done daily
b. Wear clothing made with cotton fabrics while oxygen is in useCotton fabrics
should be used rather than synthetic or woolen fabrics.
c. Apply petroleum-based lubricant to the nares as needed
d. Store full oxygen tanks on their side
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved onces. Which of the following actions should the nurse take?
a. Contact the facility chaplain to visit with the client
b. Explain the process of leaving the facility against medical advice
c. Make a referral to social services
Obtain referral to ensure that the client’s needs at home are met. They can set up home care or hospice services for the client if needed
d. Encourage the client to continue with inpatient care
A nurse is caring for a client who has a clogged percutaneous gastronomy feeding tube. Which of the following actions should the nurse take first?
a. Obtain a prescription for the client to receive an enzyme product
b. Aspirate the client’s tube
c. Flush the client’s tube with 30 ml of water
d. Change the position of the client
Least restrictive intervention first
A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?
a. Administer a bowel preparation the night before the procedure
b. Place the client on bed rest for 24 hr after the procedure
c. Perform pulmonary function tests following the procedure
d. Instruct the client to avoid coughing during the procedure
It is important for the nurse to remind the client to avoid coughing and to lie still during a thoracentesis to avoid puncturing the pleura
A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
a. Weight gain
b. Decrease in anteroposterior diameter of the chest
c. HCO3- 24 mEq/L
d. pH 7.31
Respiratory acidosis is an expected finding for a client who has COPD
A nurse is caring for a client who has a DVT. Which of the following actions should the nurse take?
a. Teach the client to massage the affected extremity
b. Instruct the client to elevate the affected extremity when sitting
The nurse should instruct the client to elevate the affected extremity to reduce edema and facilitate venous return
c. Assess pulses proximal to the affected area
Assess pulses distal to the affected area
d. Apply a cold compress to the affected extremity
Apply warm, moist compresses to the affected extremity
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?
a. Drainage system located above the client’s chest level
BELOW
b. Continuous bubbling in the water-seal chamber
AIR LEAK
c. Occlusive dressing on the insertion site
An occlusive dressing on the insertion site prevents air from leaking and is an expected finding d. Drainage of 125 ml/hr
Chest tube drainage should be less than 70 ml/hr
A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?
a. Determine the client’s reading skills
Assess patient first
b. Instruct the client on the technique for esophageal speech
c. Provide the client with an alphabet board
d. Show the client how to use an artificial larynx
A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a
blood transfusion that might potentially save their life. Which of the following actions should the
nurse take first?
a. Document the client’s refusal in the medical record
b. Honor the cient’s decision to refuse the blood transfusion
c. Explore the client’s reasons for refusing the treatment
The first action the nurse should take when using the nursing process is assessment
d. Discuss the client’s refusal with provider
Transient strabismus- or nystagmus is an expected finding for a newborn until the age of 3-4 months
Overlapping sutures- occurs with molding following a vaginal delivery and is an expected finding for a newborn
A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client’s visual loss?
a. An increase in the intraocular pressure
Glaucoma leads to an increase in intraocular pressure, causing mild headaches and foggy vision
b. Deterioration of the macula
Macular degeneration is caused by deterioration of the macula, resulting in decreased central vision
c. Increased opacity of the lens
A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration d. Vitreous hemorrhage
Bleeding following damage of retinal blood vessels, which can occur due to elevated blood pressure or uncontrolled diabetes
A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect?
a. Fever
b. Shortened femoral neck
c. Edema
Compartment syndrome causes increased pain, pallor and parasthesias from increased edema in the compartment involved
d. Dark brown urine
A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
a. The last time the provider evaluated the client
b. The client’s most recent ventilator settings
c. The time of the client’s last dose of pain medication
The time of the client’s last dose of pain medication is important to include so the receiving nurse can anticipate what time to give the next dose
d. The frequency in which the client presses the call button
A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect?
a. Decreased hematocrit
Increase in hematocrit due to loss of fluid volume
b. Hypokalemia
hyperkalemia
c. Hyponatremia
d. Increased albumin decrease
A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?
a. Advocacy is a leadership role that helps others to self-actualize
b. Subordinates are advocates for the nurse manager
c. Adovcacy encourages elients to rely on health care staff for decision making
d. Nurse manager should distrust people who advocate against inappropriate professional practices
A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?
a. Place the client in the lithotomy position
b. Elicit a vagal response by performing gentle rectal stimulation
c. Adminsiter oral bisacodyl 30 min prior to the procedure
d. Insert a lubricated gloved finger and advance along the rectal wall
Clonidine is an indirect-acting antiadrenergic agent used for hypertension, severe pain, and
ADD. The nurse should inform the client that dry mouth, or xerostomia, is a common adverse effect of clonidine.
A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?
a. Agency for Healthcare Research and Quality
AHRQ’s goal is to improve the quality of health care services for all populations, including lowincome groups and minorities
b. National Institutes of Health
Focuses on biomedical research to improve specific diseases
c. Department of Agriculture
Focuses on the availability of food and nutrition services for US citizens
d. World Health Organization
Focuses on improving health of the world’s global population by developing initiatives and conducting research that benefit all countries
A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?
a. Perform ADLs for the client to promote rest
Allow client to perform their own ADLs to promote joint mobility and independence
b. Allow for frequent rest periods throughout the day
c. Use heat to reduce joint inflammation
Use ice to reduce joint inflammation and heat to alleviate joint discomfort
d. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain
Do not administer more than 3 g of acetaminophen each day
Indication of hemorrhaging: rapid decrease in BP, increased HR
Cushing’s Triad: ICP, increased pressure in brain
Signs: bradycardia, irregular respirations, widened pulse pressure
A nurse is caring for a school-age child who dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?
a. Hematocrit 45%
Above the expected range of 32%-44%
b. Urine specific gravity 1.035
Above expected range of 1.005-1.030
c. Serum sodium 138 mEq/L
Expected range of 136-145 mEq/L
d. BUN 19 mg/dL
Above expected reference range of 5-18 mg/dL for a child and is an indication that dehydration is still present
A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
a. Weight loss
b. Jaundice
The nurse should monitor the client for jaundice and report any indication to the provider. Clients who take valproic acid are at risk for liver damage, which can lead to jaundice
c. Bradycardia
d. Polyuria
A nurse is providing information to a client immediately before his scheduled Romberg test.
Which of the following statements should the nurse make?
a. “You will be standing with your feet 1 foot apart”
b. “You will place and hold your hands on your hips”
c. “I will be standing across the room from you to evaluate your sense of balance”
d. “I will be checking you once with your eyes open and once with them closed”
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?
a. Halos around lights
b. Floating dark spots
The nurse should recognize that floating dark spots are a manifestation of a detached retina due to bulges, folds, or holes in the affected retina
c. Pain in the affected eye
d. Blurred vision
A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?
a. Hold hands folded below the waist after donning sterile gloves
b. Pick up and pour solutions with the palm of the hand covering bottle labels
c. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape
d. Maintain sterile objects within the line of vision
A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?
a. Hypoxemia
Peep is used to improve oxygenation and treat this by strengthening gas exchange
b. Tension pneumothorax
The nurse should identify that tension pneumothorax is a possible adverse effect of PEEP. The nurse should monitor the client’s lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins.
c. Malignant hypertension
A client who is receiving mechanical ventilation is at risk for hypotension resulting from increased chest pressure and decreased blood return to the heart
d. Atelectasis
PEEP is used to prevent atelectasis by strengthening gas exchange
A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take?
a. Hold the insulin pen device perpendicular to the client’s skin to inject the medication
b. Shake the insulin pen device prior to injecting the medication
Do not shake
c. Withdraw the insulin from the pen device into an insulin syringe No.
d. Hold the pen device in place for 3 seconds after injecting the insulin
Hold in place briefly for 6-10 seconds after injecting
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?
a. Increase tension on the urinary catheter
Avoid increasing tension on the urinary cather because this can cause bladder irritation, bleeding, and subsequent catheter blockage, and can ultimately lead to urinary retention
b. Irrigate the catheter with 0.9% sodium chloride irrigation
Decreased urine output and bladder spasms indicate internal obstructions of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does not clear.
c. Assist the client to ambulate
Findings indicate an internal obstruction. Therefore, the nurse should keep the client in bed
d. Remorve the urinary catheter immediately
The nurse should leave the catheter in place and irrigate with 0.9% sodium chloride irrigation. Removing the catheter can cause further harm.
A nurse in a provider’s office is caring for an 18-month-old toddler who has a blood lead level of 3 mcg/dL. Which of the following actions should the nurse take?
a. Schedule chelation therapy
The nurse should schedule chelation therapy for a blood lead level greater than 45 mcg/dL
b. Contact the poison control center
The nurse should contact the poison control center for a blood lead level that is greater than 20 mcg/dL
c. Recommend rescreening in 1 yr
The nurse should identify a blood lead level of 3 mcg/dL is within the expected reference range.
The nurse should recommend rescreening in 1 yr.
d. Refer the family to social services
The nurse should consider a referral to social services for a blood lead level greater than 5 mcg/dL
A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
a. A client who is receiving verapamil and has a continuous infusion of TPN
b. A client who is taking phenytoin and is requesting a milkshake
c. A client who is receiving a diet high in potassium-rich foods and furosemide by mouth Clients taking furosemide can require a diet that is high in potassium to counteract the potassium loss this type of diuretic can cause
d. A client who is receiving an MAOI and is requesting a cheeseburger for
dinnerThe client’s food selection contains tyramine. Clients prescribed an MAOI must restrict intake of foods that contain tyramine due to adverse effects such as hypertension
A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of ICP?
a. Flex the client’s neck forward
b. Group several nursing activities to be completed at one time
c. Limit suctioning the client’s airway to 30 seconds at a time 15 seconds.
d. Place the client in a quiet environment
A nurse is caring for a client who has a prescription for a continuous passive motion machine following a total knee arthroplasty. Which of the following actions should the nurse take?
a. Turn off the CPM machine during mealtime
Turn off to promote client comfort and dietary intake
b. Maintain the client’s affected hip in an externally rotated position
Neutral alignment
c. Instruct the client how to adjust the CPM settings for comfort
Do not adjust settings as the settings are prescribed
d. Store the CPM machine under the client’s bed when not in use
Do not place on floor because it places the client at increased risk for a wound infection
A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching?
a. I will breastfeed my baby on a schedule of every 4 hrs
Respond the friend cues 8-12 times in a 24-hr period
b. I will bathe my baby daily
c. I will place my baby on her stomach for sleeping
d. I will cover my baby’s body when i wash her hair
e. I will use the bulb syringe in her mouth then in her nose
A nurse is teaching a client who has a new prescription for TPN through a central line. Which of the following information should the nurse include in the teaching?
a. I will change your IV tubing once every 48 hrs
24 hours
b. Abdominal distention is an expected effect of this therapy
This is for GI tube
c. I will need to check your gastric residual before administering feedings
Should check for enteral nutrition
d. I will need to measure your weight daily
The nurse should instruct the client that daily weight measurement is a necessary part of administering nutrition through a central line to avoid fluid overload and monitor for adequate weight gain
Mark Klimek Lectures–
Chest Tube questions: pay attention to disease and what to expect
Location of tubes: apical (up high– removing air) and basilar (bottom of lungs– removing blood) A for A, B for B Apical→
Air
Basilar→ Blood
Pneumo→ apical
Hemo→ basilar
Pneumohemo→ two tubes
You are to assume that chest surgery or trauma is unilateral unless otherwise specified. Post op R pneumonectomy→ no chest tube because no lung, no pleural space Lobectomy, wedge resection → chest tubes
Troubleshooting
Closed chest tubing devices
What to do if water seal device breaks? Positive pressure can get in pleural space. First thing to do is clamp it so nothing gets in. Second step is to cut it away from broken device. Then, put it in sterile water. Then, unclamp it since you reestablished the water seal. Better to be underwater than clamped because then stuff can go out. If clamped, nothing can go in or out. Clamp->cut->submerge->unclamp
Bubbling chest tubes
Where is it bubbling and when is it bubbling
Sometimes good and sometimes bad
____________________
Water seal
When? Intermittent
GOOD, DOCUMENT
Water seal
When? Continuous
BAD, THERES A LEAK IN THE SYSTEM, put tape on it
Suction control chamber
When? Intermittent
BAD, SUCTION TOO LOW
Suction control chamber
When? Continuous
GOOD, DOCUMENT
If something is sealed, should you have a continuous bubble– no. BAD
Suction control is opposite
First versus best thing to do in a situation
What has greater risk of infection? Straight cath or foley? Foley
Thoracentesis is an in and out chest tube
Chest tube is like a foley and thoracentesis is like a straight cath
If you're going to clamp something, need teeth to be clamped with rubber
Congenital heart defects are either trouble or not
MEMORIZE: TRouBLe (7 letters)
Trouble– need surgery asap in order to live
No trouble– no need surgery
Trouble– growth and development is delayed, bad life expectancy, go home on apnea monitor, stay at hospital for weeks
No trouble– normal growth and development, life expectancy is normal
Which way shunt blood away→ Trouble defect is right to left No trouble defects→ Left to right
Right to left shunt→ TROUBLE
Left to right shunt→ Normal
Cyanotic→ Blue, Right to left is blue, trouble is spelled that way
All congenital heart defects start with a letter T
4 Defects of Tetrology of Fallot
VarieD PictureS Of A RancH
(only need to recognize these)
VD→ ventricular defect
PS→ pulmonary stenosis
OA→ Overriding aorta
RH→ Right Hypertrophy
Your patient has tetrology of fallot, select all of the defects that follow
VD ventricular defect
PS pulmonary stenosis
OA overriding stenosis
RH right hypertrophy
Standard, universal– nothing
Contact– anything enteric (caught from intestine– fecal, oral) Hep A (anus), C.Diff, Colera, Disenteri, staph infections, RSV (transmitted droplet but contact precautions), herpes infections
-GOWN, GLOVES, HANDWASHING, DISPOSABLE SUPPLY/DEDICATED EQUIPMENT
-Private room preferred (yes to private room), can be put in same room if have same contact disease, need to be cultured before putting in same room
Droplet– Bugs that travel 3 feet on large particles (meningitis, H. Flu (which causes epiglottitis), Hep B (blood),
-Private room preferred (yes to private room unless cohorting based on culture)
-MASK, GLOVES, HANDWASHING, DISPOSABLE SUPPLY/DEDICATED EQUIPMENT, PT
WEARING MASK WHEN LEAVING ROOM
Airbourne– Measles, mumps, rubella, TB, varicella (chicken pox)
-private room REQUIRED unless cohorting
-MASK (N95), GLOVES, HANDWASHING, SPECIAL FILTER MASK ONLY FOR TB, PT MASK
WHEN LEAVING ROOM, NEGATIVE AIRFLOW
How is TB spread→ droplet, pt on airbourne
TB and RSV→ dont make sense but both transferred droplet
Shingles (herpes zoster)--> contact
Always take off in alphabetical order→ Gloves, Goggles, Gown, Mask
Always take on reverse alphabetical order for the G’s but mask comes second→ Gown, Mask, Goggles,
Gloves
Math problems–
Dosage calculations→ simple desired/have
IV drip rates→ volume x drop factor/ time in minutes
Mini (micro) drip→ 60 drops/mil (drop factor)
Macro drip→ 10 drops/mil (drop factor)
Pediatric dose→ using child’s weight
2.2lb per kg
Will always be dividing by 2.2 never multiplying
Total amount per day or amount to be given just at one time
Daily versus one time dose
IV replacement questions
(thinking with math)
Use leading zeros as long as it maintains place
Boards will tell you what you have to round to, do not have to put units
Crutches, canes, and walkers
Locomotion
How to mesure crutches→ risk reduction
How to measure length of the crutch→ 2-3 finger widths below the anterior axillary fold to a point lateral to and slightly in front of foot (no specific point of foot)
Hand grip: can be adjusted up and down: angle elbow flexion would be about 30 degrees
How to teach crutch gaits: 2 point (move a crutch and opposite foot together, then other)
3 point (two crutches and bad leg move together)
4 point (everything moved separately, move a crutch then locked in and have to move opposite foot, followed by the other crutch, then the opposite foot) and swing through (for non-weight bearing – ambutations or when saying)
Even for even→ odd for odd
Use the even numbered gaits (2,4) when weakness is evenly distributed
Use 2 point for a mild problem (mild bilateral weakness, 4 point for a severe problem (severe bilateral weakness)
Use 3 point when one leg is odd
Swing through with non-weight bearing (amputation)
Practice (100% hehe)
2 point–systemic disease, early stage
Swing through– amputation
3 point– one leg affected
4 point
Swing through– non-weight bearing
4 point
2 point
Going up and down with crutches (up with the good, down with the bad)
Lead with good→ up with good foot, then crutches (always move with bad leg)
Down with the bad→ down with the crutches, then good foot
Canes–
Hold canes on strong side
Walkers–
Pick them up, set them down, walk to them
Slow
If they must tie belongings to walker, must tie to sides than front (bc may tip over) Boards does not like wheels or tennis balls on walkers
Delusions, hallucinations–
Nonpsychosis versus psychosis
Very first thing is decide: is my patient nonpsychotic or psychotic HUGE- determine treatment, meds, length of stay, legality, etc.
1. A nonpsychotic person has insight (knows they have a problem), and is reality based (what they believe is what you believe). Distressed but not psychotic.
a. Techniques/approaches: good therapeutic communication (reflection, clarification)
i. Symptoms: DO NOT have delusions (false fixed idea or belief), hallucinations (falsed fixed sensory– 5 senses), illusions
(misinterpretation of reality, sensory experience)
2. Psychotic person has no insight and is not reality based
a. Techniques/approaches:
i. Symptoms: have delusions (false fixed idea or belief), hallucinations
(falsed fixed sensory– 5 senses), illusions (misinterpretation of reality, sensory experience)
ii. Illusion has a referent in reality→ actually something there, they just misinterpret what it means iii. Hallucination→ there is nothing there
Auditory→ hearing things that are not there
Visual→ seeing things that are not there
Tactile→ feeling things that are not there
Gusttory→ tasting things that are not there
Olfactory→ smelling things that are not there
Functional psychotic: can function in everyday life (schizophrenia, schizoaffective, major depression, manic) – bipolars are functional unless manic
Potential to learn reality (since have no damage) → teach reality
1. Acknowledge feeling (feeling in answer)
2. Present reality (I know that blank is real to you but I do not blank, tell them what reality is)
3. Set a limit (when this happens, we are not going to__)
4. Enforce the limit (cannot take away any privileges–do not punish)
ENDING CONVERSATION IS THE ONLY ENFORCEMENT
Present things positively with patients
Psychosis of dementia: actual damage to the brain, organic brain syndrome, psychotic after stroke CANNOT LEARN REALITY
1. Acknowledge their feeling
2. Redirect them (going with what they are talking about) –”lets go somewhere where you feel more safe” (do not change subject)
Do not present reality→ because they cant learn it
Reality orientation is appropriate with dementias versus presenting reality
Psychotic Delirium: temporary, sudden, dramatic, secondary, loss of reality
Usually due to some chemical imbalance in the body
These people are “crazy” for the short term because they have a temporary reaction
Delerium tremors, cocaine overdose, meth overdose, post-op, ICU, UTI in elderly, thyroid storm, adrenal crisis, -roid rage
Focus: removing underlying cause and keep them safe
1. Acknowledge feeling
2. then reassure of safety and short-term
Do not present reality because will not get it
Personality Disorder
-ABNORMAL ABN
Anitsocial
Borderline
Narcissists
-SET LIMITS-
Loosely association
Flight of ideas: make phrases that are coherent, phrases together not tightly connected
Word salad: random words
Neologlism: making up imaginary words
Narrowed self concept: psychotic refuses to leave room and refuses to change clothes. Do not make them change their room/change clothes– want to acknowledge feelings, you do not have to change your clothes/leave their room until you feel safe Ideas of reference
Diabetes Mellitus–
-error of glucose metabolism
-trouble because cannot metabolize or use primary fuel source: cells die
-Polyuria, polydipsia, polyphagia (increased swallowing)
-Low specific gravity -
Fluid volume loss
Treatment for Type 1– DIE
Diet– least important
Insulin– most important Exercise
Treatment for Type 2– DOA Diet– most important Oral Hypoglycemic
Activity
Diabetes Insipidus (polyuria, polydipsia, leading to dehydration) due to low ADH Just fluid part of diabetes mellitus
-High urine output
-Lose water
-Low specific gravity
-Fluid volume loss
SIADH (opposite from diabetes insipidus)-- high ADH
-Low urine output, oliguira
-Not thirsty because retaining water
-Gains weight suddenly
-Fluid volume excess
-High Specific Gravity
Amount of urine and specific gravity
Inverse relationship
The less the urine out, the more specific gravity
The more the urine out, the less the specific gravity
Diet, Insulin, Exercise
Diet for T2– Calorie restriction (best)
6 small feedings/day recommended
Insulin lowers blood glucose
Regular ®
-Onset 1 hr
-Peak 2 hr
-Duration 4 hr
-Clear solution, IV DRIP
-short-acting, rapid insulin
Intermediate-
-NPH
-Onset: 6 hrs
-Peak 8-10 hrs
-Duration 12 hrs
-Cloudy, suspension
-Roll instead of shake
Rapid-acting-Lispro, Humalog
-Onset: 15 min
-Peak: 30 min
-Duration: 3 hrs
-GIVE WITH MEALS
Long-acting– Lantus: glargine
-So slowly absorbed, no essential peak
-Little to no risk of hypoglycemia
-Safely give at bedtime
-Duration: 12-24 hrs
ALWAYS CHECK EXPIRATION DATE ON INSULIN
What action by nurse invalidates the manufacturers expiration date? Opening it
New expiration date: 30 days after opening, write on bottle
Refrigeration is optional– need to refrigerate at home
Unopened vials need to be refrigerated, not need to frigerate it after opening it
Exercise does the same thing as (potentiates) insulin
Sick diabetic-
Hyperglycemia, dehydration
Glucose goes up w stress even when NPO
Stay active because helps lower glucose
Complications of diabetes–
-Acute complications
-Signs and symptoms of
Hypoglycemia (caused by not enough food, too much insulin (primary cause), too much exercise) –danger: brain damage
–signs and symp: drunk, in shock
Staggering gait, slurred speech, poor judgement, delayed reaction time, labile emotions
(all over the place), decreased social inhibition
Look like in shock: low BP, increased HR, tachypnea, cold pale clammy skin, mottled extremities
–Admin rapid sugar (carbohydrate)
Any juice, popsicle, chewed up candy, milk, honey, icing, jam, jelly
Ideal combination of foods: sugar, starch, protein (orange juice and crackers, apple juice and a slice of turkey, skim milk)
Glucagon IM if unconscious, dextrose per IV (D10,50)
Hyperglycemia in T1 DKA (diabetic ketoacidosis), Diabetic Coma
Too much food, not enough medication, not enough exercise
#1 cause of DKA is acute viral upper respiratory infections within the past 2 weeks
Stress of illness was not shut off, started burning fats for fuels
Signs and symp– DKA
Dehydration (hot,flushed,dry), Ketones (blood), Kussmaul (deep and rapid), K
(potassium), Acidotic (metabolic), Acetone breath(fruit odor), Anorexia due to nausea
IV fluid fast rate, regulr insulin IV, D5 will not cause hypoglycemia
Hyperglycemia in t2, HHNK, HHNC, HHNS
Nonketotic
–Dehydration signs and symptoms
Hemoglobin A1C want to be 6 or lower
Out of control is 8 or above
7 Need workup, evaluation
Drug Toxicities–
Lithium antimanic drug, used for bipolar mania
Therapeutic 0.6-1.2
Toxic greather than or equal to 2
Grey area in between 1.2-2
Linoxin
Toxic greater than 2
When a bronchodilator doesnt work, give them a theofflin
Amniofflin 10-20
Too low, need to take more 21 toxic
Dilantin 10-20
Bilirubin (waste product from breakdown of RBCs)
Only tested in newborns
Breaking down mom’s RBCs so high bilirubin Therapeutic level– 9.9 or less (high for adult) elevated level: 10-20
Hospitalized at 14 or more
Toxicity greater than or equal to 20
Curnictorous: bilirubin in the brain, occurs when bilirubin gets to 20 and they could die
Jaundice: yellow color due to bilirubin in skin
Opistertodous: position baby assumes when have bilirubin on brain
(hyperextend due to irritation of meninges) heels will come up and touch ears and will be rigid Position they place them: on their side
Remember 2’s and 20’s
Dumping syndrome versus hiatal hernia– both gastric emptying problems
Dumping syndrome: follows gastric surgery, gastric contents dumps too quickly into duodoeum, fast rate
Hiatal hernia: regurgitation of acid into esophagus because upper part of stomach herniates into diaphragm (two stomachs) stomach empties at a normal rate, moving in the wrong direction
Dumping syndrome: cerebral impairment: a lot like being drunk, signs of shock (hypotension, tachy, cool, clammy, pale) acute abdominal distress: cramping, abdominal pain, doubling over, borburigmy, diarrhea, bloating, distention, guarding
Hiatal hernia:
____________
Practice questions
-alternate schedule therapy for glucocorticoids
-Saw Palmetto: urinary health promotion
-Chlordiazepoxide is used to alcohol use disorder acute withdrawal ____________ [Show Less]