RN Comprehensive Practice 2023 A with NGN (Answered 100% Correctly) |
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NGN: What assessment findings are consistent with Crohn's
... [Show More] disease, ulcerative
colitis, or peritonitis?
Temperature (100F)
Weight (-9.7 lbs)
Albumin level (2.4)
WBC (14)
Bowel pattern (freq. loose stools)
Abdominal pain location (RLQ)
Heart rate (105)
Temperature: Crohn's, UC & peritonitis.
-Elevation can occur with all three due to inflammation and infection.
Weight: Crohn's & UC.
-Unintended weight loss can occur due to malabsorption in the GI tract.
Bowel pattern: Crohn's.
-If the patient reported there was blood in the stool, it would be UC. Crohn's
doesn't cause tarry stools.
WBC: Crohn's, UC & peritonitis.
-Elevation can occur due to inflammation and infection.
Heart rate: peritonitis.
-Tachycardia can occur due to inflammation, infection, and dehydration.
Albumin level: Crohn's & UC.
-Because of the malabsorption in the GI tract, the body isn't receiving enough
protein.
Abdominal pain location: Crohn's.
-Because it is in the RLQ, it is more consistent with Crohn's. With patients that
have peritonitis, they experience generalized abd. pain that radiates to the shoulder
and back.
NGN: What assessment findings can indicate a transfusion reaction in a patient
receiving blood?
Urine output (150mL of clear, yellow)
Skin (pale, cool and dry)
Anxiety
Vital signs (within normal range)
Headache
Back pain
Back pain, headache & anxiety.
Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain,
tachycardia, dyspnea, hypotension.
NGN: Patient arrives with palpitations, difficulty breathing, and reports feeling
faint. Reports constipation and joint pain for x2 days. In childhood, patient
experienced physical abuse, and emotionally detached parents. Reports
nervousness and only leaving home when necessary.
PMH: freq. hospital visits due to headaches and GI distress.
Bowtie:
Condition: somatic symptom disorder
-due to physical inactivity & joint pain
Interventions: Monitor physical manifestations & assess for presence of 2nd gains
from their illness
-disorder is characterized by the presence of other real manifestations like
dizziness, nausea, back pain, and joint pain.
Monitor: Vital signs & pain.
NGN: What actions should the nurse take when her pedi patient is exhibiting
symptoms of an allergic reaction?
Administer 0.9% NS IV
Administer epi IM
Monitor urine output q2hrs
DC supplemental oxygen
Monitor vital signs frequently
DC IV medication
Administer 0.9% NS IV
Administer epi IM
Monitor vital signs frequently
DC IV medication
-Nurse should DC the Rocephin and give IV NS to help restore fluids because fluid
shifts can occur quickly during a reaction. Administering epi IM is the first line of
therapy for anaphylactic reactions because it constricts blood vessels and dilates
bronchioles. Monitoring vital sings frequently will allow the nurse to monitor for
signs of shock.
NGN: What 5 actions should the nurse plan to take with a patient experiencing
hallucinations, following alcohol withdrawal?
Administer thiamine
Maintain a low-stimulation environment
Administer chlordiazepoxide
Initiate seizure precautions
Perform a CIWA-Ar
Administer disulfiram
Administer thiamine
Maintain a low-stimulation environment
Administer chlordiazepoxide
Initiate seizure precautions
Perform a CIWA-Ar
-Nurse should plan interventions that keep the patient safe and treat the physical
manifestations of withdrawal. Use the CIWA-Ar to determine the severity of the
withdrawal. Withdrawal seizures can occur 12-24hrs after cessation of alcohol use,
therefore initiate seizure precautions to prevent injury. Administer
chlordiazepoxide (a benzodiazepine) and place patient in a low-stim environment
to decrease agitation and the risk for seizures. Administering thiamine can prevent
Wernicke syndrome.
NGN: A post-op patient is experiencing right lower extremity pain and itching,
following an emergent appy. Reports right lower extremity pain that has been
intermittent for x2 months.
Assessment: Bilat lower extremities warm to touch, pedal pulses 2+ bilat. Spider
veins noted. Distended veins noted on right lower extremity. Vital signs are within
normal limits.
Bowtie:
Condition: Varicose veins.
-due to edema & pruritis
Interventions: Elevate extremity & apply compression stockings
-to promote venous return & circulation
Monitor: Pruritis & edema
NGN: Which assessment findings require an immediate follow-up in a
schizophrenic patient?
Hyperactive bowel sounds x4
Last HCP appointment was 6 months ago
Client AO x2
Agitated
Speech disorganized
Involuntary tongue movement and foot tremor
Increase in urination and one episode of incontinence
Family c/o increased agitation and delusions
Involuntary tongue movement and foot tremor
Frequent urination and incontinence
Increase in agitation
-Patient is experiencing tardive dyskinesia
A home health nurse is evaluation a school-age child who has cystic fibrosis. The
nurse should initiate a request for a high-frequency chest compression vest in
response to which of the following parent statements?
A. "My child doesn't like to sit still for nebulizer treatments."
B. "I think that my child has been running a fever over the last couple of days."
C. "My child only has a small amount of mucus after percussion therapy."
D. "I am concerned about my child's future participation in team sports."
C. "My child has only a small amount of mucus after percussion therapy."
-The nurse should recommend a high-frequency vest for a child who has
inadequate results from other airway clearance therapy techniques. Older children
often require other techniques in addition to percussion and postural drainage to
achieve adequate mucus expectoration.
-The nurse should teach the parent techniques for administration for nebulizer
treatments to the child.
-The nurse should follow-up on reports of fever, as this could indicate a pulmonary
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