Final Exam NUR 128 Questions With Complete Solutions, Exams of Nursing

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Physical Examination - correct answersGeneral appearance Vital signs Inspect mucous membranes Assess skin color, temperature, moisture Inspect skin Inspect, palpate lymph nodes Assess MSK Check Joint ROM artificially acquired passive immunity - correct answersreceive immunity without your body making it active immunity - correct answerswhen your body creates antibodies passive immunity - correct answerswhen your body is given antibodies. Diagnostic lab changes that indicate infection - correct answersCRP WBC leukopenia 4,500 ----------- 10,000 leukocytosis CBC Blood culture, urinalysis, fecal culture, wound culture Lumbar puncture - CSF infection Side effects of NSAIDS use in the older adult - correct answersDizziness - fall risk, risk of injury Do not use/caution when giving NSAIDs to older adults because of what? - correct answersReduced kidney/liver function NSAID: should you deliver with or without food? - correct answersGive with food and lots of water indicators of a systemic reaction to inflammation - correct answersFever >100. Pulse>90 bpm RR> 20/min WBC> 12,000 or greater than 10% bands Thrombocytopenia too low platelets Leukocytosis - too high WBC Anemia too low RBC Neutropenia too low neutrophils Pancytopenia too low RBC/WBC/platelets acute ulcerative colitis: Does it affect M vs F more - correct answersEqual acute ulcerative colitis: Onset peak - correct answers15-

acute ulcerative colitis: Course of disease - correct answersChronic w/ periods of remission of symptoms and active disease. Acute ulcerative colitis: Symptoms - correct answersFatigue Anorexia Weakness Diarrhea- 5-30 stools per day w/ blood and mucus Abdominal Pain- Cramping in left lower quadrant, relieved by defecation Nursing actions to decrease cancer cells and support normal cell function - correct answersNutrition and hydration Focus on reducing complications Manage side effects Maintain optimal homeostasis Provide psychosocial support Promote balance activity/rest Collaborative treatment plan for a client with leukemia - correct answersRadiation, Chemo, Nutritionist, PT, OT, pharmacist, oncologist Treatment of side effects, Infection control/PPE/ Bleeding precaution/be alert for hemorrhage Strategies for cancer prevention - correct answersAvoid smoking, limit alcohol, eating balanced diet, regular exercise, good physical health for optimal immune function, wearing sunscreen, follow safety protocols in your workplace Strategies for cancer prevention: Early Detection - correct answersBreast cancer - self exam 3-5 days after period once a month, mammograms at 45 Prostate - age 50 get a PSA Cervical - age 30 - 65 pap smear Colorectal - age 50 get DRE fecal test Q3 years colonoscopy Q What are assessment findings that are positive indicators for breast cancer? - correct answersNontender lump (often in the upper outer quadrant), abnormal nipple discharge, a rash around the nipple area, nipple retraction, dimpling of the skin, or a change in the position of the nipple. May also be nipple pain, scaliness, ulceration, skin irritation, or discharge. Usually painless some women report burning or stinging sensation. Erythropoietin is ordered for patients that what? - correct answersfor people who have anemia associated with other chronic diseases (Chronic Renal Failure)

erythropoietin stimulates RBC production so what must be done? - correct answersadequate iron must be present, patients may require regular IV therapy. Maybe give up to 3x a week Fluid shifts from Interstitial space into vascular compartment- to do what? - correct answersMaintain blood volume Signs and symptoms of low RBC - correct answersDecreased perfusion, hypotension, decreased LOC Discharge teaching instructions for a patient with iron deficiency anemia - correct answersBleeding precautions - teeth, Frequent Oral care, non alcoholic mouthwash Use a straw to take iron Eat foods high in Iron, B12 and Folic acid Take Iron with VItamin C Do not eat with milk products, tea/coffee, antacids Energy supply and demand. Work with pt and family to identify alternative ways of performing tasks (sitting when taking shower). Help pt and family establish priorities for tasks and activities. Assist the patient to develop a schedule of alternating periods of rest and activity throughout the day. Encourage 8-10 hours of sleep at night. Do not smoke (vasoconstriction and increased carbon monoxide levels in the blood, interfering with oxygenation). Teach pt and family to monitor vital signs before and after activity. Ensure that the pt understands that chest pain, breathlessness, or vertigo; palpitations or tachycardia that does not return to normal within 4 minutes of resting; bradycardia; tachypnea or dyspnea; and/or decreased systolic bp changes may signify cardiac decompensation resulting from insufficient oxygenation. Patient and family education related to management of sickle cell disease and sickle cell crisis - correct answersProvide parents with information about SCD and the child's treatment. Even parents of a child previously diagnosed with the disorder may benefit from information about the disease process and its management. Explain the basic effect of tissue hypoxia and the effects of sickling on circulation. Teach parents to look for signs of dehydration, such as dry mucous membranes, weight loss, and sunken fontanelles in infants. Make sure both the child and the family understand the triggers and precipitating factors for sickle cell crises. Encourage them to avoid situations that cause crises. (dehydration/hypoxemia, cold, stress, fever, acidosis, high altitudes) Provide the family with careful instructions about infusion therapy. When reg blood infusions are used, the resulting iron overload is damaging to body organs. (iron chelating agents) Instruct parents that it is important to inform all treating physicians and dentists of the child's medical condition. Special precautions are needed when a child undergoes

surgery of any kind, because hypoxemia resulting from anesthesia is a major surgical risk. Because infection is especially dangerous for the patient with SCD, recommendations for patients of all ages include keeping current with vaccinations, plus receiving annual influenza and pneumococcal vaccinations. Family members need ongoing support to deal with the stress of having a child with a chronic condition. Provide resources, respite care for parents, and information as needed for siblings. Encourage older children with SCD to participate in activities with other children between crises, but to avoid strenuous physical exertion and contact sports. Play and social interactions that promote learning and development are important. Strategies (things a client can do) to decrease the risk of myocardial infarction related death - correct answersSmoking, moderate alcohol, diet/exercise ( 5 x wk for 30 minutes) Low fat diet - reduce cholesterol Manage chronic health conditions - HTN, DM, Hyperlipidemia Nursing care of a client with a cardiac dysrhythmia - correct answersAssess for underlying cause Assess for decreased CO MOnitor ECG Assess serum electrolytes Prepare to administer antidysrhythmic medications Prepare to assist for cardioversion Monitor vitals (treat patient not monitor) Recognize normal sinus rhythm (NSR) and be able to describe what NSR looks like - correct answers60 - 100 bpm Regular rhythm P wave 1;1 to QRS PR interval .12 -. QRS - 0.06 - 0. Identify complications of bacterial endocarditis - correct answersEmboli- Stroke, Pulmonary Embolism, Vegetation may form on valves and migrate to other parts of body Seizure Sepsis Heart attack, Heart failure, Pericarditis Valve damage/valvular insufficiency Left heart damage (brain)/Right Heart damage (lungs) Death Splenomegaly Kidney damage - renal failure/inflammation of the glomerulus Arrhythmias

How are congenital heart defects categorized? - correct answersIncreased pulmonary blood flow Decreased pulmonary blood flow Obstructive defects Mixed defects Recognition and management of a "tet spell" - correct answersHypercyanotic Squat to reduce venous return from lower extremities Pathophysiology of Hemophilia A - correct answersWell-known, but rare disorder. X linked recessive disorder Caused by a genetic mutation that results in uncontrolled bleeding due to lack of clotting factors in men who inherit the mutation. Women who inherit the mutation become carriers typically Care of the child with Hemophilia - correct answersBleeding precautions Don't give meds that cause bleeding like aspirin Give sub q injection no IM (vaccines ok) How to treat epistaxis and bleeding (ice and tip head forward and pinch bridge of nose) No contact sports/vigorous exercises Hemarthrosis -bleeding in joint causes pain, leads to joint deformity, pain, swelling, redness factor infusions/blood transfusions Nursing interventions:Care of the child with Hemophilia - correct answersno rectal temps or meds that cause bleeding sub q not IM electric razors no repeated BP on same place (manual) padded beds/cribs Physiological findings that accompany increased intracranial pressure - correct answersDecreased LOC Oculomotor dysfunction Cushing's triad - inc bp/bradycardia/apnea Headache Vision changes Pharmacological management of IICP - correct answersFluid Management Hyponatremia-Furosemide Antiepileptic drugs (AEDs) for Seizures Management of IICP - correct answersOsmotic and loop Diuretics Sedation, paralysis are chemical restraints Antipyretics

Anticonvulsants GI prophylaxis (H2 receptor antagonist or ppi) IV Fluids AVOID HTN! Vasoactive medication TPN, if enteral feeding not possible Elevate HOB 30 degrees Stool softeners Nursing considerations related to Dilantin therapy - correct answersMonitor BP, pulse and respirations, Note evidence of CNS side effects (blurred vision, dimmed vision, slurred speech, nystagmus, confusion), Gingival hyperplasia Bone demineralization- may need diet rich in VIT D and calcium, need good dental hygiene, Monitor serum calcium levels, Don't take with dairy products? monitor closely for resp. depression and cardio collapse If they stop they could go into status epilepticus. What to do for a seizure: - correct answersDo not hold them down Do not put anything in their mouth Turn patient on their side if possible to prevent aspiration Protect their head Move objects from around them to make a safe space Lower to floor (if not already on flat surface) Monitor them/stay with them throughout the seizure Check airway patency after seizure Monitor length of time Oxygen and suction at bedside Nursing interventions/strategies that promote development of sensorimotor ability post- stroke - correct answersROM, turn/reposition q2h; consult with PT and OT Passive ROM on affected side, encourage use of affected side Promote and encourage self-care Speech and language therapy (promote verbal communication) Elevate HOB 30 degrees Monitor the patient's lower extremities each shift for symptoms of thrombophlebitis. Assess for increased warmth and redness in calves; measure the circumference of the calves and thighs (monitor for DVT) Assessment findings indicative of stress - correct answersIncreased BP, HR Sweating Face flushing Muscle tension Fidgeting

Laboratory value changes associated with stress response - correct answersGlucose and cortisol levels increase Client education related to use of diazepam - correct answers(Valium) for short-term use only (Anti Anxiety) - Highly addictive Avoid grapefruit juice No time (No food/with food) indicated for taking it Avoid alcohol Nursing diagnosis associated with clients with personality disorder - correct answersSafety - Risk for other directed violence and self directed violence? Risk for injury Nursing care of a client with Post-Traumatic Stress Disorder (PTSD) - correct answersBuild trusting relationship, ensure safety, help to decrease anxiety, stress reduction techniques, identify triggers, community resources for long term care, reinforce understanding of effective coping strategies, refer to therapy and support group, giving information that there is help for them Communication strategies for a client in crisis - correct answersABC'S of communication: Achieve rapport Boil down the problem Cope with the problem Normal Therapeutic level for litium: - correct answers0.8-1. If lithium is below 0.8 what does this mean? - correct answersit means it is ineffective Lithium carbonate toxic manifestations: Mild/Moderate - correct answersn/v/d (gi upset), dizziness, weakness, tremors, fatigue, blurred vision Lithium carbonate toxic manifestations: Severe - correct answersuncontrollable eye movement, hyperthermia, death, slurred speech, renal failure, confusion, tachycardia, hypotension, coma, seizures, delirium What time of day should you take lithium? - correct answersSame time each day Tests to do when a pt is on lithium? - correct answersKidney, thyroid and liver function tests and electrolytes before administering Sodium restricted diets with lithium: - correct answerslow Na causes body to retain lithium salt, which becomes toxic

People of Asian descent have toxic effects of lithium at lower levels: true or false? - correct answerstrue What are some health problems in the older adult that affect cognitive processes? - correct answersDecreased blood flow of areas that control memory, cognitive flexibility and executive function Akathisia - correct answersrestlessness Anomia - correct answersdifficulty naming people/things Ataxia - correct answers- lack of muscle coordination

• correct answers-meaningless repetition of phrases Carphologia - correct answerslint picking behavior Echolalia - correct answersmeaningless repetition of phrases Alzheimer's diagnosis - correct answersto diagnose Alzheimer's, physicians may use medical history, mental status tests, physical and neurological exams, diagnostic tests and brain imaging. Piaget: Sensorimotor - correct answerswhere they develop a sense of self Piaget: Pre-operational - correct answerswhere they participate in imaginative play Piaget: Concrete operational - correct answerswhere they are no longer fooled by appearances Piaget: Formal operational - correct answerswhere they begin systemic deductive reasoning The Eight Stages of Erikson:Infancy - correct answersTrust vs. mistrust The Eight Stages of Erikson:Early Childhood - correct answersAutonomy vs. shame and doubt The Eight Stages of Erikson:Preschool - correct answersInitiative vs. guilt The Eight Stages of Erikson:School Age - correct answersIndustry vs. inferiority The Eight Stages of Erikson:Adolescence - correct answersIdentity vs. role confusion The Eight Stages of Erikson:Young Adulthood - correct answersIntimacy vs. isolation

The Eight Stages of Erikson:Middle Adulthood: - correct answersGenerativity vs. stagnation The Eight Stages of Erikson:Maturity - correct answersEgo integrity vs. despair Cerebrum - correct answersLeft (language, speak, logic, right side of body) Right (judgement, impulse control, creativity) IPV - correct answersRisk factors may help in predicting populations at higher risk for victimization of young children, and older adults. Criteria for nursing diagnosis of Rape Trauma Syndrome - correct answersRisk for infection Rape trauma syndrome Fear Acute pain Powerlessness Risk for ineffective coping situational low self esteem Disturbed self concept Define alcohol abuse - correct answersAlcoholism is a chronic disease with genetic, psychosocial, and environmental factors Describe the family dynamics of codependency - correct answersAn enabling codependency, is excessive emotional or psychological reliance on a partner. Medical management of opiate overdose - correct answersOpioid overdose can be reversed with the drugs Narcan, when given right away. Diagnostic tools to confirm impairment - correct answersDiagnostic tests such as the breathalyzer and blood alcohol level are the main measures for assessment. Medicate management of alcohol abuse - correct answersAntabuse is used and it is an aversion therapy.Revia or depade also known as Naltrexone. Naltrexone - correct answersreduces cravings and blocks the brain pleasure pathways associated with alcohol Antabuse - correct answersIt prevents the breakdown of alcohol and when a client drinks alcohol while taking antabuse, they experience intense vomiting as a response to the alcohol ingestion. What are the priority nursing diagnosis for alcoholism - correct answersRisk for injury Risk for violence Ineffective denial

Ineffective coping Imbalanced nutrition Chronic or situational low self esteem Deficient knowledge Disturbed sensory perception Disturbed thought processes Identify risk factors for alcoholism - correct answersLinks of found among the addiction gene location and BMI among Native Americans Being a child of an alcoholic More than half of all adults have a family history of alcoholism or problem drinking More than seven million children live in a household where at least one caretaker is depended upon or abused alcohol predisposing them to the same disposition Odynophagia - correct answersmedical term for painful swallowing Outcome goals for a client in alcohol detoxification - correct answersClient will admit alcohol is controlling their life Agree to enter an alcohol treatment facility Experience no complications as a result of alcohol abuse or alcohol withdrawal Optimal nutritional status Remain sober Participate in a support group after discharge Kindling- - correct answersphenomenon of increasingly severe withdrawal symptoms, including an increased risk of seizures, that occurs as a result of repeated withdrawal from alcohol or other sedative-hypnotics with related modes of action. ABCs of patient care - correct answersAirway Breathing Circulation Tolerance- - correct answerscan occur after chronic use. Need for more to feel the effects of the substance. Dependence- - correct answersoccurs when the individual can no longer control the use of the substance and continues in spite of the adverse effects. Addiction - correct answersis a psychological or physical need for a substance, such as, alcohol or process such as gambling Carbohydrates: What are they? - correct answersare organic components of foods that supply energy in the form of calories to the body A BMI of 25 to 29.9 - correct answersoverweight

What happens when there is excess glucose in the body? - correct answersWhen eaten in excess the body converts the extra glucose to glycogen or fat. Glycogen is stored in the liver and muscles, and fat is sub stored as adipose tissue. BMI over 30 - correct answersobese BMI greater than 40 - correct answersmorbidly obese Lipid profile (including cholesterol levels) - correct answersA cholesterol level below 160 mg/dL possible indicator of malnutrition. Serum glucose - correct answerselevated glucose levels could be an early indicator of prediabetes Prealbumin (PAB)/transthyretin (TTHY)? - correct answersHepatic protein found in the serum that provides a sensitive indication of protein deficiency Polyurea (diuresis) - correct answersis the production of an abnormally large amount of urine Polydipsia - correct answersis extreme thirst that leads to compulsive intake of fluids Anuria - correct answersis absence of urine output Oliguria - correct answersis scanty urine output Urinary frequency - correct answersis going to the bathroom greater than four to six times per day to pass urine Nocturia - correct answersis voiding at night urgency - correct answersis a strong desire to avoid Dysuria - correct answersis painful or difficult urination Urinary hesitancy - correct answersis a delay or difficulty in initiating voiding Neurogenic bladder - correct answersis impaired neurological functioning that makes it difficult to urinate increased risk for urinary incontinence - correct answersWomen Increased risk for urinary retention - correct answersMen Genetic conditions such as myelomeningocele or spina bifida and Parkinson's can lead to ________ urinating. - correct answersdifficulty urinating

Priority care for patient with urinary incontinence - correct answersMaintaining aseptic technique to reduce infection chances Client education related to management of a bowel obstruction at home - correct answersIncreasing fluid and fiber Teaching about the impact of dietary choices Kegel exercises and biofeedback Teaching not to strain too hard Collaborative interventions Laxatives promote bowel movements Stool softeners promote bowel movements Antidiarrheal agents do what? - correct answersAntidiarrheal agents slow motility of the intestine or promote absorption of excess fluids Clinical manifestations of bulimia - correct answerscycle binging and purging food, body image disturbances, abuse of laxatives, enemas, and diuretics, extreme exercise to compensate for binging, hoarding food, secretive behavior , hoarse voice, finger/knuckle scarring, Temp increases, BP decreases, dehydration s/s, electrolyte imbalance, risk of arrhythmias Nursing considerations when administering Metamucil - correct answersCan interfere with the absorption of some medications; bulk forming laxatives should be taken 2 hours before or after other meds. Always take these drugs with sufficient water; if not they may cause gastro intestinal obstruction The drugs may cause increased bloating and abdominal pain. Sugar free options are available for patients with diabetes. These drugs should not be taken long term Some preparations are made to be more appealing to children Expected outcomes for diarrhea - correct answersAntidiarrheal agents slow motility of the intestine or promote absorption of excess fluids Care of the skin of the older adult - correct answersOlder adults may only need to bathe every other day (soap causes skin to dry), use of moisturizers, proper hand hygiene for wound care, nutrition and exercise, improves blood flow Skin differences in the newborn - correct answersIn newborns the skin is very thin. The epidermis is loosely bound to the dermis, so friction can cause separation of the layers and blistering will occur. Allergic contact dermatitis - correct answersTreatment would include calamine lotion, aveeno baths, topical corticosteroids, or oral corticosteroids, and sometimes for itching children will be given Benadryl or atarax as well.

Irritant contact dermatitis - correct answersQuickly resolve with removal of the irritant Assessment findings in Cushing's Syndrome - correct answershypertension, signs of congestive heart failure, a moon face, a buffalo hump, a fragile skin, striae on the abdomen and thighs, poor wound healing, weight gain, and bruising. Dietary recommendations for a client with Cushing's Syndrome - correct answersAdequate sodium (not high or low) Parental instructions for care of a child with scabies - correct answersEveryone in contact with the child should be treated. Head to toe with scabicide medicine (except the face) Diaper dermatitis - correct answerswhat you'll see are raw moist weeping macules and papules in contact with the diaper Yeast diaper infection or candida albicans - correct answerst will look like a beefy red rash with satellite lesions meaning there's little lesions away from where the diaper was touching. Typically the skinfolds are involved in the diaper dermatitis that is caused by yeast. Care plan for contact dermatitis - correct answersAvoid contact with irritant Corticosteroid Antihistamines Barrier creams Antibiotics Nursing diagnoses associated with Tissue Integrity - correct answersRisk for infection Impaired skin integrity Nutrition, less than body requirements Allergic contact dermatitis - correct answersdelayed T cell mediated hypersensitivity reaction, and an example of this would be Poison Ivy and poison Oak Irritant contact dermatitis - correct answersoccurs when irritating substances temporarily damage the epidermis Antipyretics - correct answersUsed to reduce/control fever/body temperature Corticosteroids - correct answersUsed to lower inflammation in the body. Ease swelling, itching, redness, and allergic reactions (ex. Treat asthma) Glaucoma, fluid retention, hypertension Opiates - correct answersUsed to relax the body and relieve pain. Used for moderate- severe pain

NSAIDS - correct answersHelp to reduce pain and inflammation/swelling, mild to moderate pain GI and Cardiac SSRI - correct answersAntidepressants, work by increasing levels of serotonin within the brain Loop Diuretics - correct answersAct on the ascending limb of the loop of Henle in the kidneys. Usually used to treat hypertension and edema often due to congestive heart failure or chronic kidney failure Antibiotics - correct answersUsed to treat or prevent some types of bacterial infection. Kill bacteria or prevent them from reproducing and spreading Benzodiazepines - correct answersUsed for treating anxiety, seizures, Histamine (H2) antagonists - correct answersUsed to treat gastritis, peptic ulcers, GERD, Dilantin - correct answersdecreases abnormal electrical activity in the brain. Dilatin When to take: - correct answerssame time each day as directed Dilatin what to increase - correct answersIncrease calcium and vit D intake. Dilatin side effects - correct answersBone demineralization, gingival hyperplasia, resp depression Nursing Interventions for dilatin - correct answersMonitor BP, pulse and respirations, Note evidence of CNS side effects (blurred vision, dimmed vision, slurred speech, nystagmus, confusion), Gingival hyperplasia Bone demineralization may need diet rich in VIT D and calcium, need good dental hygiene, Monitor serum calcium levels, monitor closely for resp. depression and cardio collapse If they stop they could go into status epilepticus. Nursing consider. for lipitor - correct answersAssess for muscle pain, tenderness, or weakness