MULTIDIMENSIONAL CARE FINAL EXAM | LATEST 2024-2025 VERSION WITH QUESTIONS AND ANSWERS, Exams of Nursing

Download MULTIDIMENSIONAL CARE FINAL EXAM | LATEST 2024-2025 VERSION WITH QUESTIONS AND ANSWERS and more Exams Nursing in PDF only on Docsity! MULTIDIMENSIONAL CARE FINAL EXAM | LATEST 2024-2025 VERSION WITH QUESTIONS AND ANSWERS 65-year-old female who presents to the ED with epigastric discomfort, loss of appetite, and weight loss. History of diabetes and alcoholism. What disease does she likely have? Peptic ulcer disease GI bleeds Gastric cancer (Correct Answer) Candidiasis A nurse is caring for a patient who is status post upper endoscopic procedure. Which of the following should be included as a priority in the post-procedure assessment? Neuro assessment Gag reflex (Correct Answer) Temperature Bowel sounds A nurse is caring for a patient with a diagnosis of oral cancer who recently underwent surgery. Which of the following is a post-operative nursing priority? Airway management (Correct Answer) Prevent aspiration Monitor vital signs Provide alternate means of communication A 44-year-old pt. was recently diagnosed with gastric cancer. Sam has a wife and three small children. They are having a difficult time dealing with the diagnosis. Which of the following is a priority for this patient? Educate on treatment options Consult the dietician regarding nutritional needs Monitor lab values for abnormalities Consult social services to provide support to Sam and his family (Correct Answer) A nurse is caring for a patient who was diagnosed with lymphoma and undergoing chemo. Which of the following conditions is she at risk for developing? SATA Gastric cancer Oral cancer Candidiasis (Correct Answer) Stomatitis (Correct Answer) Gwen is an 89-year-old female who was diagnosed with gastric cancer three months ago. She has undergone chemo and radiation and recently had surgery to remove the cancer. During the surgery, they discovered that the cancer had spread to other organs. They are having difficulty deciding treatment options. Which of the following is appropriate for her care? SATA Prepare patient for additional chemo (Correct Answer) Prepare patient for additional radiation (Correct Answer) Consult the palliative care nurse (Correct Answer) Discharge the patient to hospice 56-year-old female who presented to the ED with fullness in the chest, dysphagia, and chest pain. She states that she has been having these symptoms for the past couple of months. Which of the following conditions could it be based on her symptoms? Peptic ulcer disease Based on the assessment findings, which of the following would you anticipate to be her diagnosis? Peritonitis Appendicitis (Correct Answer) Crohn's disease Ulcerative colitis What is primary intention wound healing? Wound edges are well-approximated. Place in order the wound healing process. Hemostasis -> Inflammation -> Proliferate -> Maturation T/F: Serous-sanguinous drainage is blood mixed with pus. False. What is sometimes common to see in evisceration? Fistulas, total separation of the wound, caused by IAP (increased abdominal pressure) What is a partial-thickness wound with loss of epidermis and some dermis? Stage 2 What is a full-thickness wound with loss of skin and visible subcutaneous tissue? Stage 3 What is a full-thickness wound with loss of the skin and visible bone and undermining? Stage 4 What is a wound that has more than 75% of the wound bed covered? Unstageable The Braden Scale includes sensory, moisture, activity, and ? Mobility, nutrition, and friction/shear What are some interventions to reduce the risk for skin injury? Elevate the bed no greater than 30-degrees; offload and reposition; control and inspect skin daily; encourage intake of protein, calories, minerals, and fluids. T/F: The wound assessment should include location, size, color, wound base, drainage, edges, and peri-wound skin. True. What is an ABI (ankle-brachial index) test? Determines the atrial flow, determines inadequate blood flow, determines delayed healing. T/F: Hand washing is the best way to prevent infection. True. How much PSI is needed for proper wound irrigation? 35-70 PSI What is an example of a laceration? Skin tear What is an example of a portal of entry? Blood T/F: Virulence is the power of the pathogen to cause disease. True. T/F: Standard precaution should be used for all the patients. True. Who is at greater risk of become infected? What causes shearing and friction injuries? Opposite pulling of the skin. T/F: Traction should include skin and hygiene assessment. True. The nurse should suspect ACS (acute compartment syndrome) when the patient complains of . Rapid, discoloration, pain worse than that of the fracture, weak pulse, and tightness. What fracture is complete with injury to the skin? Open. T/F: The nurse can control bleeding form a fracture by applying pressure below the site. False. T/F: A patient with musculoskeletal inflammation should avoid stretching activities. False. T/F: The nurse should include in the education, ways to prevent falls. Some activities include removal or rugs and clutter. True. T/F: Medication such as Ibuprofen can be used for arthritis. True. The nurse is performing a general survey. What is a component to observe related to musculoskeletal? Posture and abnormalities. As a nurse, you know that during aging a normal musculoskeletal change would be . Kyphotic posture T/F: Not bending forward at the waist or neck is a good way to have posture. True. T/F: Using high-heels helps with posture. False. Crepitus in osteoarthritis is due to . Loss of bone particles T/F: The abduction pillow is used to prevent internal rotation after hip surgery. True. What is an example of respiratory complication caused by immobility? Atelectasia The pain that the cause is unknown is called . Idiopathic The patient has bradypnea, what would be the best RN intervention? Respiratory therapy. A patient expresses concerns about their culture and medications. What statement is appropriate to respond? "Tell me more and let's create a plan together." Patient has vital signs of: HR 95, R 15, BP 164/100, T 98.7. What vital sign would be concerning and could indicate pain? BP 164/100 A patient bends the knees while performing exercise with physical therapy. What motion is that? Flexion T/F: Having a sedentary life doesn't affect us. False T/F: Osteoarthritis is know by having crepitus (popping/grating sounds; creaking joints) which are due to lose of bone particles. True T/F: Immobility has significant consequences in our overall health. True Immobility can cause what type of musculoskeletal damage? Foot drop (drop foot; difficulty lifting the front of the foot; the front of the foot may drag when patient is walking) A good nursing intervention to reduce atelectasis (complete/partial collapse of lungs) risk is? Encourage cough, deep breathing and turning Adding vitamins and minerals helps the immobile patient prevent . Muscle mass reduction A way to prevent GU complications on an immobile patient is . Bladder training T/F: The bladder scan is used to determine how much urine is in the gallbladder. False T/F: The semi-lateral position is also know as Sim's. True A trochanter roll is used to maintain the position of the . Trochanter T/F: The abduction pillow is used to prevent internal hip rotation. True What position is used to help the patient get up? Dangling What is a function of the musculoskeletal system? Assist with movement As a nurse you know that during aging, a normal musculoskeletal change would be? A patient that came to the clinic with kyphotic posture T/F: The nurse knows that recommending vitamin c and calcium will help prevent musculoskeletal deenetarion. False As you interview the patient complaining of pain, you know that it is important to ask them about . Trauma The nurse is performing a general survey. What is a component to observe related to the musculoskeletal system? Posture and abnormalities To perform a proper neuromuscular assessment, you need to include pain, pulse, pallor, paraesthesia (burning/prickling sensation) and (Five P's). Paralysis T/F: The nurse that pendulum exercises mean to dangle and swing the arm for 5-10 minutes. True What fracture is complete but with no injury to the skin? Closed Which fracture is caused by a rotation motion? Spiral What fracture is related to above and below force? Transverse T/F: The first bone healing stage takes up to 72 hours. True During which bone healing stage does the callus form? Third The risk for fracture includes all except? Using protective devices What causes shearing and friction injuries? Opposite pulling of the skin T/F: Medical history is not important as it does not collect related information. False How can the nurse control bleeding from a fracture? Apply pressure above the site What is the best position to prevent shock? Supine (lying facing upward) What is the main concern for the nurse taking care of a post-fracture patient? Prevention of neurovascular complications T/F: Hot spots under the cast can be a sign of pressure necrosis. True A patient with a cast should notify painful areas, pain not controlled by medication and . Unpleasant odor T/F: Traction use has a high risk for infection in the weight area. False After cast removal, it is normal to see dry skin, reduced strength, edema and . Decreased size Place in order from most important to least important to reduce infection risk: Dressing changes with aseptic technique --> Monitor vital signs --> Antibiotic administration --> Wound irrigation Place in order the most common labs performed after a fracture: Hgb &HCT --> WBC --> Ca+ --> ESR The nurse observes the following: increased edema, pain, weak pulse and skin discoloration. What should she suspect? Acute Compartment Syndrome Place in order the interventions for ACS: T/F: The patients using ear drops should keep posture straight or standing while instilling the drops. False How can you determine if the patient has auditory problems? Cues of how loud they are speaking T/F: The education for a patient losing their auditory function should include: use of hearing aids and facing them. True Some recommendations to protect the hearing include? Add close caption, use of protective devices, and avoid loud noises What exercise helps with flexibility? Stretching Which areas are an example of a 90-degree flexion? Knees and elbows What interventions help with independence? Allow the patient to perform activities When the patient can perform the motion independently it is called . AROM (active range of motion) What happens when the patient is taking vasoconstricting medications? Reduced perfusion Immobility has a high-risk for which of the following? Kidney stones, constipation (reduced peristalsis), atelectasis, and DVTs T/F: Instructing a weak patient to use 2 points of support helps reduce falls. True T/F: It is important to assess the feet of a patient with diabetic neuropathy. True What should be asked when a patient is having an MRI? Fear of close-spaces, any metal (jewelry, rods, screws), and pregnancy T/F: A patient with kyphosis doesn't have any high-risk. False What is a proper intervention for a patient with kyphosis after musculoskeletal surgery? Should be placed as a priority and auscultate lung sounds What should the nurse do when assisting with movement or mobility? Face the direction of the movement and ask the patient to push with the arms When should the patient with a purulent wound be placed in isolation? Before culture results T/F: Hip flexion of greater than 90-degrees should be avoided after hip surgery. True Place in order the activities after a patient falls: Assess neurological status --> Call for assistance --> Call the provider --> Call the family What is the first intervention if a patient with a cast complains of tingling, numbness, colorlessness and cold? Raise the limb diuretics Valvular disease long term therapy anticoagulant therapy antibiotics diet and exercise stay on meds Endocarditis inflammation of the inner lining of the heart Endocarditis findings abnormal heart sounds Pericarditis inflammation of the sac surrounding the heart Pericarditis findings *chest pain* pleural friction rub Biggest risk of pericarditis cardiac tampanode Coronary artery disease build up of plaque in coronary arteries Acute coronary syndrome progression of plaque build up (completely occludes or breaks off) Ischemia lack of oxygen to tissue Infarction death of tissue Risk factors for CAD smoking, obesity, hypertension, diet, sedentary lifestyle, diabetes Angina Pain in the heart region caused by lack of oxygen (oxygen demand of coronary muscle is higher than can be delivered) Stable angina chest pain that occurs when a person is active or under severe stress Unstable angina chest pain that occurs while a person is at rest and not exerting himself Medication for angina Nitroglycerin Nitroglycerin administration - do they take erectile dysfunction meds? DO NOT GIVE - monitor BP, every 5 minutes - 1 sublingual tab every 5 minutes, up to 3 doses - if pain does not go away with 3 tabs, give morphine What does morphine do? decreases oxygen demand and relieves pain S/S of coronary artery disease hypertension, diaphoretic, SOB, chest pain that radiates (to arm or shoulder, jaw) Hypertension treatment 1: diuretics, calcium channel blockers, ACE inhibitors 2: aldosterone blockers, beta blockers, renin inhibitors Hypertension lifestyle changes diet, exercise, stress reduction Arteriosclerosis hardening of the arteries (normal part of aging) Atherosclerosis the development of plaques in the internal layer of larger arteries, eventually developing a blockage Risk factors for atheroslcerosis - African American and Hispanics higher risk - high cholesterol/hyperlipidemia S/S of atherosclerosis decreased perfusion, poor capillary refill, tingling, pallor, cool to touch, (pulseless, pain, paralysis, paresthesia, poikilothermic/poor temp) Treatment of atherosclerosis statins, blood thinners Peripheral artery disease (PAD) lack of circulation pain, dangling relieves pain Peripheral vascular disease (PVD) lack of blood return dependent edema, elevate Treatment PVD compression and elevate Biggest complication of PVD VTE, blood clot in legs treat with blood thinners oxygen and left sided positioning Biggest risk with VTE pulmonary embolism Sickle cell anemia crescent shape RBC, allows for clotting Risk factors for sickle cell crisis stress, DEHYDRATION, infection, trauma, temp changes, pregnancy, high altitude. Sickle cell anemia treatment fluids, blood transfusion, pain management Polycythemia Vera too many RBC Hemochromatosis too much iron Leukemia caner resulting from loss of normal cell production Myeloma tumor of the bone marrow Thrombocytic purpura when circulating platelets are decreased Name type of imaging, endoscopy & biopsy for complete blood count labs CT scans, Bronchoscopy, Breast biopsy Blood protein testing (imaging, endoscopy, biopsy) MRI, Colonoscopy, bone marrow biopsy tumor marker test (imaging, endoscopy, biopsy) x-rays, cystoscopy, organ/tissue-specific circulating tumor cell tests nuclear medicine scans & laparoscopy Curative surgery Removal of the cancerous tumor when confined to a specific body location. Often used in conjunction with other treatments such as radiation and/or chemotherapy pallative surgery performed to treat the problems that the cancer or treatment of cancer has created prophylactic surgery To remove tissues that are not cancerous but can become cancerous diagnostic surgery performed to determine if cancer cells are present reconstruction/restorative surgery performed following treatment to restore the patient's body function such as breast reconstruction following a mastectomy Pre-operative care (nursing care) ensure necessary tests are performed such as blood work, EKG and chest x-ray and ensure patient has remained NPO (nothing by mouth) for the required time frame Education (nursing care) patient ed. regarding the type of procedure, post-operative management to include any restrictions, wound care, S&S of infection, medication, follow-up treatment, and follow up appointments Nutrition (nursing care) ensure pt has consult for the dietitian to assess nutritional and cultural needs Pain control (nursing care) ensure adequate pain control by assessing a pt's level of pain frequently and administering the prescribed medications Internal radiation therapy radiation treatment in which the radiation is placed inside the body in a solid or liquid form external radiation therapy radiation therapy that is site specific to the area of cancer. Treatment is administered via external machine. Requires the sites to be marked to ensure treatment targets the specific area. Nursing care for radiation therapy (rt) maintain markings for external treatment goal is to shrink or prevent further growth of the tumor Palliation goal is to relieve the symptoms of the cancer, the hope for cure or control is dismal Immunotherapy/Targeted Thearpy Goals Boost the body's immune system to help fight the cancer Stops or slows cancer cell growth Stops the spread of cancer cells Goals of Hormone Therapy controls cancers that are sensitive to hormones slows the growth of cancer cells Hormone therapy nursing care - monitor side effects of therapy - provide patient education -provide emotional and spiritual support to the pt and family Autologous stem cell transplant cells are harvested from the pt's bone marrow before the start of chemotherapy and transfused following treatment Allogenic stem cell transplant cells are from a donor that closely matches the patient stem cell transplant n.c. monitory for s&s of rejection administer prescribed medications monitor pt of s&s of infection provide emotional & spiritual support to the pt and family Passive Transport : 1. Filtration the movement of solute through a capillary membrane due to hydrostatic pressure. Fluid moves from an area of higher pressure to an area of lower pressure. Movement of fluid continues until the hydrostatic pressure is equal resulting in fluid balance or equilibrium. Passive Transport: 2. Diffusion the movement of solvent across a biological membrane (permeable, semi-permeable and impermeable) from an area of higher particle concentration to an area of lower particle concentration. Passive Transport: 3. Osmosis the movement of solvent across a semipermeable membrane from an area of lower solute concentration to one of higher concentration. Active Transport: Sodium-potassium pump the movement of solute against a concentration gradient, movement is dependent on the presence of adenosine triphosphate (ATP). Hormone Regulation of Fluid: Renin-Angiotensin-Aldosterone renin is excreted by the kidneys in response to a decrease in blood pressure, blood volume, low sodium, and low blood oxygenation. The secretion of renin causes angiotensinogen to be broken down to form angiotensin I. Angiotensin II angiotensin I is converted to angiotensin II as the blood passes through the lungs. This results in vasoconstriction to increase blood pressure. Aldosterone Providing education will be conducted to ensure their understanding of the diagnosis and treatment options. The plan will be shared with the patient. Often there are several options for treatment which are shared with the patient and family for them to make an informed decision. Formulating the care team members of the care team will be dependent on the treatment plan. Introduction of the care team is the next step after the treatment plan is decided. Allowing the patient to understand the role of each team member and how they will support them through their treatment is important. Available resources and support will be shared during this care team meeting. Tumor Lysis Syndrome Results in a release of large amounts of intracellular products (uric acid, calcium, phosphate, & potassium. These products disrupt the body's homeostasis and destroy the cell's nucleus. Is associated with hematologic malignancies, acute leukemia, and high-grade lymphoma Tumor Lysis S&S azotemia acidosis hyperphosphatemia hyperkalemia acute renal failure hypocalcemia Tumor Lysis syndrome treatment inpatient monitoring fluid resuscitation allopurinol (zyloprim) or uricase therapy correction of acidosis hemodialysis Tumor Lysis nursing care maintain ABC, vital signs and cardiac rhythm, admin meds, pt and family ed., emotional and spiritual support, manage electrolyte imbalances, prepare pt for hemodialysis Hypercalcemia of Maglignancy common with pts w/ malignant tumors. treatable but can lead to poor outcomes if undiagnosed. Hypercalcemia of malignancy: 3 major triggers 1. tumor secretion of parathyroid hormone-related protein 2. osteolytic metastasis with release of cytokines 3. tumor production of 1.25- dihydroxyvitamin D Hypercalcemia of malignancy associated with what organs? lung, breast, and kidney cancer as well as multiple-myelomas hypercalcemia of malignancy s&s fatigue anorexia nausea vomiting constipation mental status changes/ altered sensorium Fluid restriction correction of serum sodium imbalance furosemide therapy SIADH nursing care assessment for s&s monitor I&O monitor lab values implement seizure precautions manage comfort provide support Hematologic emergencies Hyperviscosity syndorme & Febrile Neutropenia hematologic emergencies: Febrile Neutropenia common side effect of chemotherapy chemo weakens normal body defense mechanism, which predisposes pt to developing infection. What are neutrophils? WBC's that ingest and destroy microbes in a process called phagocytosis. They help fight infections. Neutropenia a decreased number of neutrophils in the blood. What is febrile neutrophenia associated with? chemotherapy - associated bacterial or fungal infections Febrile Neutropenia S&S temperature +101 degree F absolute neutrophil count less than 500 per mm^3 Treatments for Febrile Neutropenia inpatient treatment antibiotic therapy determine the cause of infection temperature management Febrile Neutropenia nursing care asses s&s monitor & treat temp collect cultures implement isolation precautions monitor lab values admin meds manage comfort provide support Hypervisocsity Syndrome This is due to either a red blood cell shape deformity or an increase in serum proteins, RBC, WBC, or platelets Hyperviscosity Syndeome presents with what? a triad of systems including neurological deficits, visual disturbances, and mucosal bleeding. Hyperviscosity sydrome is associated with what? Waldentrom's macrolbulinemia, multiple myeloma, & leukemia Hyperviscosity syndrome s&s spontaneous bleeding hemorrhagic retinal veins neurologic deficits elevated serum viscosity levels radiation and/or surgical intervention epidural spinal cord compression nursing care assesss for neurological deficits mange pain administer meds prevent skin breakdown provide support Malignant Pericardial Effusion Excess fluid accumulates in pericardial sac, compresses heart, no heart movement, cardiac tamponade. Malignant pericardial effusion is associated with what? metastatic lung and creast cancer, melanoma, leukemia, lymphoma, and chemotherapy to the chest wall Malignant Pericardial Effusion S&S dyspnea fatigue distended neck veins distant heart sounds tachycardia orthopnea narrow pulse pressure pulsus paradoxus Malignant pericardial effusion treatment radiation surgical intervention malignant pericardial effusion nursing care assess for neurological deficits mange pain admin meds prevent skin breakdown provide support Superior Vena Cava Syndrome Due to compression of the superior vena cava walls by a tumor, which prohibits the venous return of blood to the heart superior vena cava syndrome is associated with what? lung cancer, metastatic mediastinal tumors, lymphoma, and indewelling venous catheters superior vena cava syndrome S&S Swelling of face and neck swelling of the arms dysphagia cough Superior vena cava syndrome treatment radiation chemotherapy superior vena cava syndrome nursing care assess respiratory and cardiac systems maintain patent airway monitor oxygenation monitor labs provide support MDC Diagnosis performed by the physician team (primary physician, oncologist, pathologist, radiation oncologist, and surgeon). is based on patient test results. MDC Treatment options determined based on the cancer types, stage, and metastasis. The plan is developed by the physician team and shared with the patient. Often the patient will be presented with options regarding their treatment to make an informed decision.