All but 2
1., 3., 4. & 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and care to the client. These interventions are initiated simply, concretely, and directed toward activities that address the client's basic needs for physiological and psychological safety and security. Concrete thinking focuses thought processes on specifics, rather than generalities, and immediate issues, rather than eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is thinking concretely include such things as: providing a blanket when the client is cold, providing food when the client is hungry, keeping promises, being honest, providing a written, structured schedule of activities, attending activities with the client if he is reluctant to go alone, being consistent in adhering to unit guidelines, and taking the client's preferences, requests, and opinions into consideration when possible in decisions concerning care.
2. Incorrect: The client should be informed of all rules, simply and clearly, with reasons for certain policies and rules. Be consistent and provide written, structured, scheduled activities. Allowing a client to break a rule would not encourage them to think about the outcomes of their actions.
3. Correct: Symptoms of hepatitis A include fever, malaise, loss of appetite, diarrhea, nausea, abdominal discomfort, dark-colored urine, and jaundice.
1. Incorrect: Hepatitis A is spread when an uninfected person ingests food or water that is contaminated with the feces of an infected person. This disease is closely associated with unsafe water, inadequate sanitation, and poor personal hygiene.
2. Incorrect: Hepatitis A infection does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis, which is associated with high mortality.
4. Incorrect: Used for hepatitis C.
2. Correct: Time-out, done immediately before the procedure, is a final verbal verification of the correct client, procedure, site, and implant. Time-out is active communication among all members of the surgical/procedural team, initiated by a member of the team before surgery.1. Incorrect: Surgical scrub should be done before entering the surgical suite.3. Incorrect: The scrub nurse does instrument and sponge counts numerous times before, during, and after the procedure.4. Incorrect: Simple inspection of the surgical site is not enough. The team must verbally communicate what is to be done, on what limb. Additionally, the limb should be marked as "This knee" or "yes".
Burns, heart failure, hip fracture, hepatic failure, acute intestinal obstruction, acute peritonitis, crushing traumatic injuries, pleural effusion, hypoalbuminemia
Ascites- liver disease, fluid in abdomen, hard to breath especially when pushing on diaphragm (measure abdominal girth, worry about hypotension)
Normal sodium levels?
Hypernatremia = ___________
Causes: Hyperventilation, Heat stroke, DI, vomiting, Diarrhea.
S/S: Dry mouth, thirst, Swollen ________, _________ changes.
Treatment: Restrict __________, Dilute client with fluids (diluting makes sodium go down),
If you have a sodium problem you have a ___________ problem (monitor I & O, daily weights, lab work.
Feeding tubes tend to ___________ the client. Getting more sodium than water concentration in feeding tubes
Causes: ___________, _____ suction (potassium is found in the stomach), Diuretics, Not eating
S/S: __________ cramps, ________ weakness, arrythmias
Treatment: Give potassium, Spironolactone makes client retain potassium, eat more potassium (spinach. potato, oranges, bananas, cucumbers, bell peppers. avocado)
The child who had a previous shunt revision and the adolescent who is 4 days post spinal fusion will be the most stable and will require the least skill level when compared with the other choices. On a general pediatric unit, the nurse would be familiar with checking for increased ICP, which would be necessary for caring for any client with a previous shunt revision. Immediately postop, the adolescent with spinal fusion would require special turning and lung assessment to prevent and observe for congestion/pneumonia, skills not acquired on a general floor. However, at 4 days postop this client should be ambulating and will not need specialized turning, so the nurse from the general pediatric unit could care for this client.
3. Incorrect: This client is more acute and requires a higher skill level. Nursing care for this child would involve frequent neurologic assessments and monitoring for infection. The child should also be monitored for signs of possible complications including bowel perforation.
4. Incorrect: This client is more acute and requires a higher skill level. The nurse on the general pediatric unit would not be experienced in caring for a child on a ventilator.
5. Incorrect: This client is more acute and requires a higher skill level. A child who is fresh post-op following a tracheostomy is at risk for airway obstruction from thick secretions, mucous plug, blood clot or dislodgement of the tube. Cardio-respiratory arrest can occur from these complications. The child is also at risk for hemorrhage. Nursing care would include frequent suctioning as needed, monitoring for early signs of airway obstruction, and trach care. The nurse from the general pediatric unit may not have the skills required to care for this child who also has cerebral palsy which could complicate the care required.
1, 2, 5
Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal.
3. Incorrect: Increased body temperature is expected as is increased diaphoresis.
4. Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome.
Ego Integrity versus Despair is the major task of those 65 and over: The developmental task for this age involves the individual reviewing one's life and deriving meaning from both positive and negative events, while achieving a positive sense of self. If the individual considers accomplishments and views self as leading a successful life, a sense of integrity is developed. On the contrary, if life is viewed as unsuccessful without accomplishing life's goals, a sense of despair and hopelessness develops.
2. Incorrect: Generativity versus Stagnation is the major task for 40-64 year olds. To achieve the life goals established for oneself while also considering the welfare of future generations. The primary developmental task during this middle age period is one in which the individual contributes to society as well as helping to guide future generations. A sense of generativity (sense of productivity and accomplishment) often results from such things as raising a family and helping to better the society. In contrast, those individuals not willing to work to better society and those who are egocentric and self-centered often develop a sense of stagnation (dissatisfaction and the lack of productivity)
3. Incorrect: Intimacy versus Isolation is the objective from 20-39 year olds to form an intense, lasting relationship or a commitment to another person. If the individual cannot form the intimate relationships (possibly due to personal needs) a sense of isolation may develop which can lead to feelings of depression.
4. Incorrect: Industry versus Inferiority is the major task for 6-12 year olds in which they attempt to achieve a sense of self confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances. The child must develop the ability to deal with the demands of learning new social and academic skills, or a sense of inferiority, failure, or incompetence may result.
A rigid abdomen may indicate bleeding or other causes of peritonitis which takes priority over the other three, more stable clients. This could lead to shock in this client. Conditions requiring immediate treatment include cardiac arrest, anaphylaxis, multiple trauma, shock, poisoning, active labor, drug overdose, severe head trauma, and severe respiratory distress.
1. Incorrect. Although this condition may be uncomfortable and could lead to renal problems if not resolved, it does not take priority over a client who is bleeding.
2. Incorrect. This person is likely experiencing pain, but this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing into the peritoneum. Remember, pain never killed anyone.
3. Incorrect. This client with a corneal laceration would be experiencing pain and needs attention to avoid vision loss. However, this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing in the peritoneum. Remember, ascites is fluid in the peritoneal cavity.
Alcohol Withdrawal Delirium usually occurs on the second or third day following cessation of or reduction in prolonged, heavy alcohol use. Symptoms are the same as for delirium: Difficulty sustaining and shifting attention. Extremely distractible; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability; disoriented to time and place; impairment of recent memory; delusions and hallucinations.
1. Incorrect: Wernicke's Encephalopathy represents the most severe form of thiamine deficiency in alcoholics. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, confusion, somnolence, and stupor. If thiamine replacement therapy is not given, death will ensue.
2. Incorrect: Korsakoff's Psychosis is identified by a syndrome of confusion, personality changes, loss of recent memory, and confabulation (filling in some memory gaps with different life events or created thoughts). It is frequently encountered in clients recovering from Wernicke's encephalopathy. Coordination may be affected, so the client may have difficulty maintaining balance. Treatment is parenteral or oral thiamine replacement.
3. Incorrect: Alcohol withdrawal typically begins 4-12 hours after cessation of or reduction in heavy and prolonged alcohol use. Symptoms include: coarse tremor of hands, tongue, or eyelids; nausea and vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood or irritability; transient hallucinations or delusions; headache; and insomnia
Migraine headaches have a pulsating pain quality, unilateral location, moderate or severe pain intensity, aggravated by or causing avoidance of routine physical activity (walking, climbing stairs). During headache at least one of the following accompanies the headache: nausea and/or vomiting; photophobia and phonophobia.
2. Incorrect: This is seen in tension headaches. Headaches last 30 minutes to 7 days. Pain is mild or moderate in intensity. It is not aggravated by routine physical activity. Nausea/vomiting, photophobia and phonophobia are not common manifestations with tension headaches. These usually start gradually, often in the middle of the day.
3. Incorrect: This is associated with cluster headaches, which are severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes. Symptoms include stabbing pain in one eye with associated rhinorrhea (runny nose) and possible drooping eyelid on the affected side. The headaches tend to occur in "clusters": typically one to three headaches per day (but may be as many as eight) during a cluster period.
4. Incorrect: Overuse of painkillers for headaches, can, ironically, lead to rebound headaches
1., 3., 4., & 6. Correct: Multiple sclerosis causes fatigue which often comes on in the afternoon and causes weak muscles, slowed thinking, or sleepiness. Vision problems are common with this diagnosis and include blurry vision, double vision, and pain on eye movement. Partial or complete vision loss can occur in one eye. Because this disease affects nerves, symptoms often affect movement such as extremity weakness, numbness, tingling, and coordination. Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign) develop because of the nerve damage that is occurring.
2. Incorrect: Drooping of one or both eyelids (ptosis) would be seen in myasthenia gravis rather than multiple sclerosis.
5. Incorrect: Limited facial expressions occur in myasthenia gravis rather than multiple sclerosis. The muscles (not nerves) that control facial expressions have been affected.