Culture and documentation
The nurse asks the patient who is in Ramadan what their preferred beliefs/practices are, this is an example of _________?
Which patient is at highest risk for osteoporosis?
a. 30-year-old male athlete
b. 65-year-old postmenopausal female
c. 45-year-old male with hypertension
d. 25-year-old pregnant female
b
What is the neurological test that assesses cerebellar function and balance?
The Romberg Test
the nurse modifies the assessment sequence for the patient in pain, what does this demonstrate?
good clinical judgement and patient centered care
when assessing an IV site, what are 3 abnormal findings the nurse is looking for?
- redness
-swelling
-infiltration
The nurse is talking to the patient about receiving blood products but the patient says it is against their religion. The nurse knows that the patient desperately needs the blood, and may die without it. What should the nurse do?
Respect the decision of the patient, as long as they are fully informed, document exact patient statement, notify provider.
The nurse is doing a head-to-toe musculoskeletal assessment and finds bilateral 1/5 strength in the lower extremities, what does this finding indicate and is this patient at a risk for?
A little bit of movement, but this patient is at a high risk of injury or falls.
The olfactory nerve assesses ______ and is tested by _____________.
Smell
asking the patient to close their eyes and smell a familiar object and identify it
what is the primary goal of a comprehensive head-to-toe assessment?
to establish a baseline and abnormalities
presbycusis is known as ________ and effects _______ CN.
hearing loss and CN 8 (vestibulocochlear)
The nurse is in a rush and uses the Spanish speaking patients daughter to be an interpreter. What is the concern?
High potential for miscommunication and potential bias
The doctor diagnosed the patient with osteoporosis and kyphosis, the patient is confused on the meanings. As the nurse, what do you tell the patient?
"Osteoporosis is a common bone disease making bones weak and brittle, often causing fractures in the hip, spine, or wrist due to reduced density. Kyphosis means that there is an exaggerated, forward rounding of the back, often called a "hunchback," resulting from a spine curvature"
which of the following symptoms are characteristic of trigeminal neuralgia?
a. Gradual hearing loss
b. Loss of smell
c. Facial drooping
d. Sudden, severe facial pain
D
a patient with a tracheostomy becomes restless, has decreased O2 sat. What is the priority action?
assess airway (possible obstruction or decanulation)
when assessing a surgical site, what finding would be a major concern for the nurse?
dehiscence, eviceration, purulent discharge, foul smell, excessive saturation, extreme redness, swelling etc.
Go into the patient chart to the correct time, document the medication administration and explain as needed. Make sure to notify the new nurse too if needed.
DOUBLE POINTS
The patient stated during the family medical history collection, that their mother had OA, but they have signs that are more indicative of RA. What would some of those signs be?
- morning stiffness lasting more than 1hr
- symmetrical joint involvement
- generally smaller joints
- systemic involvement
- joint pain, swelling and stiffness
What is included in a GCS and what is a "perfect" finding?
Eye opening, verbal response, motor response, a perfect score is 15
During the abdomen assessment, the nurse was assessing an ostomy and finds it to be ischemic. What might the ostomy look like?
the STOMA will likely be pale, dusky, black (not getting proper oxygenation and tissue is dying, may be from obstruction too)
DOUBLE POINTS
what is cranial nerve 7, how is it assessed, and what is a common disease/disorder associated with it?
facial nerve, smiling, close eyes and wrinkle forehead, common Bell Palsy
The nurse told the nursing student that it's fine to document later, but the nursing student learned that it is "best practice" to document _______ (when?)
Promptly after patient care and if possible, while in the room.
The patient met with the surgeon about cartilage degeneration between the joints, which results in excruciating pain, especially with movement. What is the likely diagnosis?
OA (osteoarthritis)
Why would an older adult be at an increased risk for falls from a neuro perspective?
due to possibility of decreased sensation and balance
The nursing student was helping the patient with a nasal cannula adapt to using the device. The patient said that their nasal cavity was getting dry, and the student knew that there was possible breakdown, so they added vaseline. what would be considered best practice or what is considered the issue?
petroleum jelly such as vaseline is NOT approved for NC due to fire hazard, rather a water based lubricant would be approved. a humidifier would also help, but the student is valid for noting the risk of breakdown.
key signs of a stroke
BEFAST
balance, eyes, face, arms, speech, time