Stress Signal
______________ involves the use of electronic devices to help the patient develop a learned awareness of the body's physiologic response to unconscious, involuntary stressors.
A. Biofeedback
B. Guided imagery
C. Cognitive behavioral therapy
D. Energy therapy
A. - biofeedback
A 3 day post op patient begins complaining of left calf pain. On assessment, the nurse notices redness and edema. Which of the following is an appropriate nursing action?
A. Apply ice to the calf
B. Remove SCDs
C. Massage the area
D. Document findings and reassess in 1 hour
B - remove SCDs until a DVT is ruled out
Box in your book! Page 948
If the patient does have a DVT, the SCDs can cause the clot to break apart resulting in a PE, stroke, or MI
Patient scenario: A 57 year old male patient has a 35 year history of smoking and is diagnosed with COPD. He is currently on 2L NC with a o2 sat of 90%. Lung sounds are diminished in the middle and right lower lobe. He has a productive cough with green mucus.
Create a FULL nursing diagnosis. Must include all 3 parts.
Impaired gas exchange related to alveolar destruction and air trapping with COPD as evidenced by o2 sat of 90% on 2LNC and diminished breath sounds.
Ineffective airway clearance related to excessive mucus production secondary to COPD as evidenced by productive cough with green sputum, diminished breath sound, and oxygen saturation of 90% on 2L.
A visually impaired diabetic patient states that she has lost the call light. What is the next action the nurse should take?
A. Clip the call light closer to the patient
B. Tell the patient that the call light is clipped closer to the bed
C. Describe the call light location then guide the patient's hand to that location
D. Instruct the patient to verbally call out for a staff member because someone is always nearby
C - this provides verbal orientation to the call light and tactile guidance
True or False: Gown, gloves, masks, and goggles should be worn during wound irrigation.
True: wound irrigation carries a risk of splashing of fluid and debris. This is a box in your book (page 623)
A patient is newly diagnosed with diabetes and requires insulin injections. He requests information about classes offered by the diabetes educator. What type of coping technique is this patient using?
A. Emotion focused
B. Problem focused
C. Avoidance
D. Denial
B. - Problem focused
The nurse is caring for a client who has atrial fibrillation. The client has been prescribed anticoagulant therapy. The nurse understands this therapy is used to:
A. Decrease blood pressure
B. Control the pulse rate
C. Improve renal function
D. Prevent blood clot formation
D - prevent blood clot formation
Post-quiz question
Afib patients are high risk for blood clots!
The nurse is teaching a client about using an incentive spirometer (IS). Which of the following should the nurse include in the teaching?
A. Inhale slowly before placing the mouth on the mouthpiece
B. Repeat the exercise 2-3 times
C. Hold breath for 10-15 seconds
D. Perform exercise every 1-2 hours
D. Perform exercise every 1-2 hours
Prequiz question!
Instruct the patient to inhale slowly with the mouth on the mouthpiece. Inhale as much as possible and hold that breath for 3 to 5 seconds. Remove mouthpiece and exhale slowly. Repeat each inhalation and exhalation 5 to 12 times. End with two controlled coughs. Perform this exercise every 1 to 2 hours per orders.
Which eye disorder involves the gradual loss of peripheral vision?
A. Glaucoma
B. Macular degeneration
C. Cataracts
D. Diabetic retinopathy
A. - Glaucoma involves loss of peripheral vision which some patients describe as tunnel vision
Macular degeneration is the loss of central vision
Cataracts is a white or yellow clouding of the lens which causes blurriness and loss of color perception
Diabetic retinopathy is damage to the blood vessels of the eye that causes a variety of vision changes.
Select all that apply: Which of the following factors affect skin integrity?
A. Age
B. Ethnicity
C. Nutritional Status
D. Mobility
E. Vascular Disease
A, C, D, and E
A 25 year old patient demands her mother and father be present during all blood testing. Which defense mechanism could the nurse document as being used by this patient?
A. Sublimation
B. Repression
C. Projection
D. Regression
D. - Regression
Regression is a defense mechanism in which a person reverts to behaviors typical of an earlier developmental stage when experiencing stress or anxiety.
The nurse is performing an assessment on a client who has a circulatory disorder. Which of the following findings indicates the client is experiencing decreased cardiac output?
A. Pulse of 72bpm
B. Decreased breath sounds
C. Diminished pulses
D. BP 127/82
C. - Diminished pulses
An abnormally slow, rapid, or irregular pulse reflects an alteration in cardiac output, which may result in an inability to meet the physiologic demands of the body
The nurse is caring for the following assigned clients. It is a priority to follow up with a client who...
A. Has asthma and nasal flaring
B. Has a new diagnosis of influenza and a pulse of 76
C. Has pneumonia and a RR of 18
D. Has COPD/chronic bronchitis and a barrel chest
A - asthma and nasal flaring
Did you catch unexpected vs. expected findings??
An asthma patient with nasal flaring is exhibiting signs of hypoxia. This is an unexpected finding that takes priority.
What is an isometric exercise and provide one example.
Isometric = Tension and relaxation of muscles without joint movement
Examples: Abdominal plank, kegels, wall sits
The nurse has just attended a conference on cognitive impairments. Which of the following does the nurse identify as a chronic cognitive impairment?
A. Sensory overload
B. Delirium
C. Dementia
D. Sensory deprivation
C - dementia (chronic)
Delirium is an acute, short term impairment
Post quiz question
Provide one example of an endocrine response to stress and a nervous system response to stress.
Endocrine: hyperglycemia
Nervous system: Tachycardia, hypertension (related to the release of hormones), flight or fight response, dilated pupils
Name 3 symptoms of heart failure and 2 interventions to implement in a patient with heart failure.
Symptoms: Weight gain, JVD, fluid overload, crackles in lungs, pink frothy sputum
Interventions: fluid restriction, low sodium diet, diuretics, intake/output monitoring, daily weights, HOB at least 30 degrees, supplemental oxygen if needed
The nurse is caring for a client who is experiencing a chronic obstructive pulmonary disease (COPD) exacerbation and is retaining carbon dioxide (CO2). Which of the following oxygen delivery devices should the nurse use on the client?
A. Nonrebreather
B. Face tent
C. Venturi
D. BVM
C - Venturi
Prequiz question!
A Venturi mask is used to ensure accuracy of the oxygen concentration delivered; it is considered for use with carbon dioxide–retaining patients. The bag-valve-mask (BVM) device uses a one-way valve to support, ventilate, and oxygenate a patient who needs ventilatory support. The nonrebreather mask looks very similar to the partial rebreather mask but the reservoir bag on the nonrebreather mask has a one-way valve that prevents exhaled air from entering the reservoir. This provides a larger concentration of oxygen in the bag for the patient to inhale. Special valves on the mask prevent room air from entering the mask but allow exhaled air to leave the mask. When a face tent is used, the oxygen is always humidified.
Which assessment finding during an admission of a patient transferred from a long term care facility does the nurse recognize as a result of immobility?
A. Bilateral elbow contractures
B. Increased muscle tone
C. Decreased cardiac workload
D. Orthostatic hypertension
A - bilateral elbow contractures
Chronic immobility leads to muscle shortening, stiff joints, and changes to connective tissue which results in contractures over time.
Transparent dressings are used for wounds with _____________________ while alginate dressings are used for wounds with ___________________.
A. Little to no drainage, dry wound beds
B. Little to no drainage, excessive drainage or bleeding
C. Autolytic debriding ,Internal packing
D. Dry wound beds, a continual need for debridement
B. Transparent dressings are used for wounds with little to no drainage, while alginate dressings are used for wounds with excessive drainage or bleeding.
Avoid alginate dressing for dry wounds.
This is a box in your book (625) and a pre-quiz question!!
Name 4 defense mechanisms that a patient may use when responding to a perceived threat.
Compensation, Denial, Displacement, Intellectualization, Projection, Rationalization, Reaction formation, Regression, Repression, Sublimation
This is a box in your book (page 719)
The nurse is caring for a client who has bilateral lower extremity deep vein thrombosis (DVT) and has been placed on bedrest. The primary health care provider (PHCP) has ordered a chest x-ray for the client. Which of the following actions is most appropriate for the nurse to take?
A. Allow the client to ambulate to the radiology department with assistance of the UAP
B. Cancel the chest x-ray because the patient is on bedrest
C. Transport the patient via bed/stretcher to the radiology department
D. Transport the patient via wheelchair to the radiology department
C. - Transport via bed/stretcher
Prequiz question!
The client has been ordered to be on bedrest due to their bilateral lower extremity DVTs. The most appropriate method of transporting this client to radiology would be via their bed. Transferring the client to a wheelchair or allowing them to ambulate to radiology does not follow the bedrest that has been ordered and is therefore incorrect. It is not within the nurse's scope to cancel the ordered chest x-ray unless ordered by the PHCP.
The nurse understands that which of the following is most likely occurring when caring for a pulmonary patient that has a bluish discoloration of the lips?
A. Increased CO2 levels
B. Hemoglobin that is not saturated with oxygen
C. Elevated WBC count
D. Decreased O2 levels
B - Hemoglobin that is not saturated with oxygen
Cyanosis is the result of deoxygenation of hemoglobin. Hemoglobin is the blood molecule that carries oxygen to tissues. Decreased o2 could also be an indicator BUT B is the more precise answer.
Don't come for me - this is in your book on page 939. I want you to understand the important of hemoglobin and oxygen carrying capacity :)
Which area of the central nervous system has most likely sustained damage if a patient exhibits lack of coordination and an unsteady gait after a traumatic brain injury?
A. Medulla oblongata
B. Articular disk
C. Brainstem
D. Cerebellum
D - Cerebellum
The Cerebellum is responsible for:
Coordination of voluntary movement
Balance and posture
Fine motor control
Smooth, purposeful motion
Medulla Oblongata - breathing, HR, BP
Articular disk is a joint structure, nothing to do with the brain
Brainstem - houses the medulla, basic life functions (drive to breathe)
The nurse is caring for a client who has pneumonia and requires supplemental oxygen at 3L/minute via nasal cannula. Upon assessment, the nurse finds the client chewing on the nasal cannula and appears to be disoriented. Which of the following actions should the nurse take next?
A. Initiate a rapid response
B. Notify the patient's provider
C. Reapply oxygen and document findings
D. Obtain a set of vital signs
D. - obtain a set of vitals and stay with patient. gather data BEFORE calling the provider or calling a rapid reponse