Fluids and Electrolytes
Sleep
Pain
Stress
Sensory
100
A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare?
0.9% sodium chloride (NS)
100
What are the stages of sleep (in the correct order)?
NREM stage 1, NREM stage 2, NREM stage 3, NREM stage 4, NREM stage 3, NREM stage 2, REM sleep, back to NREM stage 2
100
What are some behavioral responses to pain?
clenching the teeth, facial grimacing, holding or guarding the painful part, bent posture
100
What are the three stages in the general adaptation syndrome?
Alarm reaction stage Resistance stage Exhaustion stage
100
What is sensory overload?
Reception of too much sensory stimuli
200
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan?
Replace fluid, electrolytes, and nutrients.
200
What is a change in sleep patterns associated with aging?
Sleep becomes more fragmented and a person spends more time in lighter stages. Episodes of REM shorten
200
What is drug tolerance?
A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time (the patient needs more and more drug to produce the same level of pain control)
200
Getting married and having a baby is what type of crisis?
Developmental crisis
200
Name 2 interventions for a person with aphasia to help them communicate
Provide notebook or white board, laptop, Help patient develope a sign language system
300
A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?
Renal
300
What are circadian rhythms?
The biological clock that cynchronizes sleep cycle, body temp, heart rate, blood pressure, hormone secretion, elimination
300
Name 5 nonpharmacological pain interventions
Cognitive and behavioral approach Relaxation and guided imagery Distraction Music Cutaneous stimulation Cold and heat application Transcutaneous electrical nerve stimulator (TENS) Herbals Reducing pain perception and reception
300
A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. What diagnosis will the nurse expect to see documented in the chart?
Posttraumatic stress disorder
300
Name three areas of assessment for someone with a new visual deficit
History, how does the deficit affect the patient's lifestyle, psychosocial adjustment, developmental status, self-care ability, health promotion habits, and safety.
400
A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child?
Respiratory Acidosis
400
What is the purpose of sleep?
restore biological processes, renewal of cells, tissue, brain tissue restoration
400
What are patient teaching points when setting a patient up with a PCA?
The patient is the only one who should push the button, the pump is programmed so an overdose will not occur, this will allow for a more constant serum drug concentration allowing better pain control with a lower dose
400
A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse? A. “Let’s call 911 because this freshman student is suicidal.” B. “Give the freshman student this list of university and community resources.” C. “I recommend that you help the freshman student start packing bags to go home.” . D “You must make an appointment for the freshman student to obtain medications.”
B. “Give the freshman student this list of university and community resources.”
400
What are 4 symptoms of sensory deprivation?
Withdrawal by avoiding communication or socialization with others, symptoms similar to psychological illness, confusion, symptoms of severe electrolyte imbalance or under the influence of drugs
500
What are the 2 most commonly ordered lab tests?
CBC, BMP
500
What factors influence how well a person sleeps?
Lifestyle, emotional stress, exercise and fatigue, drugs and substances, disruption of usual sleep patterns, environment, food and calorie intake
500
What is the gate-control theory of pain?
Stimulation of large pressure nerve fibers closes the "gate" and blocks stimulation of small pain nerve fibers
500
Name three interventions for a patient with a high stress level
Exercise, rest, strengthen support systems, improve time management, guided imagery and visualization, muscle relaxation, assertiveness training, journal writing, stress management in the workplace
500
Name 4 nursing diagnoses that apply to patients with sensory alterations.
Risk-prone health behavior Impaired verbal communication Risk for injury Impaired physical mobility Bathing self-care deficit Situational low self-esteem Risk for falls Social isolation
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