Review Ncle x

8/13/2019 Review Ncle x

1/33

Coronary Artery Disease

Coronary artery disease (CAD)affects the arteries. When narrowing of the coronary

arteries(the large arteries that supply the myocardium with blood) occurs, the result isischemia. Narrowing of the coronary arteries is usually due to atherosclerosis.

Atherosclerosis and Arteriosclerosis

Though atherosclerosis and arteriosclerosis are related problems, they are not the same.Atherosclerosisis a typeof arteriosclerosis involving cholesterol deposits and triglyceridedeposits. Atherosclerosis is the overgrowth of smooth muscle cells. Narrowing of the

blood vessels is the result of an overgrowth of intimal smooth muscle cells. This

narrowing causes decreased blood flow to the heart and major organs.Arteriosclerosisisthe thicening and hardening of the arterial walls.

!ymptoms of arteriosclerosis and atherosclerosis include intermittent claudication,decreased circulation to the e"tremities, changes in sin color and coolness of the

e"tremities, headaches, di##iness, and loss of memory. $actors that contribute toarteriosclerosis and atherosclerosis are age, obesity, cigarette smoing, diabetes, and

familial predisposition. Treatment of systemic signs of arteriosclerosis involves weightcontrol with a diet low in fats and cholesterol. !tress reduction and smoing cessationalso help to decrease the client%s ris factors.

Conduction System of the Heart

The normal conduction system of the heart is composed of the sinoatrial (!A) node

located at the junction of the right atrium and the superior vena cava. The !A node isthe main pacer of the heart rate. This area contains the pacing cells that initiate the

contraction of the heart. The atrioventricular (A&) node is located in the interventricularseptum. The A& node receives the impulse and transmits it to the bundle of 'is, which

e"tends down through the ventricular septum and merges with the urinje fibers in thelower portion of the ventricles. $igure .*shows an anatomical drawing of the

conduction system of the human heart.
http://my.safaribooksonline.com/9780133391794/ch03lev1sec3#ch03fig02http://my.safaribooksonline.com/9780133391794/ch03lev1sec3#ch03fig02


2/33

FIGURE 3.2+lectrical system of the heart.

Heart loc!

'eart bloc can occur as the result of structural changes in the conduction system (such

as myocardial infarctions, coronary artery disease, tumors, and infections of the heart)or to"ic effects of drugs (such as digitalis).

$irstdegree A& bloc occurs when the !A node continues to function normally buttransmission of the impulse is slowed. -ecause of the conduction dysfunction and


3/33

ventricular depolari#ation, the heart beats regularly but the interval is slowed. These

clients are usually asymptomatic, and all impulses eventually reach the ventricles.

!econddegree heart bloc is a bloc in which some impulses reach the ventricles but

others do not.

/n thirddegree heart bloc or complete heart block, none of the sinus impulses reach

the ventricle. This results in erratic heart rates in which the sinus node and the

atrioventricular nodes beat independently. The result of this type of heart bloc can be

hypotension, sei#ures, cerebral ischemia, or cardiac arrest. A heart bloc is detected byassessing an electrocardiogram as illustrated in $igure ..

FIGURE 3.3'eart -loc

"o#icity to $edications

To"icity to medications such as calcium chanel blocers, betablocers, or digitalis can beassociated with heart bloc. 0lients taing betablocers or digo"in (1igitalis) should be

taught to chec their pulse rate and to return to their physician for regular evaluations

of their digitalis levels. 2udicious monitoring of the digo"in (1igitalis) blood levels is animportant factor in the care of the client. The therapeutic level for digo"in (1igitalis) is

3.456.* ng7m8. /f the client%s blood level of digo"in (1igitalis) e"ceeds *.3 ng7m8, theclient is considered to"ic. 0lients with digo"in to"icity often complain of nausea,

vomiting, and seeing halos around lights. A resting pulse rate of less than 93 bpm in an

adult client, less than :3 bpm in a child, and less than 633 bpm in a neonatal clientshould alert the nurse to the possibility of to"icity. Treatment for digitalis to"icity

includes checing the potassium level because hypoalemia can contribute to digitalisto"icity. The physician often will order potassium be given /& or orally and that the


4/33

digitalis be held until serum levels return to normal. Another medication, such as /suprel

or atropine, is fre;uently ordered to increase the heart rate. A highfiber diet will also be

ordered because constipation contributes to digitalis to"icity.

$alfunction of the Conduction System

-ecause a malfunction of the conduction system of the heart is the most common cause

of heart bloc, a pacing mechanism is fre;uently implanted to facilitate conduction.

acemaers can be permanent or temporary and categori#ed as demand or set. Ademandpacemaer initiates an impulse if the client%s heart rate falls below the

prescribed beats per minute. A setpacemaer overrides the heart%s own conductionsystem and delivers an impulse at the rate set by the physician. acemaers can be

combined with an internal defibrillation device. $igure .


5/33

Cardiac Dysrhythmias

0ardiac dysrhythmias occur when the heart loses its regular pacing capability. They are

classified according to their origins. These abnormal rhythms can be lethal or of nodanger to the client%s wellbeing. Tachydysrhythmiasare characteri#ed by a heart rate

greater than 633 bpm. /f the client has coronary artery disease, blood flow to the heartmight be decreased. Bradydysrhythmiasare characteri#ed by a heart rate less than 93

beats per minute. 1i##iness and syncopy are often the only symptoms the client notices.

The client might tolerate this slow rate, or bradydysrhythmias might cause the bloodpressure to be subnormal, leading to shoc or ischemia. Another alteration in the normal

beat the client might e"perience is bigeminy, a condition in which arrhythmias occur inpairs. The pairs can be junctional, atrial, or ventricular beats. Ajunctionalbeat is one

originating at the A& and bundle of 'is. An atrialdysrhythmia originates in the atria of

the heart, while a ventriculardysrhythmia originates in the ventricle of the heart.

!ee Table .6for characteristics and treatment of atrial dysrthymias.
http://my.safaribooksonline.com/9780133391794/ch03lev1sec5#ch03tab01http://my.safaribooksonline.com/9780133391794/ch03lev1sec5#ch03tab01


6/33


7/33

"A&E 3.' Su(ra)entricular Rhythm Characteristics

>nlie tachydysrhythmias and bradydysrhythmias, which usually originate in the atria,ventricular dysrhythmias are lifethreatening and their impulses originate in the

ventricles.

*entricular "achycardia

&entricular rhythms are those originating in the ventricle. These rhythms can result in


8/33

decreased o"ygen perfusion to the body and possible death. !ee Table .*for the

characteristics and treatment of ventricular rhythms.

"A&E 3.2 *entricular Rhythm Characteristics

-ecause ventricular tachycardia is lethal, the item writers for +C&E,might as the

student to identify an +0= rhythm. /t should be noted that ventricular tachycardia is a

rapid irregular rhythm with the absence of a wave. The rate can be *?3 bpm, and the!A node continues to discharge independently of the ventricle. &entricular tachycardia is

often associated with valvular heart disease, heart failure, hypomagnesium,hypotension, and ventricular aneurysms. $igure .@shows an +0= reading indicative of

ventricular tachycardia.
http://my.safaribooksonline.com/9780133391794/ch03lev1sec5#ch03tab02http://my.safaribooksonline.com/9780133391794/ch03lev1sec5#ch03fig07http://my.safaribooksonline.com/9780133391794/ch03lev1sec5#ch03tab02http://my.safaribooksonline.com/9780133391794/ch03lev1sec5#ch03fig07


9/33

FIGURE 3.-+vidence of ventricular tachycardia.

*entricular Firillation

Ventricular fibrillation (V-fib)s the primary mechanism associated with sudden cardiacarrest. This disorgani#ed chaotic rhythm results in a lac of pumping activity of the

heart. Without effective pumping, no o"ygen is sent to the brain and other vital organs./f this condition is not corrected ;uicly, the client%s heart stops beating and asystole is

seen on the +0=. The client ;uicly becomes faint, loses consciousness, and becomespulseless. 'ypotension, or a lac of blood pressure, and abnormal heart sounds are

present. $igure .:shows a diagram of the chaotic rhythms typical with &fib.

FIGURE 3./&entricular fibrillation diagram.

Treatment of ventricular fibrillation is done with a defibrillator set at appro"imately *33

joules. Three ;uic, successive shocs are delivered, with the third at 93 joules. /f adefibrillator is not readily available, a precordial thump can be delivered. /f cardiac arrest

occurs, the nurse should initiate cardiopulmonary resuscitation (0) and be ready to

administer firstline drugs such as epinephrine or vasopressin (itressin).Internal 0acema!er1Internal Cardiac Defirillators

An internally implanted pacemaer and cardioverter7defibrillator are used to treat

ventricular fibrillation, heart bloc, and other dysrhythmias. These devices are usually

implanted on the client%s left side and are connected to the myocardium with electricalleads. /f the client e"periences fibrillation or ventricular tachycardia, the defibrillator

delivers a shoc to the heart and corrects the pattern. The internal defibrillator alsorecords dysrhythmias the client has e"perienced so that the physician is aware of her

condition. A client with an internal cardiac defibrillator or permanent pacemaer should


10/33

be taught to

Avoid elevating her left arm above her head for appro"imately two wees or untithe doctor instructs otherwise.

Wear a medic alert stating that a pacemaer7internal defibrillator is implanted./dentification will alert the healthcare worer so that alterations in care can be

made.

Tae pulse for one full minute and report the rate to the physician.Avoid applying pressure over the pacemaer. ressure on the defibrillator orpacemaer can interfere with the electrical leads.

/nform her dentist of the presence of a pacemaer because electrical devices areoften used in dentistry.

Avoid having a magnetic resonance imaging (/) test. agnetic resonance

interferes with the electrical impulse of the implant.

Avoid close contact with electrical appliances, electrical or gasoline engines,

transmitter towers, antitheft devices, metal detectors, and welding e;uipmentbecause they can interfere with conduction.

-e careful when using microwaves. icrowaves are generally safe for use, butthe client should be taught to stand appro"imately five feet away from the device

while cooing.

eport fever, redness, swelling, or soreness at the implantation site.

/f beeping tones are heard coming from the internal defibrillator, the clientshould immediately move away from any electromagnetic source. !he should

stand clear from other people because shoc can affect anyone touching theclient during defibrillation.

eport di##iness, fainting, weaness, blacouts, or a rapid pulse rate. The clientwill most liely be told not to drive a car for appro"imately three months after

the internal defibrillator is inserted to evaluate any dysrhythmias.

eport persistent hiccupping because this can indicate a misfiring of the

pacemaer7internal defibrillator.

+ote-ecause a dye is used to identify the correct placement of the leads, the clientshould be ;uestioned regarding allergies to shell fish or iodine and advised to

force fluids after the procedure and report any difficulty voiding. (!ee the sectionB0ardiac 0atheteri#ationC for detailed instructions.)
http://my.safaribooksonline.com/9780133391794/ch03lev1sec7#ch03lev3sec5http://my.safaribooksonline.com/9780133391794/ch03lev1sec7#ch03lev3sec5


11/33

Dianostics

The e"am reviewer should be nowledgeable of the preparation and care of clients

receiving e"ams to diagnose cardiovascular problems. While reviewing these diagnostic

e"ams, the e"am reviewer should be alert for information that would be an importantpart of nursing care for these clients. The pertinent labs and e"ams are as followsD

0ardiac catheteri#ation

0ardiac 0TA

0ardiac profile

0entral venous pressure monitoring

0hest "ray

0lotting studies

0omplete blood count1oppler studies

1ye studies for cardiac functions

+chocardiogram

+lectrophysiologic studies

+"ercise Tolerance Test

$luoroscopy

/

E"ygen saturation levels!erum cholesterol and triglycerides

!erum electrolytes

Thallium scans

>ltrasonography

&ital signs

0harmacoloical Aents Used in the "reatment of Clients ithCardio)ascular Disorders

An integral part of care to clients with cardiovascular disorders is pharmacologicalintervention. These medications provide an improvement or cure of the clients% cardiacproblems. Table .


12/33


13/33


14/33


15/33


16/33


17/33


18/33

"A&E 3.% 0harmacoloic Aents Used in the "reatment of Clients ithCardio)ascular Disorders

The nursing e"am reviewer needs to focus on the drugs in Table .


19/33

A.A& node

.urinje fibers

C.!A node

D.-undle of 'is

3.A client is being treated with nitroprusside (Nitropress). The nurse is aware that

this medicationD

A.!hould be protected from light

./s a non5potassiumsparing diuretic

C.0auses vasoconstriction

D.1ecreases circulation to the e"tremities

%.A client being treated with lisinopril (Gestril) develops a hacing cough. The nurseshould tell the client toD

A.Tae half the dose to control the problem

.Tae cough medication to control the problem

C.!top the medication

D.eport the problem to the doctor

7.An elderly client taing digitalis develops constipation. The nurse is aware thatconstipation in a client taing digitalis mightD

A.1evelop an elevated digitalis level

.'ave a decrease in the digitalis levels

C.'ave alterations in sodium levels

D.1evelop tachycardia

8.The client is suspected of having had a myocardium infarction. Which diagnosticfinding is most significantF

A.81'

.Troponin

C.0reatinine

D.A!T

-.A client with an internally implanted defibrillator should be taught toD

A.Avoid driving a car

.Avoid eating food cooed in a microwave

C.efrain from using a cellular phone

D.eport swelling at the site

/.A client is scheduled for a cardiac catheteri#ation. $ollowing the procedure, the

nurse shouldD

A.Assess for allergy to iodine

.0hec pulses pro"imal to the site

C.Assess the urinary output
http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans3http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans4http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans5http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans6http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans7http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans8http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans3http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans4http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans5http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans6http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans7http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans8


20/33

D.0hec to ensure that the client has a consent form signed

9.A client with -uerger%s disease complains of pain in the lower e"tremities. Thenurse is aware that -uerger%s disease is also calledD

A.heochromocytoma

./ntermittent claudication

C.Hawasai disease

D.Thromboangiitis obliterans

':.A client with an abdominal aneurysm fre;uently complains ofD

A.A headache

.!hortness of breath only during sleep

C.8ower bac pain

D.1ifficulty voiding

Ansers to E#am 6uestions

'.Answer - is correct. The client taing furosemide is at ris for developing

hypoalemia (decreased potassium) because this drug is a non5potassiumsparingdiuretic. A potassium level of 6.: is e"tremely low and might result in cardiac

dysrhythmias. Answers A, 0, and 1 are incorrect because the levels noted in the

;uestion are within normal levels.

2.Answer 0 is correct. The pacemaer of the heart is the !A node. The impulse

moves from the !A node to the A& node on to the right and left bundle branchesand finally to the urinje fibers. This maes answers A, -, and 1 incorrect.

3.Answer A is correct. Nitroglycerine preparations should be protected from lightbecause light decreases the effectiveness of this category of medication. Answer -

is incorrect because Nitropress is not a diuretic. Answer 0 is incorrect becauseNitropress is a vasodilator, not a vasoconstrictor. Answer 1 is incorrect because

nitroglycerine does not decrease circulation to the e"tremities.

%.Answer 1 is correct. A hacing cough is a common side effect and should be

reported to the doctor. The client should not be told to half the dose because this

can result in an elevated blood pressure, so answer A is incorrect. Answer - isincorrect because taing a cough medication will mas the symptom of a possible

allergic reaction. Answer 0 is incorrect because, although the client stops taingthe medication, this answer states that the client can report the finding to the

doctor at the time of the scheduled visit. !he should report this finding

immediately.7.Answer A is correct. The client taing digitalis should avoid constipation because

constipation can lead to digitalis to"icity. Answer - is incorrect becauseconstipation will not lead to a decrease in the digitalis levels. Answer 0 is incorrect

because constipation does not result in alterations in the sodium level. Answer 1 isincorrect because digitalis to"icity will result in brachycardia, not tachycardia.

8.Answer - is correct. The best diagnostic tool for confirming that the client hase"perienced a myocardial infarction is the troponin level. Another lab value

associated with a myocardial infarction is the 0H-. Answer A is incorrect because

the 81' is also elevated in clients with muscle trauma not associated with an /.
http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans9http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans10http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que1http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que2http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que3http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que4http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que5http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que6http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans9http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03ans10http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que1http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que2http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que3http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que4http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que5http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que6


21/33

Answer 0 is incorrect because the creatinine level indicates renal function. Answer

1 is incorrect because the A!T level is elevated with gallbladder and liver disease

as well as muscle inflammation.

-.Answer 1 is correct. The client with an implantable defibrillator should report

redness, pain, and swelling at the site of the implant. Answers A, -, and 0 areincorrect because the client can drive a car, eat food cooed in a microwave, and

use a cellular phone. The client probably will be told to wait three months to drive

a car. 'e should put his food in the microwave and step five feet away from themicrowave during cooing. A cellular phone can be used but should be held in the

right hand.

/.Answer 0 is correct. The dye used in the procedure can cause a decrease in renal

function. The client%s renal function should be assessed and changes reported tothe doctor immediately. Answer A is incorrect because the client%s allergies should

be checed prior to the procedure, not after the procedure. The femoral artery iscommonly used as the site for a catheteri#ation. Answer - is incorrect because the

pulses should be checed distal to the site. Answer 1 is incorrect because the

permit should be signed prior to the procedure.

9.Answer 1 is correct. The other name for -uerger%s disease is thromboangiitisobliterans. Answer A is incorrect because pheochromocytoma is an adrenal tumor.Answer - is incorrect because intermittent claudication is pain in an e"tremity

when waling. Answer 0 is incorrect because Hawasai disease is an acutevasculitis that can result in an aneurysm in the thoracic area.

':.Answer 0 is correct. 0lients with abdominal aortic aneurysms often complain ofnausea, lower bac pain, and feeling their heart beat in the abdomen. Answer A is

incorrect because a headache is a symptom of a cerebral aneurysm. Answer - is

incorrect because, although the client with an abdominal aneurysm might haveshortness of breath, this symptom is not particular to during sleep. Answer 1 is incorrect

because difficulty voiding is not associated with an abdominal aneurysm.

www. Nursingreviewsandrationales
http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que7http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que8http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que9http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que10http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que7http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que8http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que9http://my.safaribooksonline.com/9780133391794/ch03lev1sec16#ch03que10


22/33


23/33


24/33

SOURCE: http://www.nursereview.orgCOMPREHENSIVE TEST 11.A patient tells you that her urine is starting to look discolored. Ifyou believe this change is due to medication, which of the followingpatients medication does not cause urine discoloration?. Su!"s!#ine$. %evo&op

'. Pheno!phth!ein&. (spirin2. You are responsible for reviewing the nursing units refrigerator.If you found the following drug in the refrigerator it should beremoved from the refrigerators contents?

. Corgr&$. Hu)u!in *in+e'tion,'. Uro-inse&. Epogen *in+e'tion,. A ! year old female has recently been diagnosed with anautoimmune disease. "he has also recently discovered that she is

pregnant. #hich of the following is the only immunoglobulin thatwill provide protection to the fetus in the womb?

. Ig($. Ig'. IgE&. Ig!. A second year nursing student has $ust suffered a needlestickwhile working with a patient that is positive for AI%". #hich of thefollowing is the most important action that nursing student shouldtake?. I))e&ite!0 see so'i! wor-er

$. Strt proph0!'ti' (T tret)ent'. Strt proph0!'ti' Pent)i&e tret)ent&. See- 'ounse!ing&. A thirty five year old male has been an insulin'dependent diabeticfor five years and now is unable to urinate. #hich of the followingwould you most likely suspect?

. (theros'!erosis$. i$eti' nephropth0'. (utono)i' neuropth0&. So)ti' neuropth0(. You are taking the history of a )! year old girl who has a *+I- of

). /he girl reports inability to eat, induced vomiting and severeconstipation. #hich of the following would you most likely suspect?

. Mu!tip!e s'!erosis$. (nore2i nervos'. 3u!i)i&. S0ste)i' s'!erosis0. A 2! year old female is admitted to the 1 for confusion. /hispatient has a history of a myeloma diagnosis, constipation, intenseabdominal pain, and polyuria. #hich of the following would you mostlikely suspect?

. iverti'u!osis


25/33

$. H0per'!'e)i'. H0po'!'e)i&. Irrit$!e $owe! s0n&ro)e. ho gam is most often used to treat3333 mothers that have a 3333infant.

. RH positive4 RH positive$. RH positive4 RH negtive'. RH negtive4 RH positive

&. RH negtive4 RH negtive4. A new mother has some 5uestions about *678-. #hich of thefollowing statements made by a nurse is not correct regarding 678?

. ( uthrie test 'n 'he'- the ne'essr0 !$ v!ues.$. The urine hs high 'on'entrtion o" phen0!p0ruvi' 'i&'. Ment! &e"i'its re o"ten present with P5U.&. The e""e'ts o" P5U re reversi$!e.)9. A patient has taken an overdose of aspirin. #hich of thefollowing should a nurse most closely monitor for during acutemanagement of this patient?

. Onset o" pu!)onr0 e&e)

$. Met$o!i' !-!osis'. Respirtor0 !-!osis&. Pr-inson6s &isese t0pe s0)pto)s)). A fifty'year'old blind and deaf patient has been admitted to yourfloor. As the charge nurse your primary responsibility for thispatient is?. %et others -now $out the ptient6s &e"i'its$. Co))uni'te with 0our supervisor 0our 'on'erns $out the ptient6s&e"i'its.'. Continuous!0 up&te the ptient on the so'i! environ)ent.&. Provi&e se'ure environ)ent "or the ptient.

)2. A patient is getting discharged from a ":; facility. /he patienthas a history of severe %. /he patient is primarilyconcerned about their ability to breath easily. #hich of the followingwould be the best instruction for this patient?

. eep $rething te'hni7ues to in'rese O8 !eve!s.$. Cough regu!r!0 n& &eep!0 to '!er irw0 pssges.'. Cough "o!!owing $ron'ho&i!tor uti!i#tion&. e'rese CO8 !eve!s $0 in'rese o20gen t-e output &uring )e!s.). A nurse is caring for an infant that has recently been diagnosedwith a congenital heart defect. #hich of the following clinical signswould most likely be present?

. S!ow pu!se rte$. 9eight gin'. e'rese& s0sto!i' pressure&. Irregu!r 93C !$ v!ues)!. A mother has recently been informed that her child has %ownssyndrome. You will be assigned to care for the child at shift change.#hich of the following characteristics is not associated with %ownssyndrome?

. Si)in 'rese$. 3r'h0'eph!0'. Oi!0 s-in


26/33

&. H0potoni'it0)&. A patient has recently eperienced a *I- within the last ! hours.#hich of the following medications would most like beadministered?

. Strepto-inse$. (tropine'. ('et)inophen&. Cou)&in

)(. A patient asks a nurse, @y doctor recommended I increase myintake of folic acid. #hat type of foods contain folic acids?

. reen veget$!es n& !iver$. e!!ow veget$!es n& re& )et'. Crrots&. Mi!-)0. A nurse is putting together a presentation on meningitis. #hichof the following microorganisms has noted been linked to meningitisin humans?

. S. pneu)oni$. H. in"!uen#

'. N. )eningitis&. C!. &i""i'i!e).A nurse is administering blood to a patient who has a lowhemoglobin count. /he patient asks how long to + &0s.'. The !i"e spn o" R3C is ?> &0s.&. The !i"e spn o" R3C is 18> &0s.)4. A (& year old man has been admitted to the hospital for spinalstenosis surgery. #hen does the discharge training and planning

begin for this patient?. @o!!owing surger0$. Upon &)ission'. 9ithin ;A hours o" &is'hrge&. Preopertive &is'ussion29. A child is & years old and has been recently admitted into thehospital. According to 1rickson which of the following stages is thechild in?

. Trust vs. )istrust$. Inititive vs. gui!t'. (utono)0 vs. sh)e

&. Inti)'0 vs. iso!tion2). A young adult is 29 years old and has been recently admittedinto the hospital. According to 1rickson which of the following stagesis the adult in?. Trust vs. )istrust$. Inititive vs. gui!t'. (utono)0 vs. sh)e&. Inti)'0 vs. iso!tion22. A nurse is making rounds taking vital signs. #hich of the

;


27/33

following vital signs is abnormal?

. 11 0er o!& )!e B ?> $.p.)4 88 resp/)in. 4 1>>/> )) Hg$. 1D 0er o!& "e)!e B 1>< $.p.).4 88 resp/)in.4 1> )) Hg'. < 0er o!& )!e 1>8 $.p.)4 8; resp/)in.4 ?>/=< )) Hg&. = 0er o!& "e)!e 1>> $.p.).4 8= resp/)in.4 ?>/>)) Hg

2. #hen you are taking a patients history, she tells you she hasbeen depressed and is dealing with an aniety disorder. #hich ofthe following medications would the patient most likely be taking?

. E!vi!$. C!'itonin'. Pergo!i&e&. Verp)i!2!. #hich of the following conditions would a nurse not administererythromycin?

. C)p0!o$'teri! in"e'tion$. %egionnire6s &isese

'. Pneu)oni&. Mu!tip!e S'!erosis5(P%(N:


28/33

amniocentesis. /he client asks the nurse what the physician will learnfrom this procedure. /he nurses response should be based on anunderstanding that which of the following conditions can be detectedby this test?

1. Tetr!og0 o" @!!ot.8. T!ipes e7uinovrus.D. He)o!0ti' &isese o" the new$orn.;. C!e"t !ip n& p!te.

&. /he nurse evaluates the nutritional intake of a )('year'old girl at acamp for adolescents. /he girl eats all of the food provided to her atthe camp cafeteria. 1ach of the days three meals contains foods fromall areas of the food pyramid, and each meal averages about 499calories and mg of iron. /he girl has been menstruating monthly forabout two years. #hich of the following descriptions, if made by thenurse, +1"/ describes the girls intake if her weight is appropriate forher height?1. Her &iet is !ow in '!ories n& high in iron.8. Her &iet is !ow in '!ories n& !ow in iron.D. Her &iet is high in '!ories n& !ow in iron.

;. Her &iet is high in '!ories n& high in iron.(. A client has returned from surgery with a fine, reddened rash notedaround the area where +etadine prep had been applied prior tosurgery. :ursing documentation in the chart should include

1. the ti)e n& 'ir'u)stn'es un&er whi'h the rsh ws note&.8. the e2p!ntion given to the '!ient n& ")i!0 o" the reson "or the rsh.D. nottion on n !!erg0 !ist n& noti"i'tion o" the &o'tor.;. the nee& "or pp!i'tion o" 'orti'osteroi& 're) to &e'rese in"!))tion.0. A client who is receiving a blood transfusion eperiences a hemolyticreaction. /he nurse would anticipate which of the following assessmentfindings?

1. H0potension4 $'-'he4 !ow $'- pin4 "ever.8. 9et $reth soun&s4 severe shortness o" $reth.D. Chi!!s n& "ever o''urring $out n hour "ter the in"usion strte&.;. Urti'ri4 it'hing4 respirtor0 &istress.. /he nurse is developing a comprehensive care plan for a youngwoman with an eating disorder. /he nurse refers this client toassertiveness skills classes. /he nurse knows that this is an appropriateintervention because this client may have problems with

1. ggressive $ehviors n& ngr0 "ee!ings.8. se!"i&entit0 n& se!"estee).D. "o'using on re!it0.

;. ")i!0 $oun&r0 intrusions


29/33


30/33


31/33

3P4 'using potenti!!0 serious )e&i'! 'onse7uen'es*8, not $est rtion!e "or 'he'-ing with &o'tor $out this or&er*D, not $est rtion!e "or 'he'-ing with &o'tor $out this or&er*;, not $est rtion!e "or 'he'-ing with &o'tor $out this or&er=;."trategyE %etermine the skill level involved with each patientFscare. /he : cares for patients that re5uire assessment, teaching,and nursing $udgment.

*1, st$!e ptient with n e2pe'te& out'o)e: ssign to the %PN/%VN*8, st$!e ptient with n e2pe'te& out'o)e: ssign to the %PN/%VN*D, stn&r&4 un'hnging pro'e&ure: ssign to the nursing ssistnt*;, 'orre'tBre7uires ssess)ent s-i!!s o" the RN=


32/33

&istortion o" re!it0*8, nee&s re!it0 testing "ro) nurse4 not 7uestioning*D, 7uestioning is nontherpeuti'F )0 'use ptient to voi& nurseph0si'!!0*;, nee&s &e"enseF 7uestioning wi!! "urther &istort re!it0 or e!$orte on&e!usion>."trategyE /hink about each answer.

*1, +ust the opposite is trueF !ongter) )e)or0 is )ore e""i'ient thn shortter) )e)or0*8, 'orre'tBstress o" n un")i!ir sitution or environ)ent )0 !e& to'on"usion in e!&er!0 '!ients*D, )ent! sttus n& !erning $i!it0 re not ""e'te& $0 ging4 !thoughD=

e!&er!0 '!ient )0 $e s!ower t &oing things

*;, )ent! sttus n& !erning $i!it0 re not ""e'te& $0 ging4 !thoughe!&er!0 '!ient )0 $e s!ower t &oing things1."trategyE /hink about each answer.

*1, 3P in'reses n& '!ient gins weight*8, 'orre'tB'!ients with CushingGs s0n&ro)e ten& to !ose weight in their !egsn& hve pete'hie n& $ruising*D, no 'orre!tion with urinr0 outputF potssiu) in'reses*;, no 'orre!tion with CushingGs s0n&ro)e8."trategyE /hink about each answer.

*1, re'tions 'use& $0 preservtives in insu!in4 whi'h is s)e "or !! t0peso" insu!in*8, no 'hnge in in'i&en'e o" h0pog!0'e)i or h0perg!0'e)i*D, 'o)p!i'tions re 'use& $0 $!oo& vesse! &)ge "ro) sugr n& "t&eposits4 not t0pe o" insu!in use&*;, 'orre'tBprotein )o!e'u!es re i&enti'! with hu)n insu!inD."trategyE /hink about each answer and how it relates to AI%"'related dementia.*1, not re!evnt to this 'on&ition*8, not re!evnt to this 'on&ition

*D, 'orre'tBppro2i)te!0 =


33/33

D

Documents

Review Ncle x