Podcast
Questions and Answers
Which of the following interventions should the nurse include in the plan? (Select all that apply)
Which of the following interventions should the nurse include in the plan? (Select all that apply)
Which instructions should the nurse include for parents of a child who has autism spectrum disorder?
Which instructions should the nurse include for parents of a child who has autism spectrum disorder?
Which intervention should the nurse use to maintain surgical sterile technique during a sterile dressing change?
Which intervention should the nurse use to maintain surgical sterile technique during a sterile dressing change?
What aPTT value should the nurse expect in a toddler who has hemophilia A?
What aPTT value should the nurse expect in a toddler who has hemophilia A?
Signup and view all the answers
Which action should the nurse manager take first regarding staffing changes?
Which action should the nurse manager take first regarding staffing changes?
Signup and view all the answers
Which instruction should the nurse include in the plan of care for a patient with thrombocytopenia?
Which instruction should the nurse include in the plan of care for a patient with thrombocytopenia?
Signup and view all the answers
What should be the first action when implementing an emergency preparedness plan?
What should be the first action when implementing an emergency preparedness plan?
Signup and view all the answers
What should be included in the care plan for an 8-year-old patient with cystic fibrosis?
What should be included in the care plan for an 8-year-old patient with cystic fibrosis?
Signup and view all the answers
Which diagnostic test should the nurse expect the provider to order for a child taking valproic acid?
Which diagnostic test should the nurse expect the provider to order for a child taking valproic acid?
Signup and view all the answers
What should the nurse say in response to a patient requesting to review their medical record?
What should the nurse say in response to a patient requesting to review their medical record?
Signup and view all the answers
Which lab result should the nurse report for a patient who has ESRD?
Which lab result should the nurse report for a patient who has ESRD?
Signup and view all the answers
What is the nurse's priority assessment for a patient in the fourth stage of labor receiving oxytocin IV?
What is the nurse's priority assessment for a patient in the fourth stage of labor receiving oxytocin IV?
Signup and view all the answers
What intervention should be included in the plan for a patient with mechanical restraints?
What intervention should be included in the plan for a patient with mechanical restraints?
Signup and view all the answers
What assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis?
What assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis?
Signup and view all the answers
What assessment findings can indicate a transfusion reaction in a patient receiving blood?
What assessment findings can indicate a transfusion reaction in a patient receiving blood?
Signup and view all the answers
What is the condition diagnosed for a patient who reports palpitations, difficulty breathing, and feelings of faintness?
What is the condition diagnosed for a patient who reports palpitations, difficulty breathing, and feelings of faintness?
Signup and view all the answers
What actions should the nurse take when her pediatric patient is exhibiting symptoms of an allergic reaction?
What actions should the nurse take when her pediatric patient is exhibiting symptoms of an allergic reaction?
Signup and view all the answers
What five actions should the nurse take with a patient experiencing hallucinations following alcohol withdrawal?
What five actions should the nurse take with a patient experiencing hallucinations following alcohol withdrawal?
Signup and view all the answers
What is the condition for a post-op patient who is experiencing right lower extremity pain and itching?
What is the condition for a post-op patient who is experiencing right lower extremity pain and itching?
Signup and view all the answers
Which assessment findings require an immediate follow-up in a patient with schizophrenia?
Which assessment findings require an immediate follow-up in a patient with schizophrenia?
Signup and view all the answers
Which statement by a parent would prompt a nurse to request a high-frequency chest compression vest for a child with cystic fibrosis?
Which statement by a parent would prompt a nurse to request a high-frequency chest compression vest for a child with cystic fibrosis?
Signup and view all the answers
What is the condition for a patient post-op who has abdominal pain and has not had a bowel movement in 5 days?
What is the condition for a patient post-op who has abdominal pain and has not had a bowel movement in 5 days?
Signup and view all the answers
What is an adverse effect of clonidine that the nurse should inform the patient about?
What is an adverse effect of clonidine that the nurse should inform the patient about?
Signup and view all the answers
Which action should the nurse take first when caring for a patient who had a recent stroke?
Which action should the nurse take first when caring for a patient who had a recent stroke?
Signup and view all the answers
What information should the nurse include in the educational session regarding organ donation for children with terminal illnesses?
What information should the nurse include in the educational session regarding organ donation for children with terminal illnesses?
Signup and view all the answers
Which patient condition is nationally notifiable?
Which patient condition is nationally notifiable?
Signup and view all the answers
What action should the nurse plan for a patient with rheumatoid arthritis experiencing moderate to severe pain?
What action should the nurse plan for a patient with rheumatoid arthritis experiencing moderate to severe pain?
Signup and view all the answers
What physiological change causes vision loss in patients with cataracts?
What physiological change causes vision loss in patients with cataracts?
Signup and view all the answers
Which finding should indicate to the nurse that a patient is hemorrhaging after a colonoscopy?
Which finding should indicate to the nurse that a patient is hemorrhaging after a colonoscopy?
Signup and view all the answers
How should the nurse assess an infant's rooting reflex?
How should the nurse assess an infant's rooting reflex?
Signup and view all the answers
Which finding indicates oxygen toxicity in a preschooler receiving oxygen therapy?
Which finding indicates oxygen toxicity in a preschooler receiving oxygen therapy?
Signup and view all the answers
What medication should be administered for a patient experiencing respiratory distress after receiving lorazepam?
What medication should be administered for a patient experiencing respiratory distress after receiving lorazepam?
Signup and view all the answers
What response should the nurse make to a patient grieving the loss of a partner?
What response should the nurse make to a patient grieving the loss of a partner?
Signup and view all the answers
What adverse effect should a nurse monitor for a patient taking estradiol?
What adverse effect should a nurse monitor for a patient taking estradiol?
Signup and view all the answers
What should the nurse prioritize for a patient with bipolar disorder who is becoming increasingly restless?
What should the nurse prioritize for a patient with bipolar disorder who is becoming increasingly restless?
Signup and view all the answers
What should the nurse do during the second stage of labor when early decelerations are observed?
What should the nurse do during the second stage of labor when early decelerations are observed?
Signup and view all the answers
Study Notes
Crohn's Disease, Ulcerative Colitis & Peritonitis
- Temperature elevation (100F) occurs in Crohn's disease, ulcerative colitis (UC), and peritonitis due to inflammation or infection.
- Unintentional weight loss (-9.7 lbs) indicates potential malabsorption in Crohn's and UC.
- Frequent loose stools are typical in Crohn's disease; blood in stools suggests ulcerative colitis.
- Elevated WBC (14) suggests inflammation or infection present in all three conditions.
- Heart rate of 105 indicates tachycardia associated with peritonitis, due to infection or dehydration.
- Albumin level (2.4) is low in Crohn's and UC because of inadequate protein absorption; abdominal pain in the RLQ is common in Crohn's.
Transfusion Reaction Indicators
- Symptoms of a transfusion reaction include back pain, headache, and anxiety alongside potential fever, chills, chest pain, tachycardia, dyspnea, and hypotension.
- Vital signs may initially remain stable but require careful monitoring.
Somatic Symptom Disorder
- Characterized by somatic symptoms linked to psychological issues, such as difficulty breathing, palpitations, and joint pain.
- Interventions include monitoring vital signs and assessing for secondary gains related to the illness.
Allergic Reaction Actions in Pediatrics
- Immediate actions include administering 0.9% NS IV and epinephrine IM, due to their critical role in anaphylactic reactions.
- Frequent monitoring of vital signs is essential for detecting shock.
Alcohol Withdrawal Management
- Thiamine administration prevents Wernicke syndrome; chlordiazepoxide and a low-stimulation environment help manage withdrawal symptoms.
- Initiate seizure precautions as withdrawal seizures may occur within 12-24 hours post cessation of alcohol.
Varicose Veins Assessment
- Assessment reveals bilateral lower extremity warmth and distended veins.
- Management includes elevating the affected extremity and applying compression stockings.
Schizophrenia Assessment Follow-up
- Tardive dyskinesia is indicated by involuntary tongue movements and foot tremors.
- Increased agitation and frequency of urination may also require immediate follow-up.
Cystic Fibrosis and Airway Clearance
- The need for a high-frequency chest compression vest arises if percussion therapy is ineffective, indicated by minimal mucus production.
- Teaching nebulizer administration to the child is also crucial.
Post-Operative Complications
- Abdominal pain and hypoactive bowel sounds may suggest intestinal obstruction, especially with a lack of bowel movement over 5 days.
- Semi-Fowler's positioning and IV fluids are indicated to alleviate distention.
Clonidine Adverse Effects
- Monitor for dry mouth as a common adverse effect; other potential side effects include constipation, dry eyes, and rashes.
Stroke Patient Transfer
- Assessing the patient's functional limitations prior to transfer is essential for safe mobilization strategies.
Education on Organ Donation
- Clear communication regarding organ donation's non-disfiguring nature to the family helps facilitate decision-making during end-of-life care.
Notifiable Infectious Conditions
- Botulism in adolescents is nationally notifiable and should be reported to CDC due to its potential severity and need for intervention.
Rheumatoid Arthritis Pain Management
- Frequent rest periods should be incorporated while allowing patient autonomy in ADLs fosters independence and mobility.
Cataracts and Visual Acuity
- Increased opacity of the lens characterizes cataracts, leading to decreased visual acuity; not to be confused with other ocular conditions such as glaucoma.
Hemorrhaging Post-Colonoscopy
- A rapid decrease in blood pressure signals possible hemorrhage, while an expected feeling of fullness following the procedure is normal.
Infant Reflex Assessment
- The rooting reflex can be assessed by stroking the infant's cheek, prompting a turn towards the side touched.
Oxygen Toxicity in Cystic Fibrosis
- Substernal pain indicates potential oxygen toxicity in patients receiving prolonged oxygen therapy.
Lorazepam Overdose Management
- Flumazenil is the anticipated medication to reverse lorazepam effects during respiratory distress.
Grief Responses
- Acknowledging the patient’s difficulty is a therapeutic communication technique to encourage expression of grief.
Estradiol Monitoring
- Headaches should be monitored and reported as they may indicate serious complications such as thromboembolic events.
Bipolar Disorder Management
- Moving a restless patient to a quiet space is crucial to prevent harm to others during a manic episode.
Labor Monitoring
- Early decelerations during labor are normal; continued FHR monitoring is essential unless other concerning signs emerge.
Stroke Recovery Care
- Supporting the affected arm on a pillow prevents injury and subluxation due to weakness following a stroke.
Autism Spectrum Disorder Care
- Employing a reward system for behavior modification effectively provides structure and predictability for children with autism.### Surgical Asepsis
- Sterile items must remain in direct sight to ensure they are untainted.
- Maintain sterile technique by positioning hands away from the body and above waist level.
- Items should be kept at least 2.5 cm (1 inch) from the edge of the sterile field.
Hemophilia A
- Normal activated partial thromboplastin time (aPTT) values range from 30-40 seconds.
- Expect aPTT value of 45 seconds for a toddler with hemophilia A, indicating prolonged clotting time.
Staffing Challenges in Long-Term Care
- First action for a nurse manager facing staffing difficulties is to form a committee to investigate staffing issues.
- Understanding the current needs is crucial before implementing changes, representing the assessment stage of the nursing process.
Care Plan for Thrombocytopenia
- Instruct patients to avoid venipunctures to minimize bleeding risk due to decreased platelet counts.
- Neutropenic precautions apply to low white blood cell counts, including restricting visitors and prohibiting fresh flowers.
Emergency Preparedness Plan
- Notify the incident commander first when implementing an emergency plan to establish command hierarchy and maintain order.
Cystic Fibrosis Management
- Administer high-dose antibiotic therapy due to the rapid metabolism of antibiotics in children with cystic fibrosis.
- Implement contact precautions and ensure a high-calorie, high-protein diet with included activities of daily living (ADLs).
Monitoring Patients on Valproic Acid
- Serum liver enzyme levels should be monitored due to the potential for hepatic toxicity associated with valproic acid.
Patient's Right to Access Medical Records
- Patients have the right to access and review their medical records, which is a legal obligation for healthcare facilities under HIPAA.
Reporting Lab Values in ESRD
- Report elevated sodium levels (148) to the healthcare provider, indicating hypernatremia in a patient with end-stage renal disease.
Fourth Stage of Labor Priorities
- The priority assessment is the amount of vaginal bleeding, as patients are at risk for hemorrhage post-delivery.
Management of Patients in Mechanical Restraints
- Continuous observation by a staff member is required for patients in restraints to prevent injury.
- Restraints should not be removed until the patient can follow commands and is calm. Document assessments regularly, and ensure prescription renewal every four hours for adults.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge on assessment findings related to Crohn's disease, ulcerative colitis, and peritonitis with these flashcards. Gain a deeper understanding of symptoms, lab values, and nursing considerations through interactive practice. Perfect for nursing students preparing for their exams!
