Questions and Answers
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 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?
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Which action should the nurse manager take first regarding staffing changes?
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Which instruction should the nurse include in the plan of care for a patient with thrombocytopenia?
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What should be the first action when implementing an emergency preparedness plan?
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What should be included in the care plan for an 8-year-old patient with cystic fibrosis?
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Which diagnostic test should the nurse expect the provider to order for a child taking valproic acid?
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What should the nurse say in response to a patient requesting to review their medical record?
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Which lab result should the nurse report for a patient who has ESRD?
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What is the nurse's priority assessment for a patient in the fourth stage of labor receiving oxytocin IV?
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What intervention should be included in the plan for a patient with mechanical restraints?
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What assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis?
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What assessment findings can indicate a transfusion reaction in a patient receiving blood?
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What is the condition diagnosed for a patient who reports palpitations, difficulty breathing, and feelings of faintness?
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What actions should the nurse take when her pediatric patient is exhibiting symptoms of an allergic reaction?
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What five actions should the nurse take with a patient experiencing hallucinations following alcohol withdrawal?
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What is the condition for a post-op patient who is experiencing right lower extremity pain and itching?
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Which assessment findings require an immediate follow-up in a patient with schizophrenia?
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Which statement by a parent would prompt a nurse to request a high-frequency chest compression vest for a child with cystic fibrosis?
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What is the condition for a patient post-op who has abdominal pain and has not had a bowel movement in 5 days?
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What is an adverse effect of clonidine that the nurse should inform the patient about?
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Which action should the nurse take first when caring for a patient who had a recent stroke?
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What information should the nurse include in the educational session regarding organ donation for children with terminal illnesses?
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Which patient condition is nationally notifiable?
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What action should the nurse plan for a patient with rheumatoid arthritis experiencing moderate to severe pain?
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What physiological change causes vision loss in patients with cataracts?
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Which finding should indicate to the nurse that a patient is hemorrhaging after a colonoscopy?
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How should the nurse assess an infant's rooting reflex?
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Which finding indicates oxygen toxicity in a preschooler receiving oxygen therapy?
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What medication should be administered for a patient experiencing respiratory distress after receiving lorazepam?
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What response should the nurse make to a patient grieving the loss of a partner?
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What adverse effect should a nurse monitor for a patient taking estradiol?
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What should the nurse prioritize for a patient with bipolar disorder who is becoming increasingly restless?
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What should the nurse do during the second stage of labor when early decelerations are observed?
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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.
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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!
