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MS Final Exam
| Question | Answer |
|---|---|
| Pts immune system not working very well highest priority is | wash your hands |
| Older postop pt who has a wound infection, what finding on assessment | first sign is confusion |
| What would a nurse do to stay protected against aids pt | standard precautions |
| HIV pt assessing them how do you know how the disease has progressed to aids | opportunistic infections; yeast infection, thrush (infections most people aren’t affected by) |
| Try to ambulate pt w/ anemia signs of an issue | dyspnea on assertion. HR abnormal respiratory rate ↑ 20 abnormal HR ↑ 100 |
| Pt has a lot of bruising ask pt | if they are on aspirin |
| Planning care platelet count 30,000 mm plan of care | Too low, so pt is at risk for bleeding |
| Nursing obtaining history for pt w/ iron deficiency anemia what would correlate w/ dx | vegetarian who doesn’t eat red meat |
| Blood levels low | take iron and folic acid; If wbc low take zinc and folic acid. C/B bone marrow not producing enough or autoimmune disease, AIDS, chemo ect. low platelet precautions: CB chemo r/f bleeding. Can get an infusion of platelets to increase. |
| Pt has thrombo cytopenia (↓ platelet count) | low platelet count; what instructions to gv to pt on discharge; don’t use hard tooth brush electric razor avoid aspirin |
| Pt has excessive catecholamine release; adrenaline release, epinephrine, and norepinephrine causes | sympathetic response ↑ hr and ↑ resp |
| Pt has hormone deficiency most important one to monitor | Thyroid hormone |
| Pt has acromegaly | abnormal growth hormone release. ↑ in feet, hands, and jaw; can expect soft tissue changes but not bone |
| Pt who SIADH what happens | Retain fluid; delusional hyponatremia. HOLD fluids for pt |
| Pt has Spiro lactone- potassium sparing diuretic what should they avoid eating | avoid K + |
| ↑ dose corticoid steroids | must be weaned off b/c adrenal gland needs to start producing hormones again |
| Dietary hyperthyroid | ↑ calories, carbs, and proteins b/c body needs more of these to burn off due to ↑ energy level |
| Pt has subtotal thyroidectomy | hypocalcemia; check w/ trousseau and chevosicks |
| Hypoglycemia give pt | 4 oz juice; complex carb= if unable to swallow give glucagon (releases glucose from liver). |
| Pt 15 yr hx of DM; Pt can’t feel anything in feet | check to mk sure tack not in foot ect |
| Pt DM visually impaired wants to know if daughter can draw up meds | 3 weeks refrigerated w/ needles upright |
| Keto acidosis what to expect | fruity breath; rapid and deep respirations |
| Pt on IV insulin for hyperglycemia monitor | Potassium b/c insulin drives K into cells. |
| Assessing pt, nurse thinks pt could have respiratory acidosis what kind of pts at r/f | hypo ventilating, COPD, asthma, and opioids (↓ O2 & ↑ CO2) |
| Pt getting discharged teach them r/f metabolic alkalosis | taking antacids |
| Pt has COPD has cough low grade temp what info would be useful to have | has sputum changed color (might be viral or not urgent) |
| Pt has asthma can’t get a deep breath in, decreased breath sounds and no wheezing | check oxygen saturation. |
| When checking 4 pt’s w/ asthma which one you assess first | HR is ↑ b/c pt could be in distress |
| Pt has frequent asthma attacks and severe arthritis pain | Ask pt which meds they take b/c NSAIDS can trigger asthma |
| Pt being sent home on inhaled corticoid steroid meds nurse should teach pt | rinse mouth out after, don’t use for rescue inhaler; used for long term |
| Pt w/ lung disease which symptoms would nurse know to intervene | Check breathing, check hr, accessory muscles, or edema |
| Pt worried about catching flu | tell pt to get flu shot |
| Pt has pneumonia wants to know how to get rid of sputum | drink atleast 2L of water a day |
| Pt has nicotine patch and wants to smoke | DON’T; can cause heart attack |
| Pt dizzy from supine to sitting orthostatic hypotension, what should nurse do? | check bp |
| Cardiac Cath procedure what should the nurse check before the procedure | Check for iodine or shellfish allergy b/c of contrast dye |
| Assessing pt in outpatient clinic how would you know if Left sided heart fail | Crackles, winded easily, poor exercise tolerance |
| Admitting pt to pcu what might tell you the pt has right sided heart failure | lower extremity edema |
| Pt prostatic valve replacement | risk for getting blood clot |
| Pt has severe heart failure what position is best | sit pt up w/ pillows under arm in high fowlers |
| Pt chart has order lovastatin what should you monitor for?= | watch liver enzymes (statins metabolized in liver) |
| Pt new dx hypertension | avoid sodium & canned foods |
| Pt w/ venous ulcer assessment findings | brown discolorations |
| Pt has peripheral artery disease had percutaneous angioplasty | monitor for bleeding or occlusion |
| Pt on warfarin pt says are you going to take me off heparin | keep on cpl days b/c warfarin takes a couple of days to get to therapeutic levels. |
| Pt has suspected coronary disease what’s the difference between angina and MI | angina relived w/ nitro/ rest |
| Lab test w/ chest pain | Check Troponin 1 |
| Pt has glaucoma what increases IOP that patient should avoid | don’t bend over, don’t wear tight shirt or ties, don’t strain |
| Pt w/ macular degeneration where would you put the tv | on side of the pt |
| Which med puts pt at ↑ risk for hearing loss | Gentromyocin (antibiotics) |
| Pt has ruptured ear drum wants to know what to do now | ear drum will prob heal by itself |
| Meniere’s Disease is an inner ear disorder and causes dizziness, vertigo, tinnitus; has a lot of vertigo | stand up slowly, don’t bend over, ask for help: look up right answer; The vertigo may cause severe nausea and imbalance. Hearing loss may become permanent. |
| Pt has migraines and is on beta blockers to help manage them teach pt | monitor pulse |
| Pt has bacterial meningitis what to know | who they came into contact w/; know if living in dorm, group home ect |
| Parkinson’s how would you help to prevent respiratory complications | sitting pt up, limit exercise, |
| Daughter has Alzheimer’s want to know new med if going to make dementia better | will only slow it down, but won’t make disease better won’t cure |
| Pt has Alzheimer’s is going home what are some safety things | bracelet, geri-chair, distractions, door locks |
| ALS and MS difference | ALS kills you respiratory; Pt can live a long time w/ MS |
| When assessing pt what to expect to find (ascending when getting worse)= | Descending when pt is getting better. |
| Pt with Myasthenia Gravis take meds what do they need about eating and timing w/ meds | Take meds 45-60 minutes before they eat. (increases muscle strength and helps w/ swallow) |
| Pt has a brain attack is a stroke causes embolic stroke | dysrhythmias- atrial fib |
| Immune system want to know what antibodies do | fight off infection… neutralize virus, mark bacteria to be destroyed by wbc, activate compliment system |
| Anterior pituitary hyperfunction what physical characteristics would you see | protrusion of the jaw, deepens voice, enlarged hands/feel, cyphosis, sweating (diaphoresis) |
| Fml pt in ER what kind of symptoms that would say EKG | fatigue when resting, indigestion, sob, bloated |
| Pt prescribed diuretic (loop) for control of htn teach | diet high in K; fluid loss lowers bp so change positions slowly, causes confusion |
| Bacterial meningitis should be doing in plan of care | wash hands, droplet ISO |
| Pt discharged who has epilepsy= fenotonin let pt know | need to wear med alert bracelet, seizure diary, take meds at same time every day, avoid triggers |
| Pt w/ Parkinson what symptoms | Pill rolling motion, shuffling gait, tremors, no facial expressions |
| Cataracts what would you expect to see | Blurred vision, halo effect |
| Pneumonia temp resp 30 bp 130/76 hr 100 O2 stat 91% | give Oxygen, get sputum culture, give antibiotics, give antipyretic for fever |
| Left sided HF s/s | Dyspnea, orthopnea, nocurnal dyspnea, fatigue, displaced apical pulse, S3 heart sound (gallop), pulmonary congestion (dyspnea, cough, bibasilar crackles), frothy sputum, altered mental status, oliguria (decreased urine output). |
| Right sided HF s/s | Jugular vein distention, ascending dependent edema, abdominal distention, ascites, fatigue, weakness, nausea and anorexia, polyuria at rest (nocturnal), liver enlargement (hepatomegaly) and tenderness, and weight gain |
| Pt has multiple sclerosis early onset what are the s/s | Fatigue is the first symptom, sensitivity to temp, stiffness in extremities Flexor spasms esp at night, deep tendon reflexes, positive Babinski’s reflex, and absent abdominal reflexes. |
| Pt has status epilepticus what drug/drugs (seizure longer than 5 minutes) | Diazepam (valium, lorazapama), Phenytoin (Dilantin) |
| Tonic seizure | Tonic-clonic seizure= lasts 1-2 min, but not more than 5, alteration in vision, smell, or emotional feeling. Tonic Phase: Stiffening of muscles, loss of consciousness, cessation of breathing, dilated pupils, and development of cyanosis. |
| Clonic Phase Seizure | Rhythmic jerking of extremities, irregular resp, biting of the cheek or tongue, bladder/bowel incontinence. |
| Postictal Phase | May last for several hours; unconsciousness may last for 30 minutes. Pt awakens slowly and is usually confused and disoriented. PT often reports headache, fatigue, and muscle aches. Pt may not have memory of what happened just before the seizure. |
| Absence seizure | Most common in children; loss of consciousness lasting a few seconds, blank staring, and automatisms (behaviors that pt are unaware of, such as lip-smacking or picking at clothes). Resumes baseline neuro function, with no apparent sequelae. |
| Partial or focal/local seizure | Seizure activity begins in one cerebral hemisphere. |
| Complex partial seizure | Have associated automatisms, loss of consciousness for several minutes, amnesia may occur immediately prior to and after the seizure. |
| Simple partial seizure | Consciousness is maintained throughout. Activity may consist of unusual sensations, a sense of déjà vu, autonomic abnormalities (change in HR) unilateral abnormal extremity movements, and or offensive smell. |
| Unclassified or idiopathic Seizures | Don’t fit into other categories. These types account for 50% of all seizure activities, and occur for no known reason. |
| Guillain-Barre syndrome | is a disorder causing demyelination and axonal degeneration resulting in acute, ascending and progressive neuropathy, characterized by weakness, paranesthesia and hyporeflexia. |
| Client has lump in breast; tearful scheduling mammogram; what do you tell her? | a. Explore feelings – reassure b. Unless there is a relative – it may be benign |
| Endometriosis patient – married and children – thinks she’s infertile | a. Not always infertility |
| Age 20 – endometriosis s/s | a. Pain with intercourse b. Pain while on period |
| Finasteride for 4 weeks – no reduction in symptoms what should you tell the patient? | a. It can take up to months for results to be seen |
| Benign prostatic hyperplasia pt is having difficulty urinating what should you tell pt? | a. Prostate is providing pressure on the urethra |
| Nurse doing an assessment there is a lesion – smooth integrated area | a. Put on gloves |
| Syphilis precautions | a. Gloves when touching skin |
| Pelvic inflammatory disease from gonorrhea – sterility cause? | a. Could cause scaring in fallopian tubes b. Untreated for long time |
| Disease process – ectopic pregnancy cause | Pelvic inflammatory disease |
| Bacterial meningitis – plan of care | a. Plan to monitor for tachycardia b. Provide emesis basin c. Administer antipiuretic medication d. Skin assessment e. Elevate head of the bed d/t increased risk for ICP |
| Phenytoin – instructions | a. Don’t drive until 6 months’ seizure free b. Medical alert bracelet c. Seizure frequency diary d. Avoid triggers e. Take medicine as prescribed |
| Prevention of resp complications in parkinson’s patient | a. Head of bed 30 degrees or more to prevent aspiration |
Created by:
acacianero
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