Adaptive Exam HARD (boardvitals)

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ATI: BOARD VITALS

34 terms m_c_e_1Preview Boardvitals 81 terms tkuritzPreview ATI comprehensive predictor STUDY...198 terms h_trtPreview Board V 111 terms Sha A pregnant client in the 3rd trimester calls the OB office and reports to the nurse that she has had several headaches for the past 2 days. Which nursing actions is most appropriate?

• Ask the client is having cold/flu symptoms
• advice the client to eliminate coffee and other sources

of caffeine

• Instruct the client to take two aspirins and lie down for

a hour

• Request the client come to the office immediately

4: REQUST THAT THE CLIENT COME TO THE OFFICE IMMEDIATLY

--- A persistent heachache may be due to pregnancy induced hypertension (PIH) Which procedure is most often consented to with an implied client consent?A- A MRI with contrast B- A minor surgical procedure C- Tube thoracostomy D- Administration of an IM injection

D- ADMIN. OF IM INJECTION

Types of consent: Implied, Expressed, Verbal, Written

Implied: routine procedures (vitals BS check, IM injection) consent as result of admission.Major procedures- (MRI, intubation, diagnostic tests) need written consent -Client must e competent, informed of the procedure and risks. Must be given voluntarily, without coercion.

Nurse manager implementing a procedural change using Lewin's stages of change theory. Which action should the nurse manager plan to take during the MOVING stage of change?A- Identify the problem B- Inform the charge nurses that a change to establish procedures is needed C- Require the charge nurses to comply with the new procedures D- Set target date for the implement of the new procedure

D- SET TARGET DATE FOR IMPLEMENT OF THE NEW PROCEDURE

2nd stage of Lewin's change theory is the moving stage. During the moving stage, the nurse manager should develop the plan for change and set the target date +task associated: -develop a plan for introducing (including goals, objectives and strategies) -Include all team members who will be affected -identify those who support the change and those that are resistant -set a target date -implement the strategies -offer support and encouragement

THREE STAGES: 1st- Unfreezing (identify the problem, determine need for change

then obtain buy-in from the members of the group) 2nd- Moving 3rd- Refreezing stage (focus on integration of the new procedures with the charge nurses) Which of the following are elements of tier 1 of infection control? SATA A- Placing a client in a private room B- using negative pressure C- Wearing gloves when coming into contact with blood/body fluids D- Performing hand hygiene between clients E- Bagging contaminated laundry before removing it from the room

C- WEARING GLOVES

D- PERFORMING HAND HYGEINE

E- BAGGING CONTAMINTATED LAUNDRY

*Precautions to prevent the spread of infection (two tiers) Tier 1- standard precautions during ANY client care.Tier 2- Specific precautions against transmission (airborne, or droplet precautions) Epidemiologically important pathogenic organisms may require second-tier precautions (contact, droplet, airborne IN ADDITION to standard precautions) A RN is assessing a client with anemia due to folic acid deficiency. Which of the following may have caused the clients condition? SATA A- Dementia B- Gastric Ulcer C- Crohns D- Methotrexate E- Aspirin

C- CROHNS

D- METHOTREXATE

Folic acid/ folate known as vitamin B9. Involved in the synthesis of adenosine, guanine, and thymine components of DNA Causes MEGALOBLASTIC anemia. ( large, abnormal red blood cells)

Symptom: anorexia, weight loss, weakness, sore tongue, headache, palpations,

irritability000 and behavioral disorders Causes of folic deficiency: heavy alcohol, smoking, intake of medications such as metformin & methotrexate. GI disorders (Crohns & celiac) Dialysis, hemorrhage, and hemolytic anemia (prevents utilization of folate)

TX: involves supplementation

A nurse is positioning a client after a liver biopsy. Which of the following is the correct position?Liver biopsy is done at the bedside. Clients with liver disease reduce production of vitamin K dependent clotting factors II, VII, X and XI with prolonged bleeding as a result. Vitamin K may be prescribed several days before Biopsy needles is inserted into the liver through the 7th intercostal space while the client is in supine position. Instruct client to Inhale and exhale deeply several times before holding the breath for approximately ten seconds Instruct the client to right-sided lying position after the position after the procedure (puts pressure on the site to prevent bleeding)

According to the American academy of pediatrics, which of the following development health screening should be performed on the 24-month-old child? SATA A- Weight for length

B- BMI

C- Head circumference D- Autism screening E- Behavioral assessment

B= BMI

C- HEAD CIRCUMFERENCE

D- AUTISM SCREENING

E- BEHAVIORAL SCREENING

Developmental screening is an important part of the comprehensive health appraisal of a child. -Tools that are used to provide reliable and objective markers of developmental functions include the Denver Developmental Screening Test and the Denver II

• By 24 month, a child support should have a well-child exam including several

components to check the child's developmental health: Weight and BMI,

measurement of head circumference, screening for autism and behavioral assessment RN is informing a client entering perimenopause. Which of the following is true? SATA A- Vaginal rugae increases B- Vaginal pH increases C- Vaginal lubrication increases D- Vasomotor instability occurs E- Estrogen increases F- Vulvar tissue atrophies G- Pelvic pain

B- VAGINAL PH INCREASES

D-VASOMOTOR INSTABILITY OCCURS

F- VULVAR TISSUE ATROPHIES

Cessation of messes. Unavoidable life event in a women's life. This is due to a increase of hormone estrogen.S/S- erratic menstrual cycles, valvular tissue atrophy, rising of vaginal pH, dec in vaginal rugae Psychological Symptoms- moodiness, nervousness, insomnia, anxiety, inability to concentrate & depression. Hot flashes and night sweats are physiological reactions from DEC in estrogen

• primary symptoms- vasomotor symptoms, sleep difficulties and mood

problems.Client with end stage renal disease, receiving hemodialysis. Which of the following should the nurse include in the plan of care. SATA A- Monitor the clients weight daily B- Encourage the client to comply with fluid restrictions C- Evaluate intake and output D- Instruct the clients about restricting calories for carbohydrate E- Monitor the client for elevated potassium levels.

A- WEIGH THE CLIENT DAILY

-determine fluid retention

B- ENCOURAGE THE CLIENTS TO COMPLY WITH FLUID RESTRICTIONS

-helps to slow fluid retention

C- EVALUATE INTAKE AND OUTPUT

-increase in fluid retention

E- MONITOR THE CLIENTS FOR ELEVATED K LEVEL

-depends on urinary output, GFR decreases, the excretion of K decreases Carbohydrates are not restricted for a client who has ESKD ESKD will require close monitoring of calories, protein, sodium, K and fluids to determine adequate levels

A 65 year old client with poorly controlled diabetes.Admitted to the hospital. During intake the nurse notes right hand appears deformed A- Peyronie's contractures B- Muscular dystrophy deformities C- Dupuytren's contracture D- Ehlers- Danlos syndrome deformity C- Dupuytren's contracture In this condition the fingers are bent, in the direction of the palm and cannot be extended.Develops from fibromatosis in the palm. Characterized by progressive fibrosis of the palmar fascia, beginning with a nodule in the palm.

Rationale:

A- Peyronie's disease refers to an acquired, localized fibrotic disorder of the tunica albuginea of the penis.B- Variety of types of muscular dystrophy D- Ehlers-Danhos syndrome is characterized by skin hyperextensibility, joint hypermobility and tissue fragility -Dupuytren contracture should be advised to apply heat. ROM exercises should be performed several times a day The RN administering ethacrynic acid (Edecrin) for a client with decompensated heart failure. Which of the following are true about this drug? SATA A- Weigh should be taken daily B- It does not affect urine output C- It is taken orally D- Administer with NSAID E- It is ototoxic F- It is best administer at bedtime

A- WEIGH SHOULD BE TAKEN DAILY

E- IT IS OTOXIC

Loop diuretic. Prescribed to reduce/eliminate fluid in the body by inhibiting sodium and chloride reabsorption at the loop of Henle in the kidneys.Weigh should be assessed before, during after administration IV.Taken with meals to avoid GI disturbances. Administered in the morning and in late afternoon to prevent Nocturia that might occur is administered at bedtime Take Ethacrynic acid as directed and take missed doses as soon as possible Drug may cause orthostatic hypotension, implement fall precautions Normal Hemodynamic measurementsCVP- 1-8 mmHg Pulmonary artery wedge pressure- 4-12 Pulmonary artery diastolic - 5-15 Pulmonary artery systolic pressure- 15-26 RN is assessing a client for silent aspiration in a client with neurogenic disorder that is experiencing dysphagia.Which manifestation indicates silent aspiration A- Displays continual tongue rolling while eating B- Attempts to rapidly swallow with each breath C- Displays no coughing when food enters the airway D- Attempts to regurgitate food after swallowing

C- DISPLAYS NO COUGHING WHEN FOOD ENTERS THE AIRWAY

Also, the client will have manifestations of silent aspiration within 24 hours, such as aspiration pneumonia A client is admitted to the hospital for acute gastritis and ascites secondary to chronic alcohol disorder and

cirrhosis. It is important for the RN to assess client for:

A- Blood in stool B- Food intolerance C- Complaints of nausea D- Hourly urine output

A- BLOOD IN THE STOOL

Erosion of blood vessels may lead to hemorrhage, a life threatening situation further complicated by dec prothrombin production, which occurs with cirrhosis Clients with cirrhosis, or other liver disease are at risk for multiple medical complications: bleeding from the esophagus or stomach, ascites (fluid buildup in the abdomen) encephalopathy, edema, bacterial infections of the peritoneum (gut lining) and liver cancer