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ANCC Med-Surg Certification
d - ✔A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of DVT. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96 seconds?a. Increase the heparin infusion flow rate by 2 mL/hrb. continue to monitor the heparin infusion as prescribedc. request a prothrombin timed. stop the heparin infusion a - ✔A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching? a. "you may no longer be able to feel chest pain."b. "your level of activity tolerance will not change."c. "after 6 months, you will no longer need to restrict your sodium intake."d. "you will be able to stop taking immunosuppressants after 12 months." a - ✔A nurse is assess a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect?A. confusionB. friction rubC. hypertensionD. dry skin d - ✔A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?A. administering IV morphine sulfateB. administering oxygen at 2 :/min via nasal cannulaC. helping the client to the bedside commodeD. assisting with thrombolytic therapy D - ✔A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?A. ventricular depolarizationB. Guillain-Barre syndromC. myelodysplastic syndromeD. Valvular disease C - ✔A nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?A. obtain blood samples for laboratory testingB. Tell the client to report vision changesC. Place the head of the bed at 45 degreesD. initiate an IV a - ✔a nurse is caring for a client who has HF and is experiencing AF. The nurse should plan to monitor for and report which of the following findings to the provider immediately?a. slurred speechb. irregular pulsec. dependent edemad. persistent fatigue b - ✔A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find?a. inc abdominal girthb. weak peripheral pulsesc. jugular vein distentiond. dependent edema b - ✔a nurse is caring for a client who is being treated for HF and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as
an adverse effect of these medications?a. SOBb. lightheadednessc. dry coughd. metallic taste c - ✔a nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following findings can indicate cardiac tamponade?a. sternal instabilityb. inc WBC countc. BP 140/82 mmHg on inspiration and 154/90 mmHg on expirationd. sinus rhythm with occasional premature atrial contraction and HR 88/min d - ✔A nurse is preparing a client for coroncary angiography. The nurse should report which of the following findings to the provider prior to the procedure?a. hemoglobin 14. g/dLb. history of peripheral arterial diseasec. urine output 200 mL/4 hrd. previous allergic reaction to shellfish a - ✔A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?a. "I can't get rid of these hiccups."b. "I feel dizzy when i stand."c. "My incision site stings."d. "I have a headache." b - ✔A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching?a. apply the new patch to the same site as the previous patchb. place the patch on an area of skin away from skin folds and jointsc. keep the patch on 24 hr per dayd. replace the patch at the onset of angina c - ✔A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?a. serosanguinous drainage on dressingb. severe pain with coughingc. urine output of 20 mL/hrd. increase in temp from 36.C (98.2F)- 37.5C (99.5F) d - ✔A nurse caring for a client following an abdominal aortic aneurysm resection. Which of the following is the priority assessment for this client?a. neck vein distentionb. bowel soundsc. peripheral edemad. urine output b - ✔A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions?a. delivery of precordial thumpb. vagal stimulationc. administration of atropine IVd. defibrillation a - ✔A nurse is providing discharge teaching for a client who has HF. The nurse should instruct the client to report which of the following findings immediately to the provider?a. weight gain of 2 lb in 24 hrb. inc of 10 mmHg in systolic BPc. dyspnea with exertiond. dizziness when rising quickly c - ✔A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an
✔A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a MI?a. myoglobinb. c-reactive proteinc. creatine kinase- MBd. Homocysteine d - ✔a nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy?a. hemoglobin 14 g/dLb. minimal bruising of extremitiesc. reduced circumference of affected extremityd. INR 2. b - ✔A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following?a. tendon painb. persistent coughc. frequent urinationd. constipation a, b, c - ✔A client is being evaluated in the ED for a possible brain attack (stroke). Assessment findings consistent with a brain attack include which of the following? (select all that apply)a. facial droopb. slurred speechc. weakness of affected extremityd. crackles in lungse. decreased urine output c - ✔A client is admitted with a diagnosis of acute stroke. The provider orders "diet as tolerated." Before feeding this client, which nursing action is priority?a. determine client's food preferencesb. elevate the head of the bed 30 degreesc. assess client's swallowing reflexd. review serum albumin level to determine appropriate diet a - ✔Which of the following recommendations is best for the nurse to suggest to a client as a way to keep BP under control?a. follow a regular exercise programb. attend a stress-reduction support groupc. avoid use of tobacco and limit alcohol intaked. increase intake of fruits and veggies a - ✔which of the following assessment findings indicate to the nurse the client is experiencing left-sided HF?a. fatigue and dyspneab. Cheyne-Stokes breathing and orthostatic hypotensionc. liver tenderness and peripheral edemad. anorexia and dependent edema a, c, e - ✔the nurse is teaching a group of adult clients about risk for coronary artery disease, especially MI. This nurse should instruct this group of clients about which of the following as ways to decrease incidence of CAD and MI? (select all that apply)a. "if you smoke, quit"b. "be sure to consume at least 10% of your calories from saturates fats."c. "Engage in moderate exercise for 20-30 minutes 3-5 times a week."d. "jog at a mild pace for at least one hour a day."e. "check BP regularly." a - ✔Which client response requires a focused GI assessment?a. "I take ibuprofen 600 mg three times a day for arthritis pain."b. "I experienced occasional constipation."c. "I have had dentures for 3 years."d. "spicy foods upset my stomach." b -
✔After abdominal surgery, what is the most reliable assessment that suggests return of peristaltic movement?a. presence of normal bowel soundsb. client report of passing flatusc. client report of hungerd. absence of nausea c - ✔when administering a new medication to an older client, the nurse understands that:a. the dose may need to be increased to greater-than-normal levelsb. close monitoring is needed because toxic levels may developc. the dose may need to be decreased to lower-than-normal levelsd. nausea and vomiting may develop rapidly and are common side effects in older adults d - ✔A 59 year old man was admitted to the hospital with dysphagia, stating that he has been having more difficulty swallowing food, even when he has chewed it throroughly and drinks plenty of water. A CT scan shows an area for a possible esophageal tumor. The client unergoes a biopsy and is awaiting results. The client asks, "what am I going to do if this is cancer?" What is the most appropriate nursing response?a. "You will have surgery to remove it."b. "I would choose to get radiation."c. "The doctor will go over the options with you."d. "You sound as if you are concerned about the biopsy results." b - ✔The client with a long history of osteoarthritis is at risk for developing GERD if he or she:a. weighs 220 poundsb. frequently takes NSAIDs for painc. consumes food with calcium supplementationd. has limited physical mobility a - ✔A priority nursing intervention in the care of a client with a hiatal hernia is:a. providing nutrition educationb. promoting regular exercisec. providing medication educationd. instructing the client on signs and symptoms of intestinal strangulation b - ✔Which assessment variable requires immediate intervention post esophagectomy?a. BP 170/88b. respiratory rate 28c. temp 38.1d. pain 6/ a - ✔An older client diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea, and vomiting, and fatigue for the past 24 hours. The nurse should monitor the client for what priority assessment?a. dehydrationb. hypokalemiac. hypernatremiad. perineal skin breakdown c - ✔A client has recently been placed on corticosteroids as treatment for ulcerative colitis. the nurse should monitor the client's laboratory results for evidence of which condition?a. hypernatremiab. hypercalcemiac. hyperglycemiad. hyperkalemia c - ✔What priority laboratory analysis should the nurse review when caring for a client with Crohn's disease?a. c-reactive proteinb. serum albuminc. hemoglobind. potassium d - ✔A client is admitted to the acute medical client care unit. The nurse reviews her admission lab results. Which result supports a diagnosis of malnutrition?a. serum albumin 3.5 g/dLb. hematocrit 37%c. Hemoglobin 12g/dLd. Prealbumin 13 mg/dL a -
✔A nurse is providing discharge teaching for a client who has chronic cholecystitis. Which of the following food selections by the client indicated the teaching was effective? a. unsalted nutsb. bolognac. cheddar cheesed. bananas a - ✔A nurse is providing discharge for a client who has gastritis and a new prescription for famotidine. Which of the following client statements indicated the teaching was effective?a. "I should make sure the water I drink is filtered."b. "I should expect immediate pain relief after starting this therapy."c. "I will drink iced tea with my meals and snacks."d. "I will monitor by blood glucose level regularly while taking this medication." c - ✔What symptom does the nurse expect the client with intussusception to exhibit?a. decrease in pulseb. extremely elevated body temperaturec. singultus (hiccups)d. frequent bloody stools false - ✔emotional stress is a risk factor for irritable bowel syndrom (IBS)true false d - ✔which ethnic group has a higher incidence of colorectal cancer?a. hispanicb. asianc. caucasiand. african-american b - ✔A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?a. bloody diarrheab. board-like abdomenc. periumbilical cyanosisd. increased bowel sounds a, d, e - ✔a nurse is assessing a client who has appendicitis. Which of the following findings should the nurse expect?a. oral temp 38.4b. WBC 6,000/mm3c. bloody diarrhead. nausea and vomitinge. right lower quadrant pain a - ✔A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which of the following findings as an indication of acute gastric dilation?a. hiccupsb. elevated BPc. bradycardiad. left lower quadrant pain c - ✔A nurse is caring for a client who has hepatic encephalopathy. The client asks the nurse if she can have a larger portion of beef for dinner. Which of the following responses by the nurse is appropriate?a. "Beef is too high in fat, but can i request chicken as a substitute."b. "You need to increase your fluid intake. Would you like beef and noodle soup?"c. "You should limit your animal protein intake. Can I get you a veggie burger instead?"d. "You need to limit calories. Would you like some sugar-free gelatin?" d - ✔Immunity that is developed by vaccination or immunization is known as:a. natural activeb. passive acquiredc. innate/natived. artificial active c - ✔A patient with inflammation has a high eosinophil count. The nurse recognizes that this finding most likely indicated that:a. humoral and cell-mediated immunity is being stimulatedb. the inflammatory response has been stimulated by infectionc. tissue
damage has been caused by an allergen-antibody reactiond. the inflammation has become chronic with persistent tissue damage b - ✔Which cell types associated with the inflammatory response participate in phagocytosis?a. neutrophils and eosinophilsb. macrophages and neutrophilsc. macrophages and eosinophilsd. eosinophils and basophils b - ✔A nurse is providing discharge teaching for a client who has chronic hepatitis C. which of the following statements by the client indicates an understanding of the teaching?a. "I will avoid alcohol until I'm no longer contagious."b. "I will avoid medications containing acetaminophen."c. "I will decrease my intake of calories."d. "I will need treatment for 3 months." c - ✔A nurse is providing discharge teaching for an older adult client who has mild diverticulitis. which of the following client statements indicates an understanding of the teaching?a. "I may experience right lower quadrant pain."b. "I will remain active by working in my garden every day."c. "I should eat foods that are low in fiber."d. "I will use a mild laxative every day." a - ✔A nurse is providing discharge teaching for a client who has GERD. Which of the following client statements indicates the teaching was effective?a. "I will decrease the amount of carbonated beverages I drink."b. "I will avoid drinking liquids for 30 minutes after taking a chew-able antacid tablet."c. "I will eat a snack before going to bed."d. "I will lie down for at least 30 minutes after eating each meal." d - ✔A nurse is reviewing the lab results of a client who has hepatic cirrhosis. Which of the following lab findings should the nurse report to the provider?a. Albumin 4.0 g/dLb. INR 1.5c. Bilirubin 0.2 mg/dLd. Ammonia 180 mcg/dL b - ✔A nurse is providing discharge teaching for a client who has a new prescription for medications to treat peptic ulcer disease. The nurse should identify that which of the following medications inhibits gastric acid secretion?a. calcium carbonateb. famotidinec. aluminum hydroxided. sucralfate b - ✔A nurse is providing teaching about dietary management to prevent dumping syndrome for a client who is post-op following a gastrectomy. The nurse should encourage the client to include which of the following foods in his diet?a. lactose- reduced milkb. eggsc. grape juiced. honey c - ✔A nurse is providing discharge teaching for a client following an ileostomy. The nurse should instruct the client to report which of the following findings to the provider? a. intolerance to high-fiber foodsb. liquid ileostomy outputc. dark purple stomad. sensation of burning during bowel elimination d - ✔A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which of the following findings should the nurse expect?a. negative fecal occult blood
✔A nurse is assessing a client who has upper GI bleeding. Which of the following findings should the nurse expect?a. hypoactive bowel soundsb. epigastric painc. hypotensiond. pernicious anemia a, d, e - ✔A nurse is caring for a client who has ulcerative colitis. The client has had several exacerbation over the past 3 years. Which of the following instructions should the nurse include in the plan of care to minimize the risk of further exacerbation (select all that apply)a. use progressive relaxation techniquesb. increase dietary fiber intakec. drink two 240 mL (8oz) glasses of milk per dayd. arrange activities to allow for daily rest periodse. restrict intake of carbonated beverages d - ✔A nurse is assessing a client immediately following a paracentesis for the treatment of ascities. Which of the following findings indicates the procedure was effective?a. presence of a fluid waveb. increased HRc. equal pre- and post-procedure weightsd. decreased shortness of breath c - ✔A nurse is providing discharge teaching for a client who has a new colostomy and is concerned about flatus and odor. Which of the following foods should the nurse recommend?a. eggsb. fishc. yogurtd. broccoli c - ✔A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider?a. spider angiomasb. peripheral edemac. bloody stoolsd. jaundice d - ✔Which clinical manifestation reported by a client suggests to the nurse that anemia is a possibility?a. difficulty sleepingb. cold hands and feetc. chronic headachesd. shortness of breath a - ✔A nurse is caring for a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. The nurse should monitor for and report which of the following findings immediately to the provider?a. watery diarrheab. vaginitisc. feverd. nausea and vomiting d - ✔A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client is anxious about the upcoming surgery. Which of the following is an appropriate action for the nurse to take?a. sympathize with the clients feelingsb. reassure the client that the surgery will go finec. change the topic of discussiond. provide concise, factual information d - ✔A nurse is providing preoperative teaching for a client. which of the following prescribed medications should the nurse instruct the client to discontinue 48 hours prior to the surgery?a. furosemideb. digoxinc. prednisoned. warfarin a - ✔A nurse is reviewing the medical record of a client who is to undergo general anesthesia for surgery. The nurse should report which of the following findings to the provider?a. K+ level 2.8 mEq/Lb. Na level 140 mEq/Lc. INR 1.5d. BUN 12mg/dL
c - ✔A nurse is caring for a client who is post-op and has a Jackson-Pratt drain in place. Which of the following interventions should the nurse use to ensure proper functioning of the drain?a. secure the drain to the client's bed sheetb. clamp the drain when the client is ambulatingc. empty and compress the drain reservoir as neededd. keep the drain higher than the surgical incision d - ✔A nurse is providing teaching for a client who is scheduled to undergo moderate (conscious) sedation for a bronchoscopy. The nurse should verify that the client understands the procedure when the client states which of the following?a. "I will need to complete a bowel prep the day before the procedure."b. "I will drink plenty of fluids the morning of the procedure."c. "I can eat as soon as the procedure is over."d. "I can expect to feel sleepy for several hours after the procedure." a - ✔A nurse is taking a preoperative medication history on a client who is scheduled for surgery. Which of the following medications should the nurse recognize as placing the client at risk for complications due to interaction with anesthetic agents?a. captoprilb. atorvastatinc. ranitidined. ciprofloxacin c - ✔A nurse is caring for a client who is post-op following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications?a. instruct the client to exhale into incentive spirometer ever 1-2 hrb. minimize amount of pain med the client receives to prevent sedationc. advise the client to splint the surgical incision when coughing and deep breathingd. reposition the client every 8 hours for the first 48 hours b - ✔A nurse is providing preoperative teaching for a client who is scheduled for a mastestomy. Which of the following statements by the client indicated a need for further teaching?a. "I should wait 3-4 weeks after surgery to do water aerobics."b. "Ill wait until a week after surgery to start hand strengthening exercises."c. I should avoid having blood from the arm on the side I had my mastectomy."D. "ill be able to shower after the doctor moves the drain." b - ✔A nurse is providing teaching for a client who is in the immediate post-op period and has a PCA pump. Which of the following statements should the nurse include in the teaching?a. "You will receive a dose of medication every time you push the button."b. "do not allow your family to push the PCA button if you are sleeping."C. " you cannot receive too much medication by pushing the button."d. "Do not push the PCA button until your pain reached a severe level" c - ✔A nurse is assessing a client in the PACU to determine if he is ready for discharge. Which of the following assessment findings indicated that the client is ready for discharge?a. the clients pre-op BP was 140/90 mmHg and her post-op BP is 100/ mmHgb. the client rates her pain at 4 on a 0-10 scalec. the client is able to move all four extremities on commandd. the client requires tactile stimulation a -
✔A nurse is caring for a client who has an NG tube set to continuous low suction following a gastrectomy. Which of the following findings should the nurse report to the provider?a. gastric distentionb. absent bowel soundsc. incisional pain of 9/10d. small amount of bloody drainage in the NG tube c - ✔A nurse is caring for a client during surgery. To help prevent neuromuscular complications during the surgical procedure, the nurse should take which of the following actions?a. administer an IV bolus of normal salineb. massage the client's lower extremities during the procedurec. support the client's bony prominence with foam paddingd. extend the clients joints and maintain position with padded straps b - ✔A nurse is caring for a client who has surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform?a. cut a slit in a 4 inch square gauze pad to place around the drainb. use sterile technique when performing dressing changesc. establish a clamping schedule prior to removald. apply negative pressure when emptying the drain c - ✔A nurse is assessing a client's recovery from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first?a. painb. coldc. touchd. warmth c - ✔A nurse is completing a pre-op assessment for a client who is a jehovah's Witness. Which of the following should the nurse recognize as a situation that could pose special care needs for this client?a. having pre-op blood drawnb. giving info about sexual historyc. providing informed consent to receive blood productsd. receiving care from a nurse of the opposite gender a - ✔A surgical nurse enters the surgical suite to ensure surgical asepsis is maintained. Which of the following observations requires an intervention?a. the scrub tech is wearing a watch under his scrubsb. the circulating nurse opens dressing packages before applying sterile glovesc. the surgeon has her hands folded 5 cm above the waistd. the holding area nurse is performing client education a - ✔A nurse is monitoring a client receiving succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops malignant hyperthermia?a. administer dantroleneb. institute seizure precautionsc. measure blood glucosed. give IV atropine d - ✔A nurse is completing an intial PACU assessment of a client who is post-op following a total knee arthroplasty and received spinal anesthesia. Which of the following findings indicated the need to notify the provider?a. the client states having numbness to the lower extremities bilaterallyb. spinal anesthesia is at T10 levelc. The client rouses to tactile stimulid. the client reports chest pain b - ✔A nurse is preparing a client for surgery. The client appears apprehensive and asks multiple questions about the risks of the procedure. Which of the following actions
should the nurse take before witnessing the client's signing of the informed consent?a. explain the risks and benefits of the surgery to the clientb. ask the surgeon to speak to the client for clarificationc. reassure the client that the procedure is necessary for recoveryd. document the client's lack of pre-op teaching c - ✔A nurse who is working in the surgical suite should check that the rooms are maintained at a cool temp with low humidity to decrease which of the following?a. risk for malignant hyperthermiab. amount of anesthetic agents clients needc. risk of infectiond. amount of oxygen clients need d - ✔A nurse is providing discharge instructions for a client who is post-op following abdominal surgery. Which of the following client statements indicated a need for further teaching?a. "I will call my doctor if I have an increase in temp or wound drainage"b. "I will eat foods high in protein and vitamin C during my recovery"c. "I will complete the entire course of antibiotics."d. "I will remain on bed rest until my follow-up appointment with my doctor." b - ✔A nurse is caring for a client who is post-op following a total hip arthroplasty. Which of the following assessment data indicated the client is at an increased risk for infection?a. use of herbal remediesb. long-term use of corticosteroidsc. excessive exposure to sunlightd. diet high in cholesterol b - ✔A nurse is assessing a client who is 2 days post-op following a total prostatectomy. The nurse notes the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take?a. apply an ice pack to the clients right calfb. elevate the client's right extremityc. administer testosterone to the clientd. gently massage the client's right half c - ✔Which client response during a genitoreproductive history requires further exploration by the nurse?a. "I have had one pregnancy and one child"b. "I began my menses at age 14"c. "I would rather not answer questions about by sex life with my husband."d. "My breasts hurt in the beginning of my menstrual cycle." a - ✔Which ethnic group has a higher frequency of developing testicular cancer?a. caucasianb. african americanc. hispanic/latinod. asian american d - ✔A woman on oral contraceptives reports increasing fatigue and shortness of breath over the past 6 months. The nurse should evaluate the client's diet for deficiency in what nutrients?a. proteinb. vit b1 and folic acidc. vit a and cd. vit b6 and b c - ✔What is the estimated number of deaths in males each year attributed to breast cancer in the US?a. 100b. 225c. 450d. 600 c - ✔A premenopausal woman reports a mass in her right breast. She also has greenish-brown discharge from the nipple, redness and swelling over the mass, and
✔an older male is being evaluated for hydronephrosis. what priority health history question may provide info about a possible cause of this disorder?a. "do you have high BP?"b. "do you have difficulty starting and continuing urination?"c. "do you have a family history of kidney disease?"d. "have you had a recent UTI?" b - ✔The client who has undergone a transurethral resection of the prostate (TURP) is at high risk for developing:a. perforationb. hemorrhagec. infectiond. bladder spasms a - ✔How many American males are estimated to die of testicular cancer annually?a. 350b. 520c. 725d. 1050 Point in RLQ abd of appendix. Tenderness indicates appendicitis - ✔Mc burney's point Place fingers under rt coastal margin and instruct to take deep breath. Increased tenderness with sudden stop during inhalation is a positive murphy's sign - ✔Murphy's sign All assessment used to r/o appendicitis - ✔Obturator muscle, psoas sign, Rovsing's sign Out dated and not recommended to use for assessment for DVT - ✔Homan's sign Pain from a jarring movement to indicate peritonitis with appendicitis. Stand on toes and drop to heals or increaded pain with walking or running - ✔Jar sign(markle sign) Acute cardiac tamponade- pericardial effusion
- Disended neck vein's
- Distant heart sounds
- Hypotention Treatment- pericardiocentesis - ✔Beck's triad
- Nystagmas- repetitive uncontrolled movements of the eyes
- Intention tremor- tremor that worsens as approaches end of intended movement
- Scanning or staccato speech- broken speech and each syllable pronounced separately - ✔Charcot's triad for MS Inf. of bile duct caused by bacteria ascending from junction with duodenum 1.Jaundice
- Fever, usually with rigors
- RUQ ABD pain - ✔Charcot's triad for ascending cholangitis Signs of increased ICP
- HTN- widened pulse pressure
- Bradycardia
- Irregular respirations- cheyne- stokes( slow, fast, slow period of apnea then slow,fast,slow - ✔Cushing's triad
Deep and labored. Presents in severe metabolic acidosis- DKA and kidney failure - ✔Kaussmaul breathing Signs of fat embolism
- Mental status changes
- Petechiae-late sign
- Dyspnea - ✔Bergman's triad Sign of meningitis- supine flex neck will cause involuntary flexion of hips and knees - ✔Brudzinski sign Sign of meningitis- lift flexed knee and slowly extend will cause back pain if positive - ✔Kernig's sign Nerve hyperexcitability (tetany) seen with hypocalemia Abnormal reaction to stimulation of facial nerve Inflate bp cuff to greater than systolic and hand and wrist with involuntarly curl inward - ✔Chvostek's sign Trousseau' sign is positive when a patient is holding a clenched fist over his chest to describe dull, pressing chest pain consistent with the discomfort of angina pectoris. - ✔Levine sign B: Choice B would show a lateral wall MI. Choice A would show an anterior MI. Choice C would show an inferior wall MI. Choice D would show a posterior wall MI. - ✔A patient is diagnosed with a lateral wall ST segment elevation myocardial infarction (STEMI). What do you expect the EKG to show? a. ST elevation in leads V1 -V b. ST elevation in leads I, aVL, V5, V c. ST elevation in leads II, III, aVF d. ST elevation in leads V7, V8, V commonly caused by E.coli in elderly males and/or those who are not sexually active and have normal immune function. In sexually active males with a history of unprotected sex, the causative organisms are likely gonorrhea and/or chlamydia. Cases of epididymitis caused by Staph aureus are rare. Epididymitis caused by cytomegalovirus (CMV) is incredibly rare unless the patient is immunocompromised. - ✔Epididymitis Nimodipine or Nimotop is a calcium channel blocker which causes vasodilation of the blood vessels. is hypervolemia, hypertension, and hemodilution. These three factors will maintain the patency of the vessels, making it difficult for them to vasoconstrict. Vasospasm left unchecked can cause stroke, neurological compromise, and death. - ✔Triple H therapy for Subarachnoid Hemorrhage- induced Vasospasm Adverse effects caused by dx procedure or treatment -
Understand Apply Analyze Evaluate Create - ✔Bloom's Taxonomy(6 levels of learning)
- Cognitive: Learning and gaining intellectual skills and mastering categories of effective learning (knowledge, comprehension, application, analysis, synthesis, and evaluation). ·
- Affective: Recognizing categories of feelings and values from simple to complex (receiving and responding to phenomena, valuing, organizing, and internalizing values). ·
- Psychomotor: Mastering motor skills necessary for independence, following a progression from simple to complex (perception, set, guided response, mechanism, complex overt response, adaptation, and origination). - ✔Bloom's Taxonomy(3 types of learning) Soften impact of longterm ,complex illness/injury - ✔Tertiary Early detection and Treatment to halt or slow progress - ✔Secondary Prevention - ✔Primary Sx to move undescended testicle or resolve testicular torsion - ✔Orchiopexy Removal of one or both testicules - ✔Orchiectomy Sensorimotor (0 -2): Infants learn about cause and effect and the permanence of objects. · Preoperational (2 -7): Thinking is concrete and tangible at the preconceptual stage, and later becomes intuitive. These children are egocentric. Concrete operational (7 -11): Children develop the concept of conservation and reasoning becomes inductive. Formal operational (11 -15): Adolescents develop the ability to use abstract thought and to develop and test hypotheses. - ✔Piaget's stages of Cognitive Development Involuntary movements. May become permanent or become worse. Treatments include stopping the drug that caused it and in some cases Botox injections may be effective - ✔Tardive dyskinesia
- Right task: The nurse determines an appropriate task to delegate for a specific patient. 2. Right circumstance: The nurse has considered all relevant information to determine appropriateness of delegation. ·
- Right Person: The nurse chooses the right person based on education and skills to perform the task. ·
- Right direction: The nurse provides a clear description of the task, purpose, limits, and expected outcomes. ·
5.Right supervision: The nurse must supervise, intervene as needed, and evaluate performance. - ✔"5 rights of delegation" Autocratic leaders make decisions independently and strictly enforce rules. Bureaucratic leaders follow organizational rules exactly and expect others to do so, as well. Laissez-faire leaders exert little direct control and allow others to make decisions with little interference. Participatory leaders present a potential decision and make a final decision based on input from team members. Consultative leaders present a decision and welcome input, but rarely change their decisions. Democratic leaders present a problem and ask the team to arrive at a solution, although these leaders make the final decision. - ✔Types of leadership stress is a body response to demands requiring positive or negative adaptation, characterized by the "generalized adaptation syndrome," which includes 3 stages: · Alarm: Fight or flight response. · Resistance: The body mobilizes to resist a threat, focusing on those organs most involved in an adaptive response. · Exhaustion: As the body is weakened and overwhelmed, organs/systems begin to deteriorate (hypertrophy/atrophy) and can no longer cope with stress, resulting in stress-related illnesses and eventual death. - ✔Selye's biological theory of stress and aging Expressive aphasia- left frontal - ✔Broca's aphasia Receptive aphasia- damage to Lt posterior temporal - ✔Wernicke's aphasia Undescended testicles - ✔Cryptorchidism Decrease in bone density - ✔Osteopenia Causes anemia - ✔Thalassemia major Rare inherited disorder that causes an amino acid called phenylalanine to build up in the body. Treated with strict diet of avoiding foods high in protein. - ✔Phenylketonuria (PKU) Assessment: Collecting data, history, and completing a physical exam. · Diagnosis: Analyzing data, determining needs and problems, and applying a nursing diagnosis. · Planning: Setting priorities, setting goals and expected outcomes, and planning interventions and strategies of care. · Implementation: Applying interventions/treatments. Evaluation: Reassessing and auditing. - ✔Nursing process Preinteraction Phase Assessment: gathering information; assessing one's feelings, fears, and anxieties about working with a particular client
