Hesi study set
taking it at bedtime does
self testicular exam
pap-spears and mammograms
increased fluid intake will treat hypercalcemia
a hard, rigid abdomen and an elevated WBC count this is a medical emergency
Aspirin inhibits platelet aggregation and won’t help prevent sickle cell crisis. Hydroxyurea is prescribed for some people to help prevent sickle cell crisis. High altitudes increase oxygen demand and therefore can also precipitate a crisis. Tobacco, alcohol, and dehydration can precipitate a sickle cell crisis and should be avoided.
Before obtaining a sample for HIV testing, the nurse should make sure that an informed consent form has been signed. The nurse should explain why she is obtaining the sample — in this case, for HIV testing, not for routine testing. Gloves are necessary to obtain the sample. Eye protection should also be worn if splashing is likely. The client should be informed of the test results whether they are positive or negative.
In a client with AIDS, deterioration of the central nervous system (CNS) can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Dysfunctional grieving may be relevant in AIDS, these diagnoses don’t take precedence for a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective tissue perfusion: cerebral isn’t
1. ^ Initially apply cold.
2. ^ Instruct the client to elevate the ankle for 48 to 72 hours.
3. ^ Provide crutch gait training.
4. X Tell the client that pain typically worsens 24 hours after the injury.
5. ^ If needed, apply an elastic bandage from the toes to midcalf.
1. Medially in the antecubital space
2. Midway between the superior iliac spine and symphysis pubis
3. ^ On the inner aspect of the ankle, below the medial malleolus
4. Along the top of the foot, over the instep
google posterior tibial pulse images
1. ^ Lying supine
2. Lying on the stomach
3. Lying on the left side
4. Lying on the right side
1. Administer sleeping medication before bedtime.
2. Ask the client each morning to describe the quality of sleep during the previous night.
3. Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation.
4. ^ Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
3. ^ Lag
1. Relaxation techniques that aid in reducing pain by releasing muscle tension and relieving anxiety
2. Distraction techniques to help block the painful stimuli
3. Guided imagery to assist with blocking out uncomfortable stimuli
4. ^ Self-education about methods to assist in becoming pain-free
1. A respiratory rate of 24 breaths/minute with accessory muscle use
2. ^ Clear breath sounds and non-labored respirations
3. Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds
4. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds
1. ^ “Have you noticed a change in your memory?”
2. “Have you noticed a change in your muscle strength?”
3. “Have you had any coordination problems?”
4. “Have you had any problems with your eyes?”
1. Adding air decreases pain caused by the injection.
2.^ Adding air prevents the drug from flowing back into the needle track.
3. Adding air prevents the solution from entering a blood vessel.
4. Adding air ensures that the client receives the entire dose.
1. Preventing the spread of the infection
2. ^ Debriding the wound
3. Keeping the wound moist
4. Reducing pain
Select all that apply:
1.^ Notifying the client’s primary physician
2. ^ Covering the wound with saline-soaked sterile gauze
3. Giving the client a dose of antibiotics
4. Ordering an abdominal binder from the supply department
5. Pushing the organs back into the abdomen
6. Covering the wound with sterile gauze
1. keeping the chest drainage system below the level of the chest.
2. keeping the head of the bed slightly elevated.
3. ^ checking and taping all connections.
4. checking patency of the chest tube.
1. Perform gentle passive range-of-motion exercises.
2. Gently massage the painful joints.
3. ^ Use a bed cradle to keep linens off the joints.
4. Encourage position changes in bed every 2 hours.
1. Inadequate vitamin D intake
2.^ Inadequate protein intake
3. Inadequate massaging of the affected area
4. Low calcium level
1. Secure the elastic band tightly around the client’s head.
2. ^ Assist the client to the semi-Fowler position if possible.
3. Apply the face mask from the client’s chin up over the nose.
4. Loosen the connectors between the oxygen equipment and humidifier.
1. Increasing fluids to 2,500 ml/day
2. ^ Teaching the client how to deep-breathe and cough
3. Improving airway clearance
4. Suctioning the client every 2 hours
*manage time and resources supervise
*prioritize, and maintain ethical, legal, and quality assurance standards
*prevent errors, accidents, and injuries
*report unusual events
*maintain standard precautions, medical and surgical asepsis, and security
*health promotion and screening
*self-care and family interaction patterns
*disease prevention and family planning
*coping mechanisms and crisis intervention
*end-of-life concepts, and sensory or perceptual alterations
*spiritual influences and cultural awareness
*Basic care and comfort
*Reduction of Risk
*assist with mobility, nutrition, and hydration
*administer medication safely
*decrease risk, prevent complications
*maintain fluid and electrolyte balance
*PERFORM FOCUSED ASSESSMENT
Nursing Diagnosis- *ASSIST THE RN IN FORMULATING RELEVANT NURSING DIAGNOSIS
*COLLECT ADDITIONAL DATA WHEN NECESSARY
*PARTICIPATE IN DETERMINATION OF HEALTH TEAM’S ABILITY TO MEET CLIENT’S NEEDS
*SELECT APPROPRIATE NURSING INTERVENTIONS BASED ON THE CARE PLAN
Implementation- *DELIVER BASIC AND PREVENTIVE NURSING CARE AND CLIENT EDUCATION BASED ON THE CARE PLAN AND THE PN SCOPE OF PRACTICE
Response- *INCLUDES POTENTIAL OR ACTUAL HEALTH RESPONSE
*DESCRIBES MEASURABLE OUTCOMES THAT CAN BE DERIVED
*CITIES POTENTIAL FOR CHARGES BASED ON NURSING ACTIONS
*EXAMPLE: ALTERATION IN COMFORT, PAIN
Etiology- *INCLUDES POTENTIAL HEALTH RESPONSE
*ADDRESSES INDEPENDENT, INTERDEPENDENT, AND DEPENDENT NURSING FUNCTIONS
*EXAMPLE: RELATED TO FRACTURED LEFT ANKLE
touching without permission, with or without the intent to do harm, e.g., hitting or striking a client. If a mentally competent adult is forced to have treatment he/she has refused, battery occurs
Invasion of Privacy
LIBEL: Written statement that may cause harm to a person’s reputation
SLANDER: Verbal statement that may cause harm to a person’s reputation
and small meals in the evening.
a) Offer softer consistencies and
moisten dry food.
b) Position the patient upright
with his or her head slightly
forward when eating and
drinking, using compensatory
maneuvers (chin tuck, head
turn) as necessary.
c) Discourage talking and eating
at the same time and avoid
distractions while eating.
d) Review principles of nutrition
and basic food groups so
patients can select foods that
provide a balanced diet.
b. Consult with a dietitian to determine
nutritious food choices.
c. Consult with a speech pathologist to
determine the safest, most effective
Nursing recommendation: Nurses
should adopt the previous protocols to
facilitate swallowing, avoid aspirations,
and optimize nutritional and fluid status
C. Nursing management of fatigue
Batenjany, Koopman, & Ricci, 2008)
A. Symptom description to be obtained during the
2. Quality or character of the weakness
3. Quantity or severity of the weakness
4. Timing (onset, duration, frequency) of
the weakness and relation to medication
5. Setting in which weakness occurs and/or
6. Aggravating or trigger factors (e.g., change
in emotional state, heat, humidity, infection,
7. Alleviating factors (e.g., rest)
B. Assessment techniques (Table 2 and Table 3)
(Howard, 2008; MGFA, 2000)
1. Ocular muscles
a. Eyelids for ptosis, diplopia (double
vision), extraocular muscles
2. Bulbar muscles
a. Chewing, swallowing, speech
3. Facial muscles
a. Flattening of the nasolabial fold, smile
symmetry, facial expression, resistance
to eyelid and lip closure, inability to
puff out cheeks
4. Head and neck muscles
a. Head drop
5. Limb muscles
care with attention to all systems and ventilatory
support and institution of measures
to minimize neuromuscular blockade.
a. Plasma exchange or IV
b. Identification and removal of offending
be knowledgeable in the differentiation of
the two different types of MG crises, myasthenic
crisis or cholinergic crisis, and
should recognize that both are care priorities.
In either situation, nurses should
perform a complete respiratory and neuromuscular
assessment, which is essential to
identify ineffective respiratory function and
impaired gag and swallow, and initiate the
appropriate airway-management strategies
and oxygen delivery (Level 3) (Vassar et al.,
3. Assess and document respiratory status,
rate, rhythm, and breath sounds.
4. Assess gag and cough reflexes and quality
of voice; notify the physician of changes
5. Obtain baseline FVC (normal > 60 mg/kg).
6. Obtain NIF (normal > -70 cmH2O) and
continue to monitor (Mehta, 2006; Vassar
et al., 2008).
nursing management for fatigue and energy conservation; stress-reduction techniques, pacing all activities, increased rest or sleep, and aerobic exercise; remain physically active; Identify self-care techniques and develop strategies to decrease activity intolerance and risk for injury and promote energy conservation at home, at work, and in the community. Use interdisciplinary team to screen for depression, need for PT, and/or OT; provide for periods of rest when planning activities; Use consistent routines, allowing for sufficient time; Assess a patient’s abilities and restrictions to carry out daily activities including ADLs. Assess for weakness and/or visual impairment associated with self-care deficits and the need for assistive devices.
A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body’s first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don’t take precedence because they aren’t as life-threatening as infection.
Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
The client with irritable bowel syndrome needs to be on a diet that contains at least 25 grams of fiber per day. Fatty foods are to be avoided because they may precipitate symptoms
Opioids may mask changes in the level of consciousness (LOC) that indicate increased ICP and shouldn’t be given. Saying acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate. Aspirin is contraindicated in conditions that may cause bleeding, such as trauma, and for children or young adults with viral illnesses because of the danger of Reye syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his LOC.
Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client’s urine output is adequate.
An acute addisonian crisis is a life-threatening event caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison’s disease is at risk for infection; however, reducing infection isn’t a priority during an addisonian crisis. Impaired physical mobility and Imbalanced nutrition: Less than body requirements are also appropriate nursing diagnoses for the client with Addison’s disease, but they aren’t priorities during a crisis.
Because of the weight of the flaccid extremity, the shoulder may disarticulate. A sling will support the extremity. The other options won’t support the shoulder.
The nurse should show the client how to check his pulse rate. The client should be instructed to check his pulse rate before and after using his nebulizer and to call the physician if his pulse rate increases by more than 30 beats/minute. The nurse should instruct the client to use his nebulizer exactly as prescribed. Using the nebulizer more often than prescribed can cause the drug to lose effectiveness, or to produce uncomfortable adverse effects. The client should also be instructed to notify his physician if his shortness of breath worsens, the drug becomes less effective, or he develops palpitations, nervousness, or a hypersensitivity reaction such as a rash
Expressing concern about the parents’ feelings is the most appropriate response. False reassurance, such as telling parents not to worry, isn’t helpful. Encouraging parents to look at how ill other children are also isn’t helpful because the focus of the parents is on their own child. Asking what the concern is reinforces the parents’ concern without addressing it.
Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative isn’t a type of evaluation.
Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and strength have no effect on drug absorption. The amount of body fat at the injection site may help determine the size of the needle and the technique used to localize the site; however, it doesn’t affect drug absorption (unless the nurse inadvertently injects the medication into the subcutaneous tissue instead of the muscle).
• Say to the client, “You’re feeling upset about the news you got about the transplant.”
Silence is a therapeutic communication technique that allows the nurse and client to reflect on what has taken place or been said. By waiting quietly and attentively, the nurse encourages the client to initiate and maintain a conversation. By reflecting the client’s implied feelings, the nurse promotes communication. Using such platitudes as “We all have days when we don’t feel like going on” fails to address the client’s needs. The nurse should not leave the client alone because he may harm himself. Reminding the client of the treatment frequency doesn’t address his feelings.
Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn’t occur in DVT.
Recognizing an individual’s positive health measures is very useful. General health in the previous 10 years is important; however, the current activities of an 85-year-old client are most significant in planning care. Family history of diseases for a client in later years is of minor significance. Marital status information may be important for discharge planning but isn’t as significant for addressing the immediate medical problem.
The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. The nurse should also encourage the client to sleep in a darkened room that’s well ventilated and at a comfortable temperature. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if commonsense interventions fail.
Encouraging the client to verbalize her thoughts will help her to problem-solve. Telling her not to stop taking the medication is too directive and doesn’t encourage exploration on the part of the client. Asking the client if her husband understands the importance of taking the medication conveys negative judgment. Asking if the client has discussed the issue with her physician might be appropriate, but it may also give the impression that the nurse doesn’t want to discuss the problem with the client.
Having someone who has had a similar surgery and concerns speak to the client would be beneficial. The client is coping normally and doesn’t need professional help at this time. Discussing the concerns with the client’s husband doesn’t address the client’s needs. In fact, the client may feel that the nurse violated confidentiality.
Drugs administered intradermally (injected between the skin layers just below the surface stratum corneum) diffuse slowly into the local microcapillary system. Slow diffusion is necessary during diagnostic allergy testing because rapid introduction of an allergen into a sensitive client could cause a life-threatening allergic reaction.
The nurse should delay the administration for 30 minutes after the client finishes eating because food interferes with the drug’s absorption. The nurse should then document in the medication administration record the exact time that the medication was administered. Administering the medication with 8 oz of water won’t facilitate absorption. The medication shouldn’t be withheld, just delayed.
In depersonalization disorder, the client feels detached from his body and mental processes. The client is usually oriented to time, place, and person. Unexpected and sudden travel to another location is one of the characteristics of dissociative fugue. Clients with depersonalization disorder commonly feel the outside world has changed.
A client in alcohol withdrawal should be medicated with a benzodiazepine, such as lorazepam, to prevent progression of symptoms to alcohol-withdrawal delirium, a life-threatening withdrawal syndrome. Disulfiram is used during early recovery, not during detoxification. Progressive muscle relaxation isn’t particularly effective during withdrawal. Close monitoring during withdrawal is appropriate after the client has been medicated for withdrawal symptoms.