HESI NURSING EXIT EXAM Part II

HESI NURSING EXIT EXAM Part II Myxedema coma - CORRECT ANSWER-extreme hypothyroidism(abrupt med cessation), rare with a high mortality rate = decreased cardiac output leads to decreased tissue perfusion which leads to brain and organ depletion leading to multiorgan failure Myxedema coma treatment - CORRECT ANSWER-Replace thyroid hormone with Levothyroxine and give stress dose hydrocortisone; watch electrolytes, warm slowly and give ventilator support if needed Which adaptation of the environment is most important for the nurse to include in the plan of care for a pt with Myxedema? - CORRECT ANSWER-Maintain a warm temperature in the pt's room Levothyroxine for Hypothyroidism - CORRECT ANSWER-+take first thing in the morning before eating +monitor HR +hold if HR is > 100 bpm The nurse suspects a Post-op thyroidectomy pt may have had the inadvertent removal of the parathyroid when the pt begins to experience which symptoms? - CORRECT ANSWER-+tingling of the lips, hands & toes +positive Chvostek's sign +harsh, vibratory sounds on inspiration A pt is admitted to the hospital with a diagnosis of Addison's crisis. The nurse places a peripheral saline lock. Regarding which prescriptions should the nurse question the HCP? - CORRECT ANSWER-+K+ 20 mEq in 100 mL Saline IV over 60 min +10% Calcium chloride 5 mL IV over 10 min TX for adrenal insufficiency will be D5NS, Hydrocortisone, & Dextrose Addison's disease - CORRECT ANSWER-+hyposecretion of cortisol & aldosterone +S/SX: hypovolemia, hypoglycemia, hyponatremia & hyperkalemia Cushing's syndrome - CORRECT ANSWER-+caused by prolonged exposure to high levels of glucocorticoids +S/SX: moon face, buffalo hump, hypertension, abdominal striae, truncal obesity +hyperglycemia, hypernatremia, hypocalcemia, hypokalemia A 52-yo pt who had an abdominal hysterectomy for cervical adenocarcinoma in situ is preparing for discharge. Which recommendation about women's health & screening exams should the nurse offer? - CORRECT ANSWER-Continue the annual Pap smear & mammogram, biannual clinical breast exams, & monthly breast self-examinations After discontinuing hormone replacement therapy HRT, a 76-yo pt reports she is experiencing increased vaginal discomfort during intercourse. What action should the nurse take? - CORRECT ANSWER-Suggest the use of a vaginal cream or lubricant STDs include: - CORRECT ANSWER-Chlamydia Candidiasis Trichomoniasis Herpes genitalia Human Papillomavirus Gonorrhea Syphilis Acquired immunodeficiency syndrome HIV A pt who had a vaginal hysterectomy the previous day is saturating perineal pads with blood & requires frequent changes during the night. What is the nurse's priority action? - CORRECT ANSWER-Monitor the pt's VS q2h. The pt should not need a pad changed more than 1 pad q4h After removing a pt's Foley, how many hours can they safely go without urinating? - CORRECT ANSWER-+6-8 hrs w/o voiding after Foley removal The nurse assigned to the women's health unit received the morning report. Which pt should the nurse assess first? - CORRECT ANSWER-A 49-yo pt 1 day Post-vaginal hysterectomy who is saturating pads every 3 hours Prostatitis - CORRECT ANSWER-+fever, chills, back pain, dysuria, frequency, cloudy urine +need blood cultures, UA, WBC count & PSA +TX: ABX & anti-inflammatories +from frequent STIs Erectile dysfunction - CORRECT ANSWER-+inability of an adult male to achieve an erection; impotence +TX: Sildenafil; may cause Hypotension; contraindicated in pts taking NTG Which pt must be assessed first? - CORRECT ANSWER-38-yo male who is "increasingly stuporous" after an aneurysm repair Glasgow Coma Scale - CORRECT ANSWER-+eye opening, motor response, verbal response Max=15 pts, below 7= coma Neurological vital signs - CORRECT ANSWER-Pupil size, Limb movement, VS Late S/SX of Decreasing LOC: Cushing's triad - CORRECT ANSWER-+r/t ICP (HTN, Bradycardia, Widening pulse pressure, DEC RR, febrile) +can be decorticate or decerebrate ICP GOAL - CORRECT ANSWER-<20 mm Hg +Mannitol & Steroids to reduce swelling +sometimes Barbituates are used to induce coma +avoid Narcotics! Which change in the status of a pt being treated for increased ICP warrants immediate action by the nurse? - CORRECT ANSWER-Pt's pulse changes from 88 to 68 bpm (Cushing's Triad) MAP - ICP = CPP - CORRECT ANSWER-Cerebral Perfusion Pressure > 70 mm Hg The nurse is planning a class on stroke prevention for pts with HTN. What info is most important to provide to the class? - CORRECT ANSWER-Medication compliance During the evaluation, which assessments indicate an early sign of increased ICP for a pt newly diagnosed with a cerebral vascular accident? - CORRECT ANSWER- +alteration in the ability to respond to questions +alteration in the ability to respond to verbal stimuli Ischemic stroke - CORRECT ANSWER-+a clot that may be a thrombus or embolus, causing obstruction of blood flow to the neurons Hemorrhagic stroke - CORRECT ANSWER-+occurs when a blood vessel in the brain leaks or ruptures; also known as a brain bleed +may be subarachnoid or intracranial TIA - CORRECT ANSWER-transient ischemic attack....mini stroke, no dead tissue Late signs of a pt diagnosed with a CVA - CORRECT ANSWER-HR of 50 bpm, BP 192/60 FAST - CORRECT ANSWER-Face-droops, Arms-can't lift, Speech-can't talk, Time- call 911 tPA must be administered within _________________ hours of onset - CORRECT ANSWER-3-4.5 The nurse is planning a class on stroke prevention for pts with HTN. What info reflects accurate prevention measures that the pts can undertake? - CORRECT ANSWER- +eliminate tobacco products +limit salt intake to 1500 mg/day +walk up to a mile per day Which pt should be assigned to a graduate nurse orienting to the neurological unit? - CORRECT ANSWER-A pt with multiple sclerosis who needs the first dose of Interferon The nurse is providing safety education to a pt diagnosed with Parkinson's who is prescribed Carbidopa-Levodopa. The nurse knows that safety education has been effective when the pt verbalizes which statement? - CORRECT ANSWER-+I will apply sunscreen when I walk outdoors +I will remember to keep hydrated & monitor urine output Parkinson's disease - CORRECT ANSWER-+A disorder of the central nervous system that affects movement, often including tremors +pill rolling +rigidity +bradykinesis +NO PROTEIN, limit grains, thicken liquids The nurse is caring for a pt hospitalized with Guillain-Barre' Syndrome (destruction of the myelin sheath from the feet up). Which info would be most important for the nurse to report to the HCP? - CORRECT ANSWER-*A decrease in cognitive status TX: HOB @ 45 degrees, Plasmapheresis, Vented, IV Immunoglobulin MS - CORRECT ANSWER-Demyelination of the CNS due to chronic inflammation There will be flares & remissions, but no cure TX: Corticosteroids, Interferon, Immunosuppressants, muscle relaxants for spasticity Myesthenia Gravis - CORRECT ANSWER-+worsens with exercise and improves with rest +ACH receptors fill up & become impaired +pt tires easily, no cure To diagnose: IV Tensilon Test TX: Anticholinesterase Agents, "Mestinon" +sit upright when eating & 1 hr afterward +chin down to swallow Golden Hour in a Spinal Cord Injury - CORRECT ANSWER-+A, B, Cs! +RESP status (patent airway) +NEURO status +Vitals! +Immobilize! Stabilize! +Mannitol & Betamethasone to stop cerebral swelling +ABOVE C8 = Quadri/Tetriplegia +BELOW C8 = Paraplegia Autonomic Dysreflexia: occurs in pts with spinal cord injuries at or above T6 - CORRECT ANSWER-"I have the worst headache I've ever had in my life!!"(potentially life-threatening emergency!) HOB @ 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (triggers) administer Nitrates or Hydralazine (may cause stroke, MI, seizures) +assess for Paralytic Ileus Which action by the UAP requires immediate f/u by the nurse? - CORRECT ANSWERAccompanying a pt who has lupus erythematosus to sit outside in the sun during a break Pt with Lupus cannot sit in the sun Fractures: assess for the 5 P's - CORRECT ANSWER-Pain, Pallor, Pulselessness, Paresthesia, Paralysis The nurse is assessing a pt who is scheduled for surgical fixation of a compound fracture of the right ulna. Which finding should the nurse report to the HCP? - CORRECT ANSWER-Paresthesia distal to the fracture site A post-menopausal woman with a BMI of 19 has come to the clinic for her annual wellwoman exam. Which teaching plan topic is most important for the nurse to prepare for this high-risk pt? - CORRECT ANSWER-Osteoporosis TX: Alendronate (Fosamax) after taking, no food, & remain upright for 30-60 min The nurse is conducting an osteoporosis screening clinic at a health fair. What info should the nurse provide to individuals who are at risk for osteoporosis? - CORRECT ANSWER-+limit alcohol & stop smoking +perform weight-bearing exercises +implement home safety to prevent falls +Vitamin D supplementation Rheumatoid arthritis (RA) - CORRECT ANSWER-+chronic systemic disease characterized by autoimmune inflammatory changes in the connective tissue throughout the body +starts in small joints bilaterally +DEC ROM +Diagnosed with an erythrocyte sedimentation rate +blood test to determine presence of Rheumatoid Factor RA drug therapy protocol: - CORRECT ANSWER-High-dose ASA or NSAIDS Prednisone DMARDS: Methotrexate, Sulfasalazine or Plaquenil Lupus Erythematosus - CORRECT ANSWER-+collagen autoimmune disorder {Butterfly rash} (1) discoid affects skin & face only (2) systemic affects all body systems +Triggers: sun, stress, drugs, pregnancy, infectious agents +Kidney involvement is the leading cause of death +Cardiac involvement is the 2nd leading cause The nurse observes an older male pt with glaucoma administer eye drops by tilting his head back, instilling each drop close to the inner canthus, & keeping his eye closed for 15 seconds. What action should the nurse take first? - CORRECT ANSWER-+Review the correct steps of the procedure with the pt +After instilling eye drop, press on inner canthus for five minutes, both sides +TX: 4 different eye drops per day The nurse is teaching an 86-yo pt who has glaucoma & bilateral hearing loss. Which intervention should the nurse implement? - CORRECT ANSWER-Speak in a lower tone of voice Ototoxic drugs - CORRECT ANSWER--NSAIDS, aspirin, aminoglycosides, vancomycin, erythromycin, loop diuretics (like furosemide), the anti-malarial medications, sildenafil (tadalafil, vardenafil) and cisplatin Hearing trauma: exposure to loud or prolonged noise - CORRECT ANSWER-+hearing loss will occur at > 90 decibels A pt with a Hx of Myesthenia Gravis presents with a HR of 112 bpm, RR 24 with accessory muscle use, anxiety, & restlessness. Which intervention demonstrates best practice? - CORRECT ANSWER-HOB @ 45 degrees Administer 2 L O2 per prescription The nurse directs the UAP to play with a 4-yo child on bed rest. Which activity should the nurse recommend? - CORRECT ANSWER-Checkers, Hand puppets, Coloring book A parent is preparing her 5-yo child for kindergarten. The child has not had any immunizations. What vaccines will be given to start school? - CORRECT ANSWERDTaP, Inactivated Polio Virus, & Varicella A 7-yo is to have a painful procedure. Which statement by the nurse best prepares the child to cope with this? - CORRECT ANSWER-"Sometimes this feels like pushing." Assess a child's pain utilizing FLACC & FACES scales - CORRECT ANSWER-Face, Legs, Arms, Cry, Consolability What vaccines would the nurse expect to be prescribed for a 2-month-old brought into the pediatrician's office for a well-baby checkup? - CORRECT ANSWER-DTaP, Hep B, HIB, IPV, & PVC A nurse is caring for a 6-yo child who had a tonsillectomy 2 hours ago. Which sign or symptom most likely relates to a complication? - CORRECT ANSWER-Frequent swallowing; place child in a side-lying position or prone