1. Clients at risk for DVT: Remaining still for hours, sitting for long periods of time,
anything that prevents circulation
2. Prevention of falls: - Handrails in bathrooms
- Ramps instead of stairs
- Wear rubber sole shoes
- Avoid scatter rugs
- Prevent clutter
- Avoid slippery floors
3. Glaucoma teaching and pathophysiology: - Increased intraocular pressure in
a hollow organ.
- When the intraocular pressure increase it leads to compression of the retinal blood
vessels and photoreceptors and their nerve fibers resulting in hypoxemia and death
of the tissue and loss of vision.
- Assure the patient can administer own eye drops correctly
- Keep follow-up appointments every 1-3 months to evaluate the IOP.
- If the patient had surgical treatment be sure to educate on the S&S of hemorrhage
and detachment including severe pain, and vision loss. These should be reported
immediately to HCP.
4. Prioritization of care for a fracture: - Maintain perfusion, improve comfort, and
prevent impaired mobility
5. Cast education and assessment: - Handle with the palms of your hands, have
patient report painful "hot spots" under the cast which might indicate area of pres-
sure necrosis, instruct patient to never put anything down into the cast, encourage
the patient/family to smell the area for mustiness or unpleasant odor (if ignored the
patient may develop a fever).
- Assess skin color and temperature, sensation, mobility, pain, capillary refill, and
pulses distal to the fracture site. CMS- circulation, movement, and sensation.
6. Osteomyelitis prevention and treatment methods: - Infection of the bone. May
be acute or chronic.
- Educate about medications, encourage compliance and to follow regimen (take full
course of medications), inform about signs and symptoms, provide comfort during
rest and with positioning, assist in ADL, coordinate physical therapy while in the
hospital to help improve mobility especially after surgery, provide mobility assistance
devices.
7. Test to determine open vs closed angle glaucoma: - Gonioscopy is used
when elevation intraocular pressure is diagnosed to determine if the glaucoma is
open-angle or closed-angle. It allows the visualization of the angle where the iris
meets the cornea.
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, Rasmussen MDC Exam 2 with Verified Answers
8. Neurovascular assessment: - CMS: circulation, mobility, sensation. Assess skin
color, temperature, sensation, mobility, pain, capillary refill, and pulses.
9. Pain assessment: - P: Palliative, Q: Quality, R: Region, S: Scale, T: Time
10. Bunions (hallux valgus): - The great toe shifts laterally, and the first metatarsal
head of the great toe enlarges
- Pain especially when shoes are worn
- Treatment: custom made shoes or surgery
11. Priority assessments for immobile patients: - Perform passive ROM exercis-
es for patients who are immobile
- Turn and reposition every 2 hours
- Assess for skin redness
12. Tinnitus: - A continuous ringing or noise perception in the ears.
13. Hyperopia: Also called farsightedness. Occurs when the eye does not refract
light enough. As a result, images actually converge behind the retina. Distant vision
is normal, but near vision is poor.
14. Immobility consequences on the respiratory system: - Decreases all muscle
strengths including the lungs, increases secretion (aspiration pneumonia is a risk),
decrease ventilation capacity in response to exercise, respiratory depth decreases
affecting ventilation, air passage blockage can lead to atelectasis (collapse of air
sacs or alveoli).
15. Hemiplegia: Paralysis of one side of the body
16. Paraplegia: Paralysis of the lower portion of the trunk and both legs
17. Paresis: Partial or incomplete paralysis
18. quadriplegia: Paralysis of all four extremities.
19. Two-point gait: - Used for partial weight-bearing, both feet; faster, but less
support than a 4-point gait.
20. Three-point gait: Non-weight bearing; faster than a 4-point gait; can use with a
walker
21. Four-point gait: Used for partial weight-bearing, both feet; patient must shift
weight constantly.
22. Eye drop administration education: - Step 1: Be in an upright position with
head slightly tilted back
- Step 2: Don procedure gloves
- Step 3: Cleanse the edges of the eyelid from the inner canthus to the outer canthus.
- Step 4: Gently rest the dominant hand on the forehead.
- Step 5: With the nondominant hand, pull the lower lid down to expose the conjunc-
tival sac.
- Step 6: Position the eye dropper about 1.5 to 2.0 cm above the patient's eye. Ask
the patient to look up, and drop the prescribed number of drops into the conjunctival
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