Adult Health 2 Final
14. The triage nurse receives a call from a network member who is riding an subconscious pal
with a couple of injuries after a motorcycle accident to the sanatorium. The caller states that
they will be arriving in 1 minute. In coaching for the patient's arrival, the nurse will gain
a. A liter of lactated Ringer's solution.
B. 500 ml of five% albumin.
C. Two 14-gauge IV catheters.
D. A retention cathete - ANS-Correct Answer: C
Rationale: A affected person with multiple trauma may additionally require fluid resuscitation to
prevent or treat hypovolemic surprise, so the nurse will assume the need for two large bore IV
traces to manage ordinary saline. Lactated Ringer's solution should be used carefully and could
not be ordered until the patient had been assessed for viable liver abnormalities. Although
colloids can also every so often be used for quantity growth, it's miles normally time-honored
that crystalloids ought to be used because the preliminary therapy for fluid resuscitation. A
catheter could likely be ordered, but inside the 1 minute that the nurse has to reap supplies, the
IV catheters could take prio
6. A affected person with Bell's palsy refuses to consume while others are present due to
embarrassment approximately drooling. The satisfactory response via the nurse to the affected
person's behavior is to
a. Appreciate the affected person's desire and set up for privateness at mealtimes.
B. Provide the patient liquid dietary supplements at frequent durations.
C. Talk the patient's worries with visitors who arrive at mealtimes.
D. Educate the affected person to chew food at the unaffected aspect of the mouth. -
ANS-Correct Answer: A
Rationale: The affected person's preference for privateness need to be reputable to encourage
good enough nutrients and decrease affected person embarrassment. Liquid dietary
supplements will lessen the patient's entertainment of the flavor of food. It might be irrelevant for
the nurse to talk about the affected person's embarrassment with traffic until the affected person
needs to proportion this data. Chewing on the unaffected facet of the mouth will enhance
vitamins and leisure of meals but will not decrease the drooling.
A 22-12 months-vintage patron with quadriplegia is fearful and flushed, with a blood pressure of
210/100 and a coronary heart charge of 50 bpm. Which of the following nursing interventions
need to be finished first?
A.) Place the patron flat in bed
b.) Assess patency of the indwelling urinary catheter
c.) Give one SL nitroglycerin pill
,d.) Raise the top of the mattress right now to ninety ranges - ANS-d.) Raise the pinnacle of the
mattress right away to 90 tiers
Rationale:
Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are
signs of autonomic dysreflexia, normally because of such noxious stimuli along with a complete
bladder, fecal impaction, or decubitus ulcer. Putting the consumer flat will reason the blood
stress to boom even greater. The indwelling urinary catheter ought to be assessed right now
after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't
used for high blood pressure or dysreflexia.
A 22-year-antique affected person is delivered to the ICU following a motorbike accident
resulting in a C5 fracture. Cervical traction has been hooked up. During the preliminary section
of care, the nurse is most involved approximately his respiratory function because
A. At the C5 degree there may be general lack of diaphragmatic and intercostal muscle
characteristic
B. Extension of edema at the web page of harm may also affect phrenic nerve feature
C. Without stomach muscle manipulate, he can't effectively cough to clear his lungs
D. Immobilization of the patient spine with cervical traction promotes pooling of respiration
secretions - ANS-B. Extension of edema on the site of damage may have an effect on phrenic
nerve characteristic
A 24-year-vintage patient is hospitalized with the onset of Guillain-Barré syndrome. During this
segment of the patient's contamination, the maximum critical evaluation for the nurse to perform
is
a. Monitoring the cardiac rhythm constantly.
B. Determining the extent of recognition q2hr.
C. Comparing sensation and energy of the extremities.
D. Acting steady assessment of respiratory feature. - ANS-Correct Answer: D
Rationale: The maximum severe hardship of Guillain-Barré syndrome is respiratory failure, and
the nurse must display breathing feature constantly. The different tests will also be blanketed in
nursing care, but they are no longer as important as breathing assessment.
A 28-12 months-antique affected person has newly diagnosed multiple sclerosis and asks many
questions on the sickness. In the nurse's rationalization of the procedure of more than one
sclerosis, which records is most accurate?
A. Multiple sclerosis is an untreatable viral ailment that destroys the basal ganglia within the
mind.
B. Nerve impulses tour too speedy over nerves that have lost their myelin coat, overloading the
brain
C. An autoimmune system reasons slow destruction of the myelin sheath of nerves in the brain
and spinal cord
,D. In more than one sclerosis, antibodies are produced towards acetycholine receptors,
resulting in blocked muscle contraction - ANS-C. An autoimmune process reasons gradual
destruction of the myelin sheath of nerves within the mind and spinal twine
A 28-year-antique affected person has lower back home following considerable rehabilitation for
a C8 spinal wire harm. The home care nurse visits and notices that the affected person's mom
and husband are appearing some of the activities of every day living that the patient become
handling during rehabilitation. Which action via the nurse is maximum appropriate right now?
A. Recognize that it's far vital for the own family to be worried in her care and guide their sports
B. Unclude the mother and husband in developing a plan of care to growth the patient's
independence
C. Tell the mother and husband to stop acting care that the patient can do herself
D. Suggest to the affected person that she do her very own care as she has been taught -
ANS-B. Unclude the mother and hysband in growing a plan of care to growth the patient's
independence
A 32-year-antique woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To
compare the patient's expected response to this remedy, what is maximum crucial for the nurse
to evaluate?
A Improved skin turgor
b Decreased cardiac fee
c Improved finger perfusion
d Decreased imply arterial pressure - ANS-c Improved finger perfusion
Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most
often regarding the palms and ft. Diltiazem (Cardizem) is a calcium channel blocker that relaxes
clean muscular tissues of the arterioles through blockading the influx of calcium into the cells,
hence decreasing the frequency and severity of vasospastic assaults. Perfusion to the fingertips
is improved and vasospastic assaults decreased. Diltiazem may additionally decrease heart
charge and blood strain, but that is not the cause in Raynaud's phenomenon. Skin turgor is
most often a reflection of hydration reputation.
A 32-yo bodily therapist is admitted to the sanatorium with possible deep vein thrombophlebitis.
Her left calf is swollen and smooth to the touch. Physician orders include duplex ultrasound
scanning left leg, bed relaxation with feed improved, and BRP for BM's only.
Duplex ultrasound scanning confirms the presence of a deep vein thrombosis, and the doctor
orders continuous IV heparin infusion. Which intervention does the nurse plan at the same time
as the affected person is receiving the heparin infusion?
A. Have diet K available in case the patient bleeds from the movement of heparin.
B. Teach the patient to given herself subcutaneous heparin injections for long-term domestic
therapy.
C. Maintain strict mattress rest to prevent accidental trauma.
, D. Notify the physician if the PTT cost is more than 180 seconds. - ANS-d. Notify the health
practitioner if the PTT cost is more than one hundred eighty seconds.
A 32-yo physical therapist is admitted to the health center with viable deep vein
thrombophlebitis. Her left calf is swollen and gentle to touch. Physician orders include duplex
ultrasound scanning left leg, mattress relaxation with feed elevated, and BRP for BM's simplest.
Which approach should the nurse use to elevate the affected person's feet?
A. Elevate the foot of the mattress above the extent of her heart.
B. Place pillows under the calf of her affected leg.
C. Gatch the bed on the knee and area pillows under her toes.
D. Place one pillow beneath her thighs and two pillows underneath her lower legs. - ANS-a.
Elevate the foot of the bed above the level of her heart.
A 38-yr-antique woman has newly diagnosed more than one sclerosis (MS) and asks the nurse
what will happen to her. What is the nice reaction through the nurse?
A. "You may have either intervals of assaults and remissions or development of nerve harm
through the years."
b. "You need to plot for a continuous loss of movement, sensory capabilities, and intellectual
competencies."
c. "You will maximum probably have a constant course of continual progressive nerve harm with
the intention to change your
personality."
d. "It is common for human beings with MS to have an acute attack of weak spot and then not to
have another symptoms
for years." - ANS-a. "You could have either durations of attacks and remissions or development
of nerve harm through the years."
Most sufferers with a couple of sclerosis (MS) have
remissions and exacerbations of neurologic dysfunction or a relapsing-remitting initial course
followed through development with or without occasional relapses, minor remissions, and
plateaus that progressively purpose loss of motor, sensory, and cerebellar capabilities.
Intellectual feature usually stays intact but patients can also experience anger, depression, or
euphoria. A few humans have chronic progressive deterioration and some may also experience
simplest occasional and mild signs and symptoms for numerous years after onset.
A 39-12 months-old female with a records of smoking and oral contraceptive use is admitted
with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory
test should the nurse assessment to evaluate the anticipated impact of the heparin?
A. Platelet depend
B. Activated clotting time (ACT)
C. International normalized ratio (INR)
D. Activated partial thromboplastin time (APTT) - ANS-D. APTT
14. The triage nurse receives a call from a network member who is riding an subconscious pal
with a couple of injuries after a motorcycle accident to the sanatorium. The caller states that
they will be arriving in 1 minute. In coaching for the patient's arrival, the nurse will gain
a. A liter of lactated Ringer's solution.
B. 500 ml of five% albumin.
C. Two 14-gauge IV catheters.
D. A retention cathete - ANS-Correct Answer: C
Rationale: A affected person with multiple trauma may additionally require fluid resuscitation to
prevent or treat hypovolemic surprise, so the nurse will assume the need for two large bore IV
traces to manage ordinary saline. Lactated Ringer's solution should be used carefully and could
not be ordered until the patient had been assessed for viable liver abnormalities. Although
colloids can also every so often be used for quantity growth, it's miles normally time-honored
that crystalloids ought to be used because the preliminary therapy for fluid resuscitation. A
catheter could likely be ordered, but inside the 1 minute that the nurse has to reap supplies, the
IV catheters could take prio
6. A affected person with Bell's palsy refuses to consume while others are present due to
embarrassment approximately drooling. The satisfactory response via the nurse to the affected
person's behavior is to
a. Appreciate the affected person's desire and set up for privateness at mealtimes.
B. Provide the patient liquid dietary supplements at frequent durations.
C. Talk the patient's worries with visitors who arrive at mealtimes.
D. Educate the affected person to chew food at the unaffected aspect of the mouth. -
ANS-Correct Answer: A
Rationale: The affected person's preference for privateness need to be reputable to encourage
good enough nutrients and decrease affected person embarrassment. Liquid dietary
supplements will lessen the patient's entertainment of the flavor of food. It might be irrelevant for
the nurse to talk about the affected person's embarrassment with traffic until the affected person
needs to proportion this data. Chewing on the unaffected facet of the mouth will enhance
vitamins and leisure of meals but will not decrease the drooling.
A 22-12 months-vintage patron with quadriplegia is fearful and flushed, with a blood pressure of
210/100 and a coronary heart charge of 50 bpm. Which of the following nursing interventions
need to be finished first?
A.) Place the patron flat in bed
b.) Assess patency of the indwelling urinary catheter
c.) Give one SL nitroglycerin pill
,d.) Raise the top of the mattress right now to ninety ranges - ANS-d.) Raise the pinnacle of the
mattress right away to 90 tiers
Rationale:
Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are
signs of autonomic dysreflexia, normally because of such noxious stimuli along with a complete
bladder, fecal impaction, or decubitus ulcer. Putting the consumer flat will reason the blood
stress to boom even greater. The indwelling urinary catheter ought to be assessed right now
after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't
used for high blood pressure or dysreflexia.
A 22-year-antique affected person is delivered to the ICU following a motorbike accident
resulting in a C5 fracture. Cervical traction has been hooked up. During the preliminary section
of care, the nurse is most involved approximately his respiratory function because
A. At the C5 degree there may be general lack of diaphragmatic and intercostal muscle
characteristic
B. Extension of edema at the web page of harm may also affect phrenic nerve feature
C. Without stomach muscle manipulate, he can't effectively cough to clear his lungs
D. Immobilization of the patient spine with cervical traction promotes pooling of respiration
secretions - ANS-B. Extension of edema on the site of damage may have an effect on phrenic
nerve characteristic
A 24-year-vintage patient is hospitalized with the onset of Guillain-Barré syndrome. During this
segment of the patient's contamination, the maximum critical evaluation for the nurse to perform
is
a. Monitoring the cardiac rhythm constantly.
B. Determining the extent of recognition q2hr.
C. Comparing sensation and energy of the extremities.
D. Acting steady assessment of respiratory feature. - ANS-Correct Answer: D
Rationale: The maximum severe hardship of Guillain-Barré syndrome is respiratory failure, and
the nurse must display breathing feature constantly. The different tests will also be blanketed in
nursing care, but they are no longer as important as breathing assessment.
A 28-12 months-antique affected person has newly diagnosed multiple sclerosis and asks many
questions on the sickness. In the nurse's rationalization of the procedure of more than one
sclerosis, which records is most accurate?
A. Multiple sclerosis is an untreatable viral ailment that destroys the basal ganglia within the
mind.
B. Nerve impulses tour too speedy over nerves that have lost their myelin coat, overloading the
brain
C. An autoimmune system reasons slow destruction of the myelin sheath of nerves in the brain
and spinal cord
,D. In more than one sclerosis, antibodies are produced towards acetycholine receptors,
resulting in blocked muscle contraction - ANS-C. An autoimmune process reasons gradual
destruction of the myelin sheath of nerves within the mind and spinal twine
A 28-year-antique affected person has lower back home following considerable rehabilitation for
a C8 spinal wire harm. The home care nurse visits and notices that the affected person's mom
and husband are appearing some of the activities of every day living that the patient become
handling during rehabilitation. Which action via the nurse is maximum appropriate right now?
A. Recognize that it's far vital for the own family to be worried in her care and guide their sports
B. Unclude the mother and husband in developing a plan of care to growth the patient's
independence
C. Tell the mother and husband to stop acting care that the patient can do herself
D. Suggest to the affected person that she do her very own care as she has been taught -
ANS-B. Unclude the mother and hysband in growing a plan of care to growth the patient's
independence
A 32-year-antique woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To
compare the patient's expected response to this remedy, what is maximum crucial for the nurse
to evaluate?
A Improved skin turgor
b Decreased cardiac fee
c Improved finger perfusion
d Decreased imply arterial pressure - ANS-c Improved finger perfusion
Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most
often regarding the palms and ft. Diltiazem (Cardizem) is a calcium channel blocker that relaxes
clean muscular tissues of the arterioles through blockading the influx of calcium into the cells,
hence decreasing the frequency and severity of vasospastic assaults. Perfusion to the fingertips
is improved and vasospastic assaults decreased. Diltiazem may additionally decrease heart
charge and blood strain, but that is not the cause in Raynaud's phenomenon. Skin turgor is
most often a reflection of hydration reputation.
A 32-yo bodily therapist is admitted to the sanatorium with possible deep vein thrombophlebitis.
Her left calf is swollen and smooth to the touch. Physician orders include duplex ultrasound
scanning left leg, bed relaxation with feed improved, and BRP for BM's only.
Duplex ultrasound scanning confirms the presence of a deep vein thrombosis, and the doctor
orders continuous IV heparin infusion. Which intervention does the nurse plan at the same time
as the affected person is receiving the heparin infusion?
A. Have diet K available in case the patient bleeds from the movement of heparin.
B. Teach the patient to given herself subcutaneous heparin injections for long-term domestic
therapy.
C. Maintain strict mattress rest to prevent accidental trauma.
, D. Notify the physician if the PTT cost is more than 180 seconds. - ANS-d. Notify the health
practitioner if the PTT cost is more than one hundred eighty seconds.
A 32-yo physical therapist is admitted to the health center with viable deep vein
thrombophlebitis. Her left calf is swollen and gentle to touch. Physician orders include duplex
ultrasound scanning left leg, mattress relaxation with feed elevated, and BRP for BM's simplest.
Which approach should the nurse use to elevate the affected person's feet?
A. Elevate the foot of the mattress above the extent of her heart.
B. Place pillows under the calf of her affected leg.
C. Gatch the bed on the knee and area pillows under her toes.
D. Place one pillow beneath her thighs and two pillows underneath her lower legs. - ANS-a.
Elevate the foot of the bed above the level of her heart.
A 38-yr-antique woman has newly diagnosed more than one sclerosis (MS) and asks the nurse
what will happen to her. What is the nice reaction through the nurse?
A. "You may have either intervals of assaults and remissions or development of nerve harm
through the years."
b. "You need to plot for a continuous loss of movement, sensory capabilities, and intellectual
competencies."
c. "You will maximum probably have a constant course of continual progressive nerve harm with
the intention to change your
personality."
d. "It is common for human beings with MS to have an acute attack of weak spot and then not to
have another symptoms
for years." - ANS-a. "You could have either durations of attacks and remissions or development
of nerve harm through the years."
Most sufferers with a couple of sclerosis (MS) have
remissions and exacerbations of neurologic dysfunction or a relapsing-remitting initial course
followed through development with or without occasional relapses, minor remissions, and
plateaus that progressively purpose loss of motor, sensory, and cerebellar capabilities.
Intellectual feature usually stays intact but patients can also experience anger, depression, or
euphoria. A few humans have chronic progressive deterioration and some may also experience
simplest occasional and mild signs and symptoms for numerous years after onset.
A 39-12 months-old female with a records of smoking and oral contraceptive use is admitted
with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory
test should the nurse assessment to evaluate the anticipated impact of the heparin?
A. Platelet depend
B. Activated clotting time (ACT)
C. International normalized ratio (INR)
D. Activated partial thromboplastin time (APTT) - ANS-D. APTT
