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VERIFIED SOLUTIONS!!
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NGN: What assessment findings are consistent with Crohn's disease, ulcerative colitis, or
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peritonitis?
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Temperature (100F) r
Weight (-9.7 lbs) r r
Albumin level (2.4) r r
WBC (14) r
Bowel pattern (freq. loose stools)
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Abdominal pain location (RLQ) r r r
Heart rate (105) - Correct Answer - Temperature: Crohn's, UC & peritonitis.
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-Elevation can occur with all three due to inflammation and infection.
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Weight: Crohn's & UC. r r r r
-Unintended weight loss can occur due to malabsorption in the GI tract.
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Bowel pattern: Crohn's.
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-If the patient reported there was blood in the stool, it would be UC. Crohn's doesn't cause
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tarry stools.
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WBC: Crohn's, UC & peritonitis.
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-Elevation can occur due to inflammation and infection.
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Heart rate: peritonitis.
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-Tachycardia can occur due to inflammation, infection, and dehydration.
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Albumin level: Crohn's & UC. r r r r r
-Because of the malabsorption in the GI tract, the body isn't receiving enough protein.
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Abdominal pain location: Crohn's. r r r r
,-Because it is in the RLQ, it is more consistent with Crohn's. With patients that have
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peritonitis, they experience generalized abd. pain that radiates to the shoulder and back.
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NGN: What assessment findings can indicate a transfusion reaction in a patient receiving
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blood?
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Urine output (150mL of clear, yellow)
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Skin (pale, cool and dry)
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Anxiety
Vital signs (within normal range)
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Headache
Back pain - Correct Answer - Back pain, headache & anxiety.
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Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain,
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tachycardia, dyspnea, hypotension.
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NGN: Patient arrives with palpitations, difficulty breathing, and reports feeling faint.
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Reports constipation and joint pain for x2 days. In childhood, patient experienced physical
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abuse, and emotionally detached parents. Reports nervousness and only leaving home
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when necessary.
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PMH: freq. hospital visits due to headaches and GI distress.
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Bowtie: - Correct Answer - Condition: somatic symptom disorder
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-due to physical inactivity & joint pain
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Interventions: Monitor physical manifestations & assess for presence of 2nd gains from r r r r r r r r r r r
their illness
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-disorder is characterized by the presence of other real manifestations like dizziness,
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nausea, back pain, and joint pain.
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Monitor: Vital signs & pain. r r r r
NGN: What actions should the nurse take when her pedi patient is exhibiting symptoms of
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an allergic reaction?
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Administer 0.9% NS IV r r r
Administer epi IM r r
Monitor urine output q2hrs r r r
DC supplemental oxygen
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Monitor vital signs frequently r r r
DC IV medication - Correct Answer - Administer 0.9% NS IV
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Administer epi IM r r
Monitor vital signs frequently r r r
DC IV medication
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-Nurse should DC the Rocephin and give IV NS to help restore fluids because fluid shifts
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can occur quickly during a reaction. Administering epi IM is the first line of therapy for
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anaphylactic reactions because it constricts blood vessels and dilates bronchioles.
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Monitoring vital sings frequently will allow the nurse to monitor for signs of shock.
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,NGN: What 5 actions should the nurse plan to take with a patient experiencing
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hallucinations, following alcohol withdrawal?
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Administer thiamine r
Maintain a low-stimulation environment r r r r
Administer chlordiazepoxide r
Initiate seizure precautions
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Perform a CIWA-Ar r r
Administer disulfiram - Correct Answer - Administer thiamine r r r rr r r r
Maintain a low-stimulation environment r r r r
Administer chlordiazepoxide r
Initiate seizure precautions
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Perform a CIWA-Ar r r
-Nurse should plan interventions that keep the patient safe and treat the physical
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manifestations of withdrawal. Use the CIWA-Ar to determine the severity of the
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withdrawal. Withdrawal seizures can occur 12-24hrs after cessation of alcohol use,
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therefore initiate seizure precautions to prevent injury. Administer chlordiazepoxide (a
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benzodiazepine) and place patient in a low-stim environment to decrease agitation and
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the risk for seizures. Administering thiamine can prevent Wernicke syndrome.
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NGN: A post-op patient is experiencing right lower extremity pain and itching, following an
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emergent appy. Reports right lower extremity pain that has been intermittent for x2
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months.
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Assessment: Bilat lower extremities warm to touch, pedal pulses 2+ bilat. Spider veins
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noted. Distended veins noted on right lower extremity. Vital signs are within normal limits.
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Bowtie: - Correct Answer - Condition: Varicose veins.
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-due to edema & pruritis
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Interventions: Elevate extremity & apply compression stockings r r r r r r
-to promote venous return & circulation
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Monitor: Pruritis & edema r r r
NGN: Which assessment findings require an immediate follow-up in a schizophrenic
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patient?
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Hyperactive bowel sounds x4 r r r
Last HCP appointment was 6 months ago
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Client AO x2 r r
Agitated
Speech disorganized r
Involuntary tongue movement and foot tremor r r r r r
Increase in urination and one episode of incontinence
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Family c/o increased agitation and delusions - Correct Answer - Involuntary tongue
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movement and foot tremor
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, Frequent urination and incontinence r r r
Increase in agitation r r
-Patient is experiencing tardive dyskinesia r r r r
A home health nurse is evaluation a school-age child who has cystic fibrosis. The nurse
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should initiate a request for a high-frequency chest compression vest in response to
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which of the following parent statements?
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A. "My child doesn't like to sit still for nebulizer treatments."
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B. "I think that my child has been running a fever over the last couple of days."
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C. "My child only has a small amount of mucus after percussion therapy."
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D. "I am concerned about my child's future participation in team sports." - Correct Answer
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- C. "My child has only a small amount of mucus after percussion therapy."
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-The nurse should recommend a high-frequency vest for a child who has inadequate
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results from other airway clearance therapy techniques. Older children often require other
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techniques in addition to percussion and postural drainage to achieve adequate mucus
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expectoration.
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-The nurse should teach the parent techniques for administration for nebulizer treatments
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to the child.
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-The nurse should follow-up on reports of fever, as this could indicate a pulmonary
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infection.
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-The nurse should discuss participation in sports activities in relation to the child's current
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physical and pulmonary health.
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NGN: A patient who is x2 post-op, following a surgical repair of a left hip fracture, is c/o of
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intermittent abdominal pain. Rates 5/10 on left side of abdomen. Pain began after eating
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dinner. Last bowel movement was 5 days prior. Reports usual pattern is x1 daily.
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Assessment: Abdomen distended, dull to percussion, firm and non-tender on palpation. r r r r r r r r r r
Hypoactive bowel sounds x4. Vital signs are within normal limits.
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Bowtie: - Correct Answer - Condition: Intestinal obstruction
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-bowel sounds hypoactive x4, last BM was 5 days prior, intermittent to constant pain.
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Interventions: Assist patient in semi-Fowler's & prepare to administer IV fluids. r r r r r r r r r r
-to relieve the pressure from the distention and reduce risk of developing fluid/electrolyte
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imbalance.
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Monitor: Bowel sounds & urine output. r r r r r
A nurse is caring for a patient who has a new prescription for clonidine. The nurse should
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inform the patient that which of the following findings is an adverse effect of this
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medication?
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