Comprehensive Predictor Retake Review
Delegation to Assistive Personal - answers - ADLs
- Bathing
- Grooming
- Dressing
- Tioleting
- Ambulating
- Feeding (without swallowing precautions)
- Positioning
- Rountine Tasks
- Bed making
- Specimen collection
- I&O
- Vital Signs ( for stable clients )
Planning Care for a Client Who Has Hypothyroidism - answers - Monitor for low Bp &
bradycardia
- Monitor for chest pain & peripheral edema
- Monitor clients weight
- reorient the client if confusion occurs
- provide frequent rest periods to avoid fatigue & decrease myocardial oxygen demands
- Monitor respiratory status
- encourage client to cough and breathe deeply to prevent pulmonary complications
- low calorie, high fiber diet , & encourage fluids to prevent constipation and promote
weight loss
- Administer cathartics and stool softeners as needed. (Avoid fiber laxatives, interfere
with absorption of levothyroxine)
- Provide extra clothing and blankets for clients who have decreased cold intolerance
- caution use of electric blankets
- Encourage verbalization of feelings and fears about body changes
- Reassure client that most physical manifestations are reversible
- use caution with CNS depressants (barbiturates or sedatives)
Signs of hypothyroidism - answers - Fatigue/ lethargy
- irritability
- intolerance to cold
,- constipation
- weight gain
- pallor
- think brittle fingernails
- depression & apathy
- joint or muscle pain
- bradycardia, hypotension, dysrhythmias
- slow thought process & speech
- hypoventilation & pleural effusion
- thickening of the skin
- hair loss
- thickening of hair on eyebrows
- dry flaky skin
- decreased acuity of taste
- impotence
- abnormal menstrual periods (menorrhagia/ amenorrhea)
- delayed physical and mental growth in children
Medication for hypothyroidism - answers levothyroxin (synthetic thyroid hormone
replacement)
Risk factors for hypothyroidism - answers - females 30 to 60 years of age
- use of lithium & amiodarone medications
- Inadequate intake of iodine
- Radiation Therapy the head and neck
What is hypothyroidism - answers underactive thyroid
Hyperthyroidism risk factors - answers - Graves' disease
- Thyroiditis
- Toxic adenoma
- Toxic nodular goiter
- Exogenous hyperthyroidism
What is hyperthyroidism? - answers overactive thyroid
Signs of hyperthyroidism - answers - nervousness/ irritability
- muscle weakness
- heat intolerance
- weight loss
- insomnia
- irregular menstrual flow
- frequent stools and diarrhea
- decreased libido
- Tremor, hyperkinesia, hyperreflexia
- Exophthalmos
- blurry vision or changes
, - bloodshot appearance of eyes
- Goiter
- Tachycardia, palpitations, dysthymia
- Elevated blood pressure
- dyspnea
Nursing care for hyperthyroidism - answers - minimize clients energy
- promote calm environment
- monitor mental status
- monitor nutritional status
- monitor I&O / weight
- provide eye protection (patches, eye lubricant, tape to close eyelids)
- monitor vital signs and hemodynamic parameters
- reduce room temp
- provide cool shower/ sponge bath
- Report a increased temp of 1*F immediately
- Avoid excessive palpation of the thyroid
Medication for hyperthyroidism - answers - Methimazole
Reinforcing Teaching About Ostomy Care - answers stoma should be moist , shinny,
and pink. The peristomal area should be intact
- use mild soap and water to cleanse the skin, then dry it gently and completely
( moisturizing soaps interfere with adherence of the pouch)
- Apply paste if necessary
- measure and mark the desired size for the skin barrier
- cut the opening 0.15 cm to 0.3 cm ( 1/18 to 1/8) in larger, allowing the stoma to appear
through the opening
- apply barrier paste to creases
Developing a Improvement Plan for Assistive Personnel - answers - performance
should reflect the staff member's job and description
- various sources of data should be collected
- data should be collected over time and not just represent isolated incidents
- actual observed behavior should be documented
- peers can be a valuable source of data
- the employee should be given the opportunity to provide input
- the unit manager to host a private meeting with the staff member
Monitoring the Performance of Assistive Personnel - answers - have ap demonstrate
the tasks before doing it
Reinforcing Teaching About Client Privacy - answers - only health care team members
directly responsible for a clients care can access that client record. Nurses cannot share
info with other clients or staff not caring for the client
- Client have the right to read and obtain a copy of their medical record
- Nurses cannot photocopy any part of a medical record
Delegation to Assistive Personal - answers - ADLs
- Bathing
- Grooming
- Dressing
- Tioleting
- Ambulating
- Feeding (without swallowing precautions)
- Positioning
- Rountine Tasks
- Bed making
- Specimen collection
- I&O
- Vital Signs ( for stable clients )
Planning Care for a Client Who Has Hypothyroidism - answers - Monitor for low Bp &
bradycardia
- Monitor for chest pain & peripheral edema
- Monitor clients weight
- reorient the client if confusion occurs
- provide frequent rest periods to avoid fatigue & decrease myocardial oxygen demands
- Monitor respiratory status
- encourage client to cough and breathe deeply to prevent pulmonary complications
- low calorie, high fiber diet , & encourage fluids to prevent constipation and promote
weight loss
- Administer cathartics and stool softeners as needed. (Avoid fiber laxatives, interfere
with absorption of levothyroxine)
- Provide extra clothing and blankets for clients who have decreased cold intolerance
- caution use of electric blankets
- Encourage verbalization of feelings and fears about body changes
- Reassure client that most physical manifestations are reversible
- use caution with CNS depressants (barbiturates or sedatives)
Signs of hypothyroidism - answers - Fatigue/ lethargy
- irritability
- intolerance to cold
,- constipation
- weight gain
- pallor
- think brittle fingernails
- depression & apathy
- joint or muscle pain
- bradycardia, hypotension, dysrhythmias
- slow thought process & speech
- hypoventilation & pleural effusion
- thickening of the skin
- hair loss
- thickening of hair on eyebrows
- dry flaky skin
- decreased acuity of taste
- impotence
- abnormal menstrual periods (menorrhagia/ amenorrhea)
- delayed physical and mental growth in children
Medication for hypothyroidism - answers levothyroxin (synthetic thyroid hormone
replacement)
Risk factors for hypothyroidism - answers - females 30 to 60 years of age
- use of lithium & amiodarone medications
- Inadequate intake of iodine
- Radiation Therapy the head and neck
What is hypothyroidism - answers underactive thyroid
Hyperthyroidism risk factors - answers - Graves' disease
- Thyroiditis
- Toxic adenoma
- Toxic nodular goiter
- Exogenous hyperthyroidism
What is hyperthyroidism? - answers overactive thyroid
Signs of hyperthyroidism - answers - nervousness/ irritability
- muscle weakness
- heat intolerance
- weight loss
- insomnia
- irregular menstrual flow
- frequent stools and diarrhea
- decreased libido
- Tremor, hyperkinesia, hyperreflexia
- Exophthalmos
- blurry vision or changes
, - bloodshot appearance of eyes
- Goiter
- Tachycardia, palpitations, dysthymia
- Elevated blood pressure
- dyspnea
Nursing care for hyperthyroidism - answers - minimize clients energy
- promote calm environment
- monitor mental status
- monitor nutritional status
- monitor I&O / weight
- provide eye protection (patches, eye lubricant, tape to close eyelids)
- monitor vital signs and hemodynamic parameters
- reduce room temp
- provide cool shower/ sponge bath
- Report a increased temp of 1*F immediately
- Avoid excessive palpation of the thyroid
Medication for hyperthyroidism - answers - Methimazole
Reinforcing Teaching About Ostomy Care - answers stoma should be moist , shinny,
and pink. The peristomal area should be intact
- use mild soap and water to cleanse the skin, then dry it gently and completely
( moisturizing soaps interfere with adherence of the pouch)
- Apply paste if necessary
- measure and mark the desired size for the skin barrier
- cut the opening 0.15 cm to 0.3 cm ( 1/18 to 1/8) in larger, allowing the stoma to appear
through the opening
- apply barrier paste to creases
Developing a Improvement Plan for Assistive Personnel - answers - performance
should reflect the staff member's job and description
- various sources of data should be collected
- data should be collected over time and not just represent isolated incidents
- actual observed behavior should be documented
- peers can be a valuable source of data
- the employee should be given the opportunity to provide input
- the unit manager to host a private meeting with the staff member
Monitoring the Performance of Assistive Personnel - answers - have ap demonstrate
the tasks before doing it
Reinforcing Teaching About Client Privacy - answers - only health care team members
directly responsible for a clients care can access that client record. Nurses cannot share
info with other clients or staff not caring for the client
- Client have the right to read and obtain a copy of their medical record
- Nurses cannot photocopy any part of a medical record
