- ANS-
11 months old - ANS-a bucket of plastic blocks
2nd degree ankle sprain, teaching. - ANS-rewrap ankle at the most distal point of the foot
and moving proximal to promote venous return. Rewrap from foot to up to my leg.
4-year-old child who has cerebral palsy - ANS-evaluate the child's need for referral to a
speech language. Patient increased the risk for dysphagia and communication difficulties
require a speech therapist.
A nurse is caring for a client who has undergone an esophagostomy and is beginning to eat
solid food. The client is at risk for aspiration due to the removal of which of the following? -
ANS-Lower esophageal sphincter
A nurse is providing instructions for a client with bipolar disorder who received a prescription
for lithium. essential instruction? - ANS-Report excessive thirst and increased urination. Low
sodium diet diminished renal function, dehydration, and interaction with other meds (thiazide
diuretic and nonsteroidal anti-inflammatory drugs). Avoid exercise in hot weather, excess
loss of sodium. Fever, diarrhea and vomiting can result in sodium loss.
Abdominal assessment - ANS-inspection, auscultation, percussion, palpation
Addison disease electrolyte manifestations - ANS-hypoglycemia, hyperkalemia,
hyponatremia, and hypercalcemia. Insufficiency of adrenal may require increased dosages
of glucocorticoids during periods of illness or stress.
Addison disease manifestations - ANS-Finding on assessment weight loss, salt craving,
orthostatic hypotension, weakness, fatigue, N/V, and hyperpigmentation
Adolescent sleep habits - ANS-adolescents have circadian rhythms that cause sleepiness at
later time of the night
alcohol level 0.40 - ANS-death can occur
Amitriptyline - ANS-at risk for anticholinergic side effects, increase daily fluids to 3 L/day
anterior fontanel - ANS-closes between 9 and 18 months
Bile acid sequestrant - ANS-is a class of drug that lower LDL
Black cohosh - ANS-affect hormones, should not be taken during the first and second
trimester of pregnancy due to estrogenic effects. It is sometimes used to stimulate uterine
contractions
chemotherapy patient, dietary intervention to minimize nausea - ANS-food that are in room
temperature, low fat foods, avoid liquid during mealtimes
CHEOPS - ANS-for children 1 to 5 years who are unable t self-report pain
CHF patient that gained 3.5 pounds in 2 days - ANS-Presence of edema, shortness of
breath, or coughing
Cholestyramine, colestipol, colesevelam - ANS-is a bile acid sequestran, S/E constipation
and bloating
culture and sensitivity test for an infected wound - ANS-identify the causative pathogenic
organisms in infection. appropriate antibiotic therapy.
Diaphoretic and epigastric pain - ANS-can be manifestations of an acute infarction or other
cardiac complications
dorsal pedis pulse - ANS-lateral to the tendon on the top of the foot