RN Comprehensive Practice 2023 A with NGN (Answered 100% Correctly) | Complete| A+ Rated

RN Comprehensive Practice 2023 A with NGN (Answered 100% Correctly) | Complete| A+ Rated NGN: What assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis? Temperature (100F) Weight (-9.7 lbs) Albumin level (2.4) WBC (14) Bowel pattern (freq. loose stools) Abdominal pain location (RLQ) Heart rate (105) Temperature: Crohn's, UC & peritonitis. -Elevation can occur with all three due to inflammation and infection. Weight: Crohn's & UC. -Unintended weight loss can occur due to malabsorption in the GI tract. Bowel pattern: Crohn's. -If the patient reported there was blood in the stool, it would be UC. Crohn's doesn't cause tarry stools. WBC: Crohn's, UC & peritonitis. -Elevation can occur due to inflammation and infection. Heart rate: peritonitis. -Tachycardia can occur due to inflammation, infection, and dehydration. Albumin level: Crohn's & UC. -Because of the malabsorption in the GI tract, the body isn't receiving enough protein. Abdominal pain location: Crohn's. -Because it is in the RLQ, it is more consistent with Crohn's. With patients that have peritonitis, they experience generalized abd. pain that radiates to the shoulder and back. NGN: What assessment findings can indicate a transfusion reaction in a patient receiving blood? Urine output (150mL of clear, yellow) Skin (pale, cool and dry) Anxiety Vital signs (within normal range) Headache Back pain Back pain, headache & anxiety. Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain, tachycardia, dyspnea, hypotension. NGN: Patient arrives with palpitations, difficulty breathing, and reports feeling faint. Reports constipation and joint pain for x2 days. In childhood, patient experienced physical abuse, and emotionally detached parents. Reports nervousness and only leaving home when necessary. PMH: freq. hospital visits due to headaches and GI distress. Bowtie: Condition: somatic symptom disorder -due to physical inactivity & joint pain Interventions: Monitor physical manifestations & assess for presence of 2nd gains from their illness -disorder is characterized by the presence of other real manifestations like dizziness, nausea, back pain, and joint pain. Monitor: Vital signs & pain. NGN: What actions should the nurse take when her pedi patient is exhibiting symptoms of an allergic reaction? Administer 0.9% NS IV Administer epi IM Monitor urine output q2hrs DC supplemental oxygen Monitor vital signs frequently DC IV medication Administer 0.9% NS IV Administer epi IM Monitor vital signs frequently DC IV medication -Nurse should DC the Rocephin and give IV NS to help restore fluids because fluid shifts can occur quickly during a reaction. Administering epi IM is the first line of therapy for anaphylactic reactions because it constricts blood vessels and dilates bronchioles. Monitoring vital sings frequently will allow the nurse to monitor for signs of shock. NGN: What 5 actions should the nurse plan to take with a patient experiencing hallucinations, following alcohol withdrawal? Administer thiamine Maintain a low-stimulation environment Administer chlordiazepoxide Initiate seizure precautions Perform a CIWA-Ar Administer disulfiram Administer thiamine Maintain a low-stimulation environment Administer chlordiazepoxide Initiate seizure precautions Perform a CIWA-Ar -Nurse should plan interventions that keep the patient safe and treat the physical manifestations of withdrawal. Use the CIWA-Ar to determine the severity of the withdrawal. Withdrawal seizures can occur 12-24hrs after cessation of alcohol use, therefore initiate seizure precautions to prevent injury. Administer chlordiazepoxide (a benzodiazepine) and place patient in a low-stim environment to decrease agitation and the risk for seizures. Administering thiamine can prevent Wernicke syndrome. NGN: A post-op patient is experiencing right lower extremity pain and itching, following an emergent appy. Reports right lower extremity pain that has been intermittent for x2 months. Assessment: Bilat lower extremities warm to touch, pedal pulses 2+ bilat. Spider veins noted. Distended veins noted on right lower extremity. Vital signs are within normal limits. Bowtie: Condition: Varicose veins. -due to edema & pruritis Interventions: Elevate extremity & apply compression stockings -to promote venous return & circulation Monitor: Pruritis & edema NGN: Which assessment findings require an immediate follow-up in a schizophrenic patient? Hyperactive bowel sounds x4 Last HCP appointment was 6 months ago Client AO x2 Agitated Speech disorganized Involuntary tongue movement and foot tremor Increase in urination and one episode of incontinence Family c/o increased agitation and delusions Involuntary tongue movement and foot tremor Frequent urination and incontinence Increase in agitation -Patient is experiencing tardive dyskinesia A home health nurse is evaluation a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? A. "My child doesn't like to sit still for nebulizer treatments." B. "I think that my child has been running a fever over the last couple of days." C. "My child only has a small amount of mucus after percussion therapy." D. "I am concerned about my child's future participation in team sports." C. "My child has only a small amount of mucus after percussion therapy." -The nurse should recommend a high-frequency vest for a child who has inadequate results from other airway clearance therapy techniques. Older children often require other techniques in addition to percussion and postural drainage to achieve adequate mucus expectoration. -The nurse should teach the parent techniques for administration for nebulizer treatments to the child. -The nurse should follow-up on reports of fever, as this could indicate a pulmonary infection