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130 Cards in this Set
- Front
- Back
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Lack of fine motor movement and
neuromuscular impairment are related to difficulties in what? |
Dressing (self care deficit)
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What part of the assessment may be delegated to the UAP?
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Vital signs
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What statement best teaches driving safety to an elderly pt?
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Turn head from side to side to compensate for loss of peripheral vision before changing lanes.
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What is a goal of Healthy People 2010?
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Focusing on blood pressure screenings in young adults.
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When is a routine physical exam recommend for a female pt age 40-65?
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Every one to three years
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What are ways to promote medication safety?
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Pill organizers, knowledge of the medications, keeping a list of medications, and using the same pharmacy.
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Adolescents are at risk for
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Suicide
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School age children need to be educated regarding
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Bicycle safety
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What is an appropriate expectation of a 2 year old toddler?
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Jumping up and down with both feet.
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What are appropriate expectations of a pre-school aged child?
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Making a tower of 10 cubes, going up steps using alternating feet, dancing.
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Temperature regulation is where on Maslow's pyramid?
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Base, making it a priority
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What is the best way a nursing assistant can provide care to an African Amer. pt c/o itching?
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Apply lanolin based lotion
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What are some conditions that would contraindicate back massage?
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Pt s/p back surgery, pt with impaired skin integrity, pt with rib fx
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Why should a pt not drink ETOH before bed?
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ETOH disturbs REM sleep
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How should a nurse instruct a mother of a febrile child to give a sponge bath?
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Sponge each area slowly and individually, sponge the child's face, arms, legs, back and buttocks. It should take about 30 minutes.
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A mother giving a sponge bath to a febrile child should discontinue the sponge bath if
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The child shivers, this may indicate the child's temp is falling too quickly, check child for pallor, cyanosis, irregular pulses.
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Which mind-body therapy increases the release of insulin in pts with diabetes?
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yoga.
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Which mind-body therapy affects the autonomic nervous system by lowering BP, oxygen consumption and
heart rate? |
Meditation
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What is hypnotherapy?
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A mind-body therapy used to help pt's gain self control and enhance self-esteem/independence
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What is imagery used for?
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To replace negative and fearful images with positive ones and enhance emotional health
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How can the nurse enhance the pt in a LTC facility's self worth?
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Empower the pt with knowledge and skills to make their health care decisions
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What self healing method should nurses use to foster their own well-being?
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Challenging the belief that others come first.
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How does a cold-pack decrease pain?
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Slowing nerve conduction and blocking nerve impulses to the affected area.
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How does heat decrease joint pain?
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By increasing tissue distensibility, increasing ROM and decreasing the viscosity of synovial fluids.
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NSAIDs are irritating to which system?
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GI
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What is a side effect of epidural analgesics?
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Urinary retention r/t increased tone in the bladder from opiate use
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What are side effects from relaxed vasculature r/t epidural opiate analgesia?
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Drowsiness, Bradycardia and Hypotension
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Which assessment by the home health nurse takes priority in a pt w/chronic pain?
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How the pain affects the pt's self care activities and the pt's ability to safely remain in the home
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What is an unbiased statement regarding pain?
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Euphoria is experienced when adequate doses of narcotics are administered
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A pt on a PCA pump states that they have been pushing the button w/no relief of pain. What should the nurse do first?
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Check for proper programming and function of the pump.
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What is the best measure of pain relief?
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When the pt indicates satisfaction of pain relief measures.
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Pain is
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SUBJECTIVE
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What is the gate control theory?
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The transmission of pain impulses to the brain are interrupted by heat, cold and pressure (such as a back rub)
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A pt w/intermittent chronic pain will have
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decreased appetite
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Autonomic responses characteristic of acute pain include
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HTN, change in heart rate and decrease is GI motility
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What is the best way to assess where a four year old patient is having pain?
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Ask them to point to the place where the pain is
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How does a four year old respond to pain?
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grimacing, rocking back and forth, rubbing the area and having aggressive behaviors
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How does a TENS unit relieve pain?
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By promoting the release of endorphins and/or Blocking small nerve fibers by stimulating larger ones (non pain receptors in the same area).
TENS unit is not anti inflammatory. |
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A patient with an active and strong sprituality will have a better adaptation to
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loss of independence
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A 13 year old patient w/chronic illness does not demostrate autonomy by
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allowing the parent to plan all daily activity.
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Which factor is important for the nurse to assess in a pt w/chronic illness who has developed some complications?
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Knowing what measures the pt has already taken to attempt to manage the illness
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Respite care is
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A way to relieve a caregiver who has been "doing it all" so they will have time for themselves w/out feeling as they are neglecting the patient and their duties to them.
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What clinical manifestation of cystic fibrosis will cause an adolescent pt to have difficulty being accepted by their peers?
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Chronic coughing
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Advances directives
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Specify the pt's wishes regarding care if they cannot speak for themselves, ADs must be signed by both the pt and two witnessess.
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Patients who have adapted to living w/with chronic illness will
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view themselves as "sick" only when the illness interferes with their daily living
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What is a priority nursing action when caring for a patient w/chronic illness?
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Taking on a supportive role by helping pt's and their families to manage the condition by teaching, counseling, advocating, managing and making referrals.
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The majority of responsibility for care of a pt with chronic illness usually
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lies with the patient themself
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Adminstration of cold liquids/medications though a PEG tube may cause
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GI discomfort
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How much water should the nurse use to flush with following administration of a medication through a PEG tube?
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Flush with atleast 5ml (or 3ml for peds) of water between each medication and 30ml after all meds have been instilled
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Why should a PEG tube be flushed with clear water between med administrations?
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To decrease the risk of lumen occlusion since many liquid medications are viscous
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The pt with a PEG tube should never be placed in
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Trendelenburg
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A pt on anticoagulants should be advised against taking laxatives and stool softeners because
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Irritation to the bowel should provoke bleeding and anticoagulants interact with many medications
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Some teaching points for a patient on anticoagulants would include
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Always wearing shoes while outside, using a night light to reduce injury at night, using a soft toothbrush
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What change in a dying child is most distressing to parents?
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Change in respiration: labored breathing, apnea, Cheyne-stokes breathing may cause the parents to think the child is suffering.
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The nurse's primary goal during care of an unconcious patient is
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maintain airway
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An unconsious patient should be
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kept NPO
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Which psychosocial nursing intervention best supports a dying pt's preferences?
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Exploring meaning, relationships and hopes
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A person who has donated their organs can still
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have an open casket
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A durable power of attorney
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Designates a specific individual to make decisions for a person in the event they become incapacitated
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Expression of a pt's wishes, such as being kept alive artificially or having a feeding tube would be in their
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living will
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A last will and testament
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directions on distribution of a person's belongings and property after death
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In a pt with impending death, the last systems to shut down would be the
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cardiovascular and respiratory systems
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Slow respirations
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occur shortly before death
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The GI, GU and integumentary systems of a dying patient
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will be some of the first systems to have malfunction before death due to the pt's blood being shunted away to the more important systems
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The first step into developing a care plan for a dying pt and their family is
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establishing a trusting relationship
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The nurse demonstrates caring and presence to the dying pt and their family by
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being available and staying at the bedside as much as possible
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What is an appropriate food to offer to a dying pt?
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Soup
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Anticholingerics are given to dying pts to
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decrease and dry secretions
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What is a constant recommendation for a dying pt?
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Remaining in Fowler's position r/t difficulty breathing and copious secretion
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Five stages of grief
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DABDA=
Denial, Anger, Bargaining, Depression, Acceptance (kubler-Ross) |
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Inertia or passivity in regards to ADLs or simple tasks may indicate
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depression
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Who provides the most significant data?
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The patient
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A substantial resolution of grief may also include
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brief periods of intense feelings at significant times such as anniversaries
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In Hispanic culture, a patient may be protected from knowing their
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prognosis
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Stoicism over pain medication is highly regarded in
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Hispanic culture
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Development of awareness suggests
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the middle stages of grief process, when life issues are bought up and thought upon but not yet resolved.
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The final stage of the grief process is
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reorganization, when the issues are resolved and the person has moved on
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Narcotics decrease
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GI motility and lead to constipation
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Which disorder is associated with conductive hearing loss of the middle ear?
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Eustachian tube dysfunction
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Damage to the vestibular cochlear nerve causes
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sensorineural hearing loss
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Functional hearing loss arises from
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psychological or emotional disturbance
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A patient who states "I now have a shadow spreading over one eye's vision" is having a
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retinal detachment, which is a medical emergency
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A blurry black hole in the center of vision indicates
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macular degeneration
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A decrease in peripheral vision may indicate
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chronic glaucoma
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Systemic effect of using pilocarpine eye drops include
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Diarrhea, hypertension and tachycardia
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Floaters and flashing lights are a sign of
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retinal detachment
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Pain and halo vision are signs of
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acute angle glaucoma
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Large doses of furosemide (Lasix) can cause
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ototoxicity and irreversible hearing loss
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A priority nursing dx for a patient that has Meniere's Disease is
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risk for injury r/t vertigo
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Which observation after cataract surgery indicates an acute rise in intraocular pressure?
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Eye pain not relieved by pain medication
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Sensory deprivation is characterized by
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depression, decreased problem solving, impaired memory and drowsiness.
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Scattered thoughts, fatigue, irritability and reduced problem solving are clinical manifestations of
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Sensory overload
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Sensory deficits include
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impaired reception and/or perception in one or more senses
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Treatment of otitis externa include
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keeping the ear dry, such as refraining from swimming or showering
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What should be used to clean the ear?
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The corner of a towel or a tuft of cotton ball, q-tips should not be inserted into the ear r/t risk of damage to the ear canal.
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Sustained noise at what level can cause progressive hearing loss?
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Between 85-95 decibles (90)
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A 120 decible level noise is
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physically painful and may cause damage to hearing after a short exposure
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How long do hearing aide batteries last?
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A few days to a few weeks, depending on frequency of use and type of battery.
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A constant whistling sound coming from a hearing aide may mean that
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the ear mold is improperly fitted or worn
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95% of patients with vertigo experience
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nausea and vomiting, putting them at risk for fluid volume deficits
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Mydriatics are used during eye surgery to
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induce relaxtion of the ciliary muscle
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A patient who has undergone mastoid and middle ear surgery should sneeze and cough with their mouth
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open to decrease pressure in the mid ear
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The patient with glaucoma takes medication to prevent
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an inceased loss in peripheral vision
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Floaters are
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small bits of protein or cells in the vitreous and r/t retinal detachment
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Bedrest in a Fowler's position is recommended in a patient with hyphema to
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keep the hyphema away from the cornea and enhance the pooling in the anterior chamber
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Ear drops should be administered to a pediatric patient by pulling the pinna
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down and back
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Ear drops sbhould be administered to the adult patient by pulling the pinna
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up and back
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Tay-Sachs disease is prevalant in
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Eastern European Jews
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American Indians have a high incidence of
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rheumatoid arthritis
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HTN is most prevalent
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in African Americans
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A belief between yin and yang, health is a state of balance within the body is
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common among Asians
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Many African Americans see health as
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harmony between mind, body and spirit and see illness from natural causes or divine punishment
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Those of the Muslim (Islam) faith do not eat
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pork and pork products
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During Ramadan, Muslims (Islamic) are required to fast from
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sun up to sun down
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Eye contact is often seen as disrespectful to
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Hispanics
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Present time orientation is common to these individuals, making walk in clinics with flexible schedules more appropriate
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Native Americans
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A curandero is
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a healer in the Hispanic community that involves the entire family in treatment of the patient and provides care in the patient's home.
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The most important reason for cultural assessment is
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to facilitate a treatment plan for the patient
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In order to appreciate the values and beliefs of others, the nurse must first
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recognize the origins of her own values and beliefs
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Native Americans often define illness as
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a disharmony with nature and the universe
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Chelation therapy for lead should be initiated
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for lead levels at greater than or equal to 45
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One of the responsibilities of a case manager is
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to provide the necessary information to manage care
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What is the rehabilitator's primary function?
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to help the patient regain the ability to perform ADL's
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A nursing diagnosis for a mother of three children who is undergoing chemotherapy may be
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impaired home maintence management
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School age children are very vulnerable to accidents involving
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motor vehicles (require education r/t pedestrians, bike safety, watching for cars, etc)
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Instructions for a parent of a child with asthma r/t home maintenence include
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wet mop bare floors weekly, use washable window shades instead of curtains and wash all bed linens in hot water
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Humidity greater than 60% encourages
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growth of mold
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Discussion of termination of home care services should take place
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at the first visit
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NSAIDs decrease pain by
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inhibiting prostaglandin synthesis and interrupting pain at the peripheral level
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Opiates decrease pain by
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binding to receptors in the dorsal horn and inhibiting the release of neurotransmitters thereby interfering with pain signals accross neurosynapses.
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