Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key


Play button


Play button




Click to flip

131 Cards in this Set

  • Front
  • Back
Which drugs directly suppress the function of the immune system?
Following surgery for a hip replacement, this patient is at risk for (3)
Wound infection, ileus and confusion
Normal tests to determine immune function include
White blood cell analyses
The preferred tests for immune function should evaluate (3)
Total counts of leukocytes and lymphocytes and humoral and cellular immunity (T cell count), phagocytic cell function and hypersensivity and specific antigen-antibody levels.
Sexually active young people who present with symptoms of the genitourinary or reproductive tract should be (3)
Questioned regarding sexual history and knowledge of STD transmission, screened for HIV and questioned for general health history.
A twenty-year-old female comes to the student health center because of persistent vaginal discharge. She admits to being sexually active for the last two years. The microbiology report obtained for this patient includes
Culture and sensitivity
Vaccines serve to prevent and control
Many viral and bacterial diseases
Common vaccines include these (3)
Diptheria, tetanus, and pertussis; measles mumps and rubella, and varicella
There is no common vaccine for
Health care workers born after 1954 should demonstrate immunity to
Measles, mumps and rubella.
Side effects may occur after having received a vaccine. Common problems include (3)
Fever, transient lymphadenopathy and chills.
The risk of hospital-acquired infections is greatly reduced by careful attention to (3)
Hand washing before and after each patient encounter, administering antibiotics to patients as directed and following safe procedures with patient care devices such as invasive lines.
Serious nosocomial infections include (3)
Clostridium difficile, methicillin-resistant staphylococcus and vancomycin-resistant enterococcus.
Isolation procedures are generally discussed in terms of two tiers; these tiers are
Standard precautions and transmission-based precautions.
Emerging infections are a category of diseases related to
World travel and immigration
A nurse who has just returned to the workforce after ten years questions you about which patients require standard precautions. You tell her standard precautions apply to
All patients.
Tissue trauma produces and inflammatory reaction in the body regardless of the cause. Which of the following are associated with the inflammatory response?
A chemotactic gradient is formed, protein-rich exudates enter the injured area and white blood cells enter the injured area.
Soft tissue trauma associated with accidents such as falls is usually
Confined to the area of injury.
Stage 1 pressure ulcers may be assessed by which of the following parameters?
Warmth, edema and hardness.
When is the most convenient time to assess the skin of your patients?
During a bath
Nursing care for a patient with a Stage 1 pressure ulcer should take into account that the ulcer
Will take weeks to months to heal depending on patient factors.
Nursing care aimed at preventing pressure ulcers is an important activity. Which of is one of the best ways to prevent pressure ulcers from forming?
Frequent position changes
Stage 3 and 4 pressure ulcers extend into deeper tissue. Treatment of these ulcers consists of
Surgical debridement
Hiatal hernia is a condition that produces and inflammatory reaction from sliding pressure. Nursing care to assist the patient with this problem should include (3)
Instruction to eat small meals several times during the day, instruction to eat sitting straight up and not lie down for an hour after meals and instruction to sleep with blocks at the head of the bed to raise the patient’s head above the diaphragm.
Frostbite is a form of thermal tissue trauma. The nurse should know what about immediate treatment?
Rewarming should be done in a warm tub of water.
Thermal burns are categorized by the depth of injury they produce. The nurse should know what related to these burns?
The color of burned skin may range from white to red.
A serious pathophysiological problem following a serious burn is
Hemodynamic instability
Nursing care for the patient with burns should include nursing interventions that (3)
Restore hemodynamic integrity, manage pain and provide emotional support, and prevent infection.
Give three true statements about informed consent for the surgical patient.
The client can refuse surgery after signing the consent form, The next of kin can sign for a confused patient or child, and the surgeon must explain the surgical risks to the patient.
Obesity places the surgical patient at greater risk for
impaired wound healing
A patient is retunred to his room following surgery. The patient is complaining of intense pain. The patient had received one-half the dosage of pain medication in the recovery room two hours earlier. Fifty milligrams of Demerol is ordered for three to four hours PRN for pain. What should the nurse do?
The nurse should give the patient fifty milligrams of Demerol now.
A temperature elevation on the first twenty-four hours after surgery probably indicates
On the third day after abdominal surgery, the nurse notes that a patient’s incision has become separated and the intestines are protruding. The first action the nurse should take is to
Cover the wound with a sterile saline dressing
A patient hwo had abdominal surgery three days ago and has been receiving opioids for pain control (50 milligrams of Demerol every four hours) is coomplaining of a distended abdomen and cramping gas pains. Her bowel sounds are hypoactive. The most immediate nursing action would be to
Assist the patient to ambulate in the hall.
Preoperative teaching by the nurse should include
How to cough, turn and deep breathe.
The best position for the nurse to place the postanesthesia patient who has not regained full consciousness is
Other important measures a nurse must implement to reduce the risk of aspiration and pulmonary complications in immobile patients include
turning and repositioning immobile patients every two hours.
If a patient requires supplemental oxygen for a time following a general anethesia, which of the following outcomes owuld indicate it is an effective therapy?
Arterial blood gas analysis of oxygen of greater than ninety-two millimeters mercury.
When caring for a patient with deep vein thrombosis who suddenly complains of chest pain, the nurse should do what two things?
Elevate the bed and call the physician.
Which of the following interventions would be most effective to promote wound healing in a dry ulcerous wound?
Wet to damp dressings changed frequently
A patient has been smoking a pack of cigarettes a day for ten years and is about to have general anethesia and surgery. It would be recommended that the patient
stop smoking; even a short cessation is better than not stopping.
In preoperative teaching for the geriatric patient, the nurse should consider
that older adults continue to function and understand.
Metabolic acidosis is characterized by
a low pH of less than 7/4 and a low plasma bicarbonate.
A patient with diabetes mellitus is complaining of headache, is confused and drowsy, and has increased respirations. The nurse is concerned about metabolic problems and knows which needs to be ordered?
Blood test for glucose and blood gases.
Which effects does the patient's age have on response to injury?
The patient's age is one variable in determining response to tissue trauma.
A hypertensive patient who has had abdominal surgery is at greater risk for
complications with wound healing
Which description explains the method used by the nurse to turn a client following a laminectomy?
A pillow is placed between the client's legs and he is turned as a unit to the side.
Which topic would be a priority in teaching a patient who takes immunosuppression drugs for the management of multiple sclerosis?
Stress management techniques
A client with multiple sclerosis experiences nocturnal urniary incontinence. Which intervention is most appropriate in this situation?
Encourage the client to wear incontinence pads.
The nurse recognizes that an early clinical sign of multiple sclerosis is
weakness in the legs
In planning for a patietn with multiple sclerosis, the nurse recognizes that the goal of care is
minimizing fatigue
A patient with myasthenia gravis is experiencing a myasthenic crisis. The nurse will expect which to happen after the patient receives a dose of Tensilon IV?
Muscle weakness will get better.
The most important nursing responsibility associated with administration of myasthenia gravis medications is
giving the drugs on time and before activities.
Which contributes to a cholinergic crisis in a patient with myasthenia gravis?
Too much anticholinesterase medicine
A client with myasthenia gravis has a very weak cough and imparied swallowing. To prevent respiratory complications, which nursing intervention is most appropriate?
Assist the patient to a sitting position with head upright while eating.
Which is a great risk for a patient with a head injury?
Hypertension from loss of compensatory mechanisms.
What is the first nursing care priority for a client who has sustained a severe closed head injury?
Maintain a patent airway.
What is the earliest indicator of increased ICP?
Restlessness and behavioral change.
Give three parameters of the Glasgow Coma Scale.
Eye-opening response, motor response and verbal response.
Which position would be the most beneficial in reducing a client's intracranial pressure?
Which would alert the nurse tha ta patient with a closed head injury is developing diabetes insipidus?
Increased urine output.
A patient has been discharged from teh emergency department after being hit in the head with a baseball. The patient has aheadache and no memory of the accident. There are no other neurological deficits. The nurse instructs the patient and family to
come back immediately if the patient cannot be awakened.
An unconscious patient responds to painful stimuli by reflex changes in body posture. The nurse would interpret the posture change as a decorticate postition if the patient
flexes and abducts his or her arms.
An unconscious patient responds to apinful stimuli by stiffly extending all his extremities and hyperpronating his arms. The nurse interprets this behavior as
decerebrate posturing.
Following a lumbar puncture, the nurse positions the patient to reduce the development of a post-procedure headache in what position?
in a supine position
A patient with a head injury has a tonic-clonic seizure while the nurse is in the room. During the seizure, it is important for the nurse to
insert an airway to maintain a patent airway.
During th epostictal phase of a seizure, the nurse can expect the patient to be
lethargic and disoriented.
The nurse incluldes cranial nerve assessment as part of the care of a patient with a head injury. To assess for the possibility of serious head trauma, the nurs eincludes in the assessment
pupillary reaction to light.
As part of the neurological exam for a patient who is unconscioius, the nurse tests the patient's gag and swallow reflex to assess
the 9 and 10 cranial nerves (glossopharyngeal and vagus).
A ninteen-year-old client is admitted to the emergency department with a C4 spinal cord injury. His head, neck and spine are immobilized with a cervical collar and backboard. Teh most important nursing assessment at this time is
breathing pattern.
During the initial assessment of a patient with a cervical spinal cord injury, the nurse recognizes the presence of spinal shock upon finding
loss of motor control, flaccid muscles and loss of sensation below the level of injury.
During the period of spinal shock, the most appropriate nursing intervention to promote urninary elimination for a client with a T6 spinal cord injury would be to
insert an indwelling bladder catheter.
A patient is admitted to the emergency department with a T10 spinal cord injury. The family asks the nurse about the extent of the patient's paralysis. The nurse's response is
a final estimate of paralysis can't be determined until after spinal shock resolves.
The first time a patient with a T10 spinal cord injury transfers from the bed to a wheelchair, the nurs eshould assess the client for
orthostatic hypotension
A client with a cervical spinal cord injury complains of a sudden throbbing headache. Which actions should the nurse take?
Check the client's blood pressure.
After two weeks in a rehabilitation unit, a patient with a T10 spinal cord injury becomes verbally abusive to the staff and demands to be transferred to a palce where the staff knows what it's doing. The nurse should respond by
accepting his anger and asking for input into his plan of care.
Methylprednisolone is administered to the patient with a spinal cord injury during the first twenty-four hours after surgery. The nurse knows that this drug will
reduce spinal chord ischemia and edema.
The nurse identifies risk for urinary tract infection as a nursing diagnosis for a patient with a chronic neurological condition. Nursuing measures to reduce this risk include instructing the patient to
drink liberal amounts of water throughout the day.
A client has a short arm plaster cast applied to reduce a fracture of the radius. Which statement by the client indicates she understands the discharge instructions?
"I should avoid pressure on the cast until it is completely dry."
A client with a displaced fracture of the right femur is placed in balanced skeletal traction using a Steinman pin. A high-priority nursing diagnosis for this client is
risk for infection related to skin disruption from the open wound.
Two days after application of a long leg cast for a tibia/fibula fracture, the client complains of pain in her foot that is unrelieved by analgesics. The client's toes are pink, but she says they feel like pins are sticking in them and they are numb. The nurse suspects
compartment syndrome.
A patient with an open fracture of the left femur undergoes and open reduction and internal fixation of the fracture with wound debridement. During the postoperative period, the nurse suspects the patient is developing osteomyelitis upon finding
high spiking temperature with chills.
Osteoporosis, a metabolic bone disorder, is characterized by
bone loss and deformity
Osteoporosis is most common in
postmenopausal women
An elderly gentleman diagnosed with Parkinson's disease is having difficulty walking. The nurse instructs the patient to
walk with a wide-based gait for stability.
If a patient has a problem that interferes with his functional status, this means that his
capacity for day-to-day activities is diminished.
A nurse can best assist a patient with a chronic neurological problem by
assisting the patient toward independence.
Older adults should receive which immunization every five to ten years?
Pneumococcal vaccine
You are caring for an adult patient with impaired respiratory function due to pneumonia. Your nursing diagnosis is one of ineffective airway clearance. You have come to this conclusion based on
tachypnea and dyspnea.
A lifestyle change imperative for individuals with immune system deficiency is to
reduce stress
Older adults have an increased incidence of infections and diseases such as cancer. Waht is the most significant factor related to this increased mortality and morbidity?
Decreased production of white blood cells.
One risk factor for an increased incidence of infection is
poor hygiene.
When choosing a course of action for an infectious disease, the decision for the treatment and management of symptoms should be made by the
health care team and family.
A patient with hepatitis B is admitted to the division. The nurse knows that
one portal of entry is by needlestick.
A patient is admitted to the division with mononucleosis. The nurse knows that
the virus is transmitted by droplet.
A hospitalized patient with active tuberculosis is to be transported to the radiology department for an X-ray. Which precautions should be taken when the patient is moved?
The patient should wear a protective face mask.
The family members of a patient with tuberculosis need
treatment with Isoniazid as a precaution.
Then nurse performing an assessment for a patient who has bacterial conjunctivitis would expect to find
purulent drainage.
Nosocomial infections are infections that
are acquired in the hospital.
Emerging infections are
diseases that are becoming epidemic.
Skin infections may manifest as
A patient with encpehalitis may demonstrate which of the following
When taking the history of a patient wiht an acute infection, the nurse should consider
recent exposure to infections agents.
A patient taking an antibiotic should be instructed to
take the entire course of medication therapy.
When reviewing a laboratory culture and sensitivity, be most aware of
related antibiotics.
Nursing measures to promote comfort for a patient with a communicable disease requiring isolation must take into account the patient's
developmental level.
Common childhood diseases such as measles, chicken pox and mumps are considered
potential for serious complications.
Passive immunity can be achieved through
An opportunistic infection occurs because the patient is
susceptible to disease due to weakened immune status.
A patient with a diagnosis of Salmonella infection was probably infected via
a food source
One of the most important activities a nurse can perform in order to prevent the spread of infection is
hand washing before and after patient care.
A patient is admitted to the emergency department with a suspected diagnosis of appendicitis. The nurse would expect the patient to exhibit
abdominal pain and elevated white blood cell count.
In the case of an accidental fall with profuse bleeding of the leg, the first action to be taken is to
apply direct pressure to the bleeding area.
In the case of an insect bite, the most serious concern is
allergic reaction
A young woman is diagnosed with Crohn's disease. The nurse understands this condition is
an inflammatory disease of the intestines.
The most important activity a nurse can advise when teaching patients and families about tissue trauma is
prevention and use of safety precautions.
A five-year-old child has been diagnosed with juvenile rheumatoid arthritis, and the parents are very concerned about whether the child will be able to play and progress in school. The nurse can assist the family by discussing exercise plans. Which would benefit the child?
Encourage normal play and range-of-motion exercises when joints are not inflamed.
If a preteen girl of boy begins to limpl and experience pain, the child should be referred to a physician for possible diagnosis of hip problems. The nurse should be aware of common complaints tha twarrant referral or treatment. Which sets of prblems require referral?
A limp and pain upon rising in the morning.
Mr. Smith, an overweight seventy-five-year-old, complains of intense pain in his big toe. He is diagnosed with gout and placed on Cholchine. The nurse knows that part of patient teaching includes
taking prescribed medication until pain subsides or GI symptoms begin.
Michael Moore is an eighteen-year-old college student who fractured his tibuia in competitive sports. Michael is in a cast but unable to bear weight and is on bed rest. He asks the nurse what he can do to his muscles so they don't become weak. The nurse would tell him to
begin doing isometric exercises of the leg.
At times, even after appropriate medical management, a patient may experience complications following a fractured bone. Early complications of which the nurse should be aware include
compartment syndrome
It is important for the nurse to evaluate the neurovascular status of a patient with a fracture. A neurovascular assessment includes
circulation, motion and sensation.
When a patient is confined to bed rest, problems of immobility may develop. Some of the problems associated with immobility include
Nursing measures to address problems of immobility should include? (3)
Range of motion exercises, proper positioning and assessment of skin.
A nurse who is caring for a fifteen-year-old clinic patient who has been diagnosed with a sexually transmitted disease is bound under law to
report the case to the local public health authority.
What incentives have been introduced that effectively reduce the rate of musculoskeletal accidents?
Mandatory seat belt legislation.
Preoperative care for patients undergoing surgery for joint replacement should include? (3)
Treatment of preexisting conditions to the extent possible, encouragement of weight loss if needed and prophylactic antibiotic treatment.
Immediate postoperative care of a patient who has had a joint replacement should include what? (3)
Monitoring the patient for the effects of surgery and anethesia, observation for hypovolemia due to blood loss and observation for joint care.
Mr. Adams has just had surgery for hip joint replacement. He is at risk for joint displacement due to his existing conditions, which include diabetes mellitus, hypertension and obesity. The nurse should be concerned if he complains of
abnormal motion (external or internal rotation of the joint).
Other indicators of hip joint displacement include which? (3)
Patient reports a popping sensation, new acute pain in the groin on the affected side and restricted ability to move limb.
The nurse should collaboratively determien appropriate outcomes fo rthe patient wiht musculoskeletal problems. Which should be considered appropriate outcomes? (3)
Patient achieves improved mobility, patient demonstrates knowledge of theraputic plan including exercise and patient achieves balance.