1. A client who was diagnosed with Parkinson’s Disease is complaining of shaking and tremors in left hand, which of the 5 stages of involvement does this client have:
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
E. Stage 5
Answer: Stage 1 Unilateral shaking and tremors of one limb.
2. A mother is visiting her son who was recently in a MVA there is clear liquid leaking from his nose and ears she rings for the nurse. What should the nurse assess for? Select all that apply
A. Halo sign
B. negative glucose
C. positive glucose
D. green drainage
Answer: A. Halo sign is yellow stain surrounded by blood on a paper towel. C. Positive for glucose both of these are signs of CSF leaking
3. If you are educating a client on what can increase ICP what would you tell them to avoid? Select all that apply
A. Coughing
B. Extreme neck or hip flexion
C. Blowing nose forcefully
D. Avoid HOB at 30
Answer: A. B. C.
4. Which client would benefit the most from the Meningococcal Vaccine?
A. A 24 year-old-mother
B. 9-old-male
C. 18-year-old college student
D. 22-year-old with HPV
Answer: C. 18-year-old college student due to residential settings in college
5. A 19-year-old female college student was just diagnosed with bacterial meningitis what results would the CSF analysis show?
A. Clear CSF
B. Bloody CSF
C. Cloudy CSF
D. Green CSF
Answer: C. Cloudy CSF
Clinical Experience
86-year-old female client was picked up by EMS form nursing home and was later diagnosed with Pneumonia. Client was SOB, chest congestion, coughing non productive, fatigue, loss of appetite, weighed 90 lbs. on 2 liters of oxygen to keep SPO2 above 92%. Was treated with IV antibiotics and breathing treatments that are administered by respiratory therapist. Client also had a stage 3 on coccyx that is being treated with wound vac and high protein shakes.
Perfusion: Impaired Gas Exchange
I: Monitor respiratory rate, depth, and effort, including the use of accessory muscles, nasal flaring, and abnormal breathing.
R: Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client’s eyes may be seen with hypoxia.
I: Auscultate breath sounds q 1-2 hours
R: The presence of crackles an wheezes may alert the nurse to airway obstruction
I: Monitor oxygen saturation continuously using a pulse oximetry
R: An oxygen saturation of less than 90% or a partial pressure of less than 80 mm Hg indicates significant oxygenation problems.
Cellular Regulation: Impaired Skin Integrity
I: Assess Ulcer for size and depth
R: To obtain a baseline and to assess treatment
I: Monitor the clients continence status and minimize exposure of the skin impairment site and other areas to moisture from urine or stool, perspiration, or wound drainage.
R: To prevent exposure to chemicals in urine and stool that can erode the skin.
I: Turn and reposition client q 2 hours
R: To prevent further damage and prevent new ulcers from developing
If a Client has a INR 4 who is most likely on Coumadin (Warfarin) it is a Anticoagulant
I: Assess patient for signs of bleeding and hemorrhage such as bleeding gums, nose bleeds, unusual bleeding, tarry black stools, hematuria, and a fall in hematocrit or blood pressure.
R: This is a sign that dose is to high and client’s blood cannot clot appropriately
I: Monitor PT/INR levels
R: Normal levels are around PT 1.5-2 INR 3-4.5 with clients with high risk of embolization therapy should be monitored to prevent bleeding or hemorrhage
I: Education client about Vitamin K intake
R: Client should limit foods that are high in vitamin K because it is the antidote of Warfarin
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
E. Stage 5
Answer: Stage 1 Unilateral shaking and tremors of one limb.
2. A mother is visiting her son who was recently in a MVA there is clear liquid leaking from his nose and ears she rings for the nurse. What should the nurse assess for? Select all that apply
A. Halo sign
B. negative glucose
C. positive glucose
D. green drainage
Answer: A. Halo sign is yellow stain surrounded by blood on a paper towel. C. Positive for glucose both of these are signs of CSF leaking
3. If you are educating a client on what can increase ICP what would you tell them to avoid? Select all that apply
A. Coughing
B. Extreme neck or hip flexion
C. Blowing nose forcefully
D. Avoid HOB at 30
Answer: A. B. C.
4. Which client would benefit the most from the Meningococcal Vaccine?
A. A 24 year-old-mother
B. 9-old-male
C. 18-year-old college student
D. 22-year-old with HPV
Answer: C. 18-year-old college student due to residential settings in college
5. A 19-year-old female college student was just diagnosed with bacterial meningitis what results would the CSF analysis show?
A. Clear CSF
B. Bloody CSF
C. Cloudy CSF
D. Green CSF
Answer: C. Cloudy CSF
Clinical Experience
86-year-old female client was picked up by EMS form nursing home and was later diagnosed with Pneumonia. Client was SOB, chest congestion, coughing non productive, fatigue, loss of appetite, weighed 90 lbs. on 2 liters of oxygen to keep SPO2 above 92%. Was treated with IV antibiotics and breathing treatments that are administered by respiratory therapist. Client also had a stage 3 on coccyx that is being treated with wound vac and high protein shakes.
Perfusion: Impaired Gas Exchange
I: Monitor respiratory rate, depth, and effort, including the use of accessory muscles, nasal flaring, and abnormal breathing.
R: Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client’s eyes may be seen with hypoxia.
I: Auscultate breath sounds q 1-2 hours
R: The presence of crackles an wheezes may alert the nurse to airway obstruction
I: Monitor oxygen saturation continuously using a pulse oximetry
R: An oxygen saturation of less than 90% or a partial pressure of less than 80 mm Hg indicates significant oxygenation problems.
Cellular Regulation: Impaired Skin Integrity
I: Assess Ulcer for size and depth
R: To obtain a baseline and to assess treatment
I: Monitor the clients continence status and minimize exposure of the skin impairment site and other areas to moisture from urine or stool, perspiration, or wound drainage.
R: To prevent exposure to chemicals in urine and stool that can erode the skin.
I: Turn and reposition client q 2 hours
R: To prevent further damage and prevent new ulcers from developing
If a Client has a INR 4 who is most likely on Coumadin (Warfarin) it is a Anticoagulant
I: Assess patient for signs of bleeding and hemorrhage such as bleeding gums, nose bleeds, unusual bleeding, tarry black stools, hematuria, and a fall in hematocrit or blood pressure.
R: This is a sign that dose is to high and client’s blood cannot clot appropriately
I: Monitor PT/INR levels
R: Normal levels are around PT 1.5-2 INR 3-4.5 with clients with high risk of embolization therapy should be monitored to prevent bleeding or hemorrhage
I: Education client about Vitamin K intake
R: Client should limit foods that are high in vitamin K because it is the antidote of Warfarin