ATI RN Concept-Based Assessment Level 3 Study Guide> .
orthostatic hypotension - Correct answercaused by DEHYDRATION from fluid loos and electrolyte imbalance
gross motor skills - Correct answerphysical abilities involving large body movements, such as walking and jumping
-EX: 9 month-old infant SHOULD be able to sit UNSUPPORTED for up to 10 MIN
Biofeedback - Correct answertechnique that uses audio and visual signals that allow client to reduce muscle tension by gaining control over autonomic physiologic functions.
How should phenytoin be administered? Why? - Correct answer-administered IV bolus
at a rate no greater than 50mg/min. -to prevent HYPOTENSION and BRADYCARDIA
Manifestations of Parkinson's Disease - Correct answertremor, rigidity, BRADYKINESIA, postural instability, depression and other psychiatric changes, dementia, autonomic symptoms, sleep disturbances
Non-Hodgkin's Lymphoma - Correct answerspreads ERRATICALLY through the LYMPHATIC SYSTEM to other organs. It also manifest in PAINLESS, swollen lymph nodes found in the CERVICAL, AXILLLARY, INGUINAL, & FEMORAL areas.
Hodgkin's lymphoma - Correct answerspreads SYSTEMICALLY from one group of lymph nodes to the next group of nodes.
Important teachings for client with new prescription of a DIAPHRAGM. - Correct answer-should remain in place for 6HR FOLLOWING INTERCOURSE
-should remove diaphragm NO MORE THAN 24HRS following intercourse
-insert diaphragm NO MORE THAN 6HR PRIOR to intercourse
-apply about 10ml (2tsp) of SPERMICIDE inside diaphragm prior to intercourse
-replace every 2 yrs.
-client should be refitted if their weight FLUCTUATE BY 20%
-client should be refitted following a ABDOMINAL SURGERY, PELVIC SURGERY, & after each pregnancy
A client with fibrocystic breast condition will... - Correct answerhave BREAST PAIN and tenderness as well ass LUMPS usually in the UPPER OUTER QUADRANT of the breast.
Expected findings of INTRADUCTAL PAPILLOMA BREAST disorder? - Correct answerfinding will include: -mass in duct and NIPPLE DISCHARGE
Expected findings of DUCTAL EXTASIS BREAST DISORDER? - Correct answerEnlarged axillary nodes and Nipple discharge.
Client with COPD will experience... - Correct answerDIGITAL CLUBBING, which DECREASES arterial O2 levels.
tophi with chronic gout - Correct answerhard, painless nodule on first toe, collection of NA urate crystals due to chronic gout, sometimes bursts with chalky discharge
Swan neck deformity - Correct answer-hyperextension of PIP joint and flexion of DIP joint
-late manifestation of RHEUMATOID ARTHRITIS (RA)
scleroderma - Correct answerchronic progressive disease of the skin and internal organs with hardening and shrinking of connective tissue
-EXPECT flexion or contracture of joints. (late manifestation)
Preferred meal plan for a patient with DIVERTICULITIS - Correct answer-advance to high-fiber diet. Best source of fiber is a BANANA which yields 3.1g of FIBER.
Diverticulitis - Correct answerinflammation of the diverticula
What type of medication can increase a patient's risk for a stroke? - Correct answer-
oral contraceptives B/C this will INCREASE the risk for developing a THROMBOEMBOLISM.
A client with HYPOPITUITARISM places the them at risk for developing what type of condition? - Correct answer-osteoporosis
How does light to moderate drinking, (150ml or 5oz of wine each day) affect the client's risk for having a stroke? - Correct answerit doesn't increase, it actually DECREASES the risk for stroke.
What is Ewing Sarcoma? What are expected manifestations of this disease? - Correct answer-rare malignant tumor arising in bone; most often occurring in children
-client will experience pain in the UPPER THIGH as well as LOCALIZED PAIN, SWELLING, & PALPABLE MASS.
What are expected findings of Multiple Sclerosis (MS)? - Correct answer-decrease visual acuity, diplopia, changes in peripheral vision, & nystagmus (repeat of uncontrolled movements).
What are expected finding of Amyotrophic Later Sclerosis (ALS)? - Correct answer-
fascifulcations of the face, twitching of the face or tongue. What is Amyotrophic Lateral Sclerosis (ALS)? - Correct answerAlso known an Lou Gherig's disease, ALS is a motor neuron disease which can lead to paralysis.
borderline personality disorder - Correct answercondition marked by extreme instability
in mood, identity, and impulse control. -client's with this condition experience SUICIDAL IDEATION & SUBSTANCE ABUSE.
narcissistic personality disorder - Correct answercharacterized by a grandiose sense of
self-importance, a preoccupation with fantasies of success or power, and a need for constant attention or admiration or ARROGANCE
historonic personality disorder - Correct answerImpulsive attention seeking behavaior
paranoid personality disorder - Correct answerA personality disorder characterized by a pervasive distrust and suspiciousness of the motives of others without sufficient basis
What are some complications of an infant born at or less than 32 weeks? - Correct answer-apnea
-nectrotizing enterocolitis (due to intestinal ischemia and immature immune system)
-hypoglycemia
-anemia
-polycythemia
-hypothermia
What teachings should the nurse include for a client that underwent a UTERINE ARTERY EMBOLIZATION? - Correct answer-client may experience flu-like symptoms for 7 days after procedure (embolectomy syndrome)
-inform client that a CLOSURE DEVICE or INJECTION that blocks blood flow to the arteries of the FIBROID TUMOR is used
-inform client that SEVERE CRAMPING may occur in the first 24hr after the procedure and can last up to 2 weeks.
What teachings should the nurse include for a client who has bipolar disorder and has a
new prescription of LITHIUM? - Correct answer-instruct client to take Li with meals to decrease irritation of gastric mucosa. -maintain adequate intake of salt (low Na can lead to Li retention, which can cause Li toxicity).
-drink at least 1.5-3L of fluids each day (dehydration can lead to Li toxicity).
-expect WEIGHT GAIN (common adverse effect of Li).
Autism Spectrum Disorder (ASD) - Correct answerA disorder characterized by deficits in social relatedness and communication skills that are often accompanied by repetitive,
ritualistic behavior.
Immunization schedule - Correct answerBirth: Hep B 2 mos: Hep B, ROTAVIUS, DTaP, Hib, Pneumococcal, Poliovirus
4 mos: Rotavirus, DTaP, Hib, Pneum, Poliovirus
6 mos: Hep B, DTaP, Hib, Pneum, Poliovirus
12 mos: MMR, VAR, Hep A, Influenza, Hib
11-12 YEARS: Tdap, Meningococcal, HPV
ADHD (Attention-Deficit Hyperactivity Disorder) - Correct answera psychological disorder marked by extreme inattention and/or hyperactivity and impulsivity
What should the nurse include in her planning for a patient who has ACUTE phase of DIVERTICULITIS? - Correct answer-Instruct the client to AVOID COUGHING (this can
increase the intra-abdominal pressure and cause BOWEL PERFORATION).
-ADMINISTER OPIOID analgesics to relieve pain (this can decrease bowel motility)
-DO NOT administer EMEMAS or LAXITIVES (this will increase bowel motility and places client at risk for bowel perforation)
-client should be NPO or on a clear liquid diet (this will decrease inflammation of the bowels).
sickle cell crisis - Correct answercondition in sickle cell anemia in which the sickled cells interfere with oxygen transport, obstruct capillary blood flow, and cause fever and severe pain in the joints and abdomen.
How should the nurse manage care for a client who is experiencing a sickle cell crisis? -
Correct answer-promote fluid intake to prevent dehydration
-monitor peripheral capillary refill, pulse O2, and skin temp every 1hr to assess PERFUSION of EXTREMITIES. -EXTEND client's knees to promote perfusion of lower extremities. -elevate head or bed to 30 DEGREES or less to increase perfusion to lower extremities.
What are the depressive manifestation of low self-esteem? - Correct answer-
hypersensitivity to criticism
-guilt
-shame
-expression of helplessness
-lack of eye contact
-pessimistic outcome on life
What are the manifestations of spiritual distress? - Correct answer-express lack of meaning in life
-anger
-refusing interactions with family
