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CASAL II Exam: Questions & Complete Solutions (100%)
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CASAL II Exam: Questions & Complete Solutions (100%)
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CASAL II Exam: Questions & Complete Solutions(100%)
A 78-year-old Mexican American client is admitted to the hospital for
hypertension. His wife passed away 6 months ago, and his only child still lives
in Mexico. Which intervention does the nurse use in dealing with this client
following his admission? Right Ans - Assess for folk medicine use
incl. Surveillance, Reporting, Med admin, error prevention Right Ans -
National Council of State Boards of Nursing (NCSBN) breakdowns in nursing
practice
Develop standardized checklist (synthesize input vs. allow) Right Ans -
SHARE
Attitudes, Knowledge, Skills (not env, jgmt or values) Right Ans - Client
centered care competencies
Sleep, Problems eating/feeding, Incontinence, Confusion, Evidence of falls,
Skin breakdown (marker conditions for longer hospitalization) Right Ans -
SPICES
safe driving more than exercise, nutrition or mental health Right Ans -
Healthy lifestyle choices for active older adults
"Tell me about support network" > leading question about death of spouse
Right Ans - widowed client says life is not fun anymore
"which cognitive problem does the nurse suspect that the client may have
discussed with the client's son" (test said Dementia) Right Ans - Dementia
vs. Alzheimers
Yes: class, new skill, new physical activity No: R&R, solitary reminiscence,
meditate 30 min/day Right Ans - Promote cognitive health
Prednisone increases risk Right Ans - skin breakdown
, Pain, pallor, paralysis, paresthesia and pulselessness Right Ans - 5 Ps of
neurovascular compromise
indicated in pulse and color, not saturation Right Ans - Perfusion
pain with passive range of motion Right Ans - Compartment syndrome
appropriate for 5 day -3 week dwell Right Ans - Midline catheter
appropriate for appendectomy, possible high volume fluids Right Ans - 18
g IV
change 12 to 24 hour Right Ans - Intermittent IV set
3 is palpable cord of 1 inch Right Ans - Phelibitis grading
anticipate shift to epidural IV Right Ans - Transfer patient with IO access 2
days
clean skin, use 70% eth/clhex, iodine+2min, no clean gloves/fingertips or
shave Right Ans - Preparation for insertion
full body sterile drape prevents infection Right Ans - central line insertion
only compatible with NS, best admin <2 hour, no more than 4 Right Ans -
Packed RBCs
contraction of interstitial fluid Right Ans - Isotonic dehydration
fluid moves from plasma to interstitial, more common Right Ans - relative
dehydration
expansion of interstitial fluid Right Ans - Fluid overload
In fluid overload, electrolyte levels normal but blood count decreased Right
Ans - hemodilution
may cause increased drug availability in elderly Right Ans - decreased
blood flow to liver
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