NURSING PRACTICE IV

GENERAL INSTRUCTIONS: 1. This test booklet CONTAINS 100 test questions. . Re!" INSTRUCTIONS TO E#A$INEES %&inte" on 'ou& !ns(e& sheet. ). Sh!"e onl' one *1+ bo, -o& e!.h question on 'ou& !ns(e& sheets. T(o o& /o&e bo,es sh!"e" (ill in0!li"!te 'ou& !ns(e&. 1. AVOI2 ERASURES.

Instructions: Ple!se en.i&.le the 3EST ANS4ER !/on5 the .hoi.es6 !n" sh!"e the .o&&es%on"in5 bo, in the !ns(e& sheet %&o0i"e". 7ou !&e !llo(e" to (&ite !n'thin5 in the test question %!%e&8 but 'ou .!n onl' (&ite the sub9e.t title6 set6 !n" sh!"in5 in the !ns(e& sheet: GO2SPEE2:

CARDIOVASCULAR: 1. A 24- year- old client comes into the clinic complaining of right- sided chest pain and shortness of breath. He reports that it started suddenly. The assessment should include which of the following interventions? a. Auscultation of breath sounds c. chocardiogram b. !hest "-ray d. lectrocardiogram # !$% . A .lient &e%o&ts &e.ent onset o- .hest %!in th!t o..u&s s%o&!"i.!ll' (ith e,e&tion. The .lient !lso h!s -!ti5ue !n" /il" !nkle s(ellin56 (hi.h is /ost %&onoun.e" !t the en" othe "!'. The nu&se sus%e.ts ! .!&"io0!s.ul!& "iso&"e&. 4hen e,%lo&in5 the .hie.o/%l!int6 the nu&se shoul" -in" out i- the .lient h!s !n' othe& .o//on .!&"io0!s.ul!& s'/%to/s6 su.h !s: a. Shortness of breath b. Inso/ni! .. I&&it!bilit' ". Lo(e& subste&n!l !b"o/in!l %!in ). The nu&se is .!&in5 -o& ! .lient (ith le-t;si"e" he!&t -!ilu&e. To &e"u.e -lui" 0olu/e e,.ess6 the nu&se .!n !nti.i%!te usin5: !. Antie/bolis/ sto.kin5s b. O,'5en c. Diuretics ". Anti.o!5ul!nts 1. A .lient (ith h'%e&tension 0isits the he!lth .lini. -o& ! &outine .he.ku%. The nu&se /e!su&es the .lient<s bloo" %&essu&e !t 1=1>? // @5 !n" notes ! A;lb (ei5ht 5!in o0e& the %!st = /onths. 4hi.h nu&sin5 "i!5nosis &e-le.ts the /ost se&ious %&oble/ in /!n!5in5 ! .lient (ith h'%e&tensionB a. Noncompliance (nona herence to therapeutic re!imen" b. 2e-i.ient kno(le"5e .. E,.essi0e -lui" 0olu/e ". I/b!l!n.e" nut&ition: $o&e th!n bo"' &equi&e/ents A. 2u&in5 !n o--i.e 0isit ! %&e n!t!l .lient (ith /it&!l stenosis st!tes th!t she h!s been un"e& ! lot o- st&ess l!tel'. 2u&in5 the !ssess/ent6 the .lient questions e0e&'thin5 the nu&se "oes !n" beh!0es in !n !n,ious /!nne&. The nu&se shoul" t!ke (hi.h !.tions to !lle0i!te the .lientsC !n,iet'B !. Tell the .lient not to (o&&' b. I5no&e the .lients un-oun"e" .on.e&ns !n" .ontinue !ssess/ents c. #$plain all nursin! proce ures an entertain all %uestions re!ar in! the care ". Re-e& the .lient to ! .ounselo& =. The nu&se is .!&in5 -o& ! .lient e,%e&ien.in5 "'s%ne!6 "e%en"ent e"e/!6 he%!to/e5!l'6 .&!.kles6 !n" 9u5ul!& 0ein "istention. 4h!t .on"ition shoul" the nu&se sus%e.tB !. Pul/on!&' e/bolis/ b. &eart failure .. C!&"i!. t!/%on!"e ". Tension %neu/otho&!, D. 4hen !ssessin5 ! .lient (ith le-t;si"e" he!&t -!ilu&e6 the nu&se e,%e.ts to note: !. As.ites b. Eu5ul!& 0ein "istention c. Air hun!er

NURSING PRACTICE IV
". Pittin5 e"e/! o- the le5s F. In ! .lient (ith .h&oni. b&on.hitis6 (hi.h si5n (oul" le!" the nu&se to sus%e.t &i5ht; si"e" he!&t -!ilu&eB !. C'!nosis o- the li%s b. 3il!te&!l .&!.kles .. P&o"u.ti0e .ou5h . Le! e ema ?. A .lient (ith !n !.ute /'o.!&"i!l in-!&.tion is &e.ei0in5 nit&o5l'.e&in b' .ontinuous I.V. in-usion. 4hi.h st!te/ent b' the .lient in"i.!tes th!t this "&u5 is %&o"u.in5 its the&!%euti. e--e.tB !. GI h!0e ! b!" he!"!.he.G b. '() chest pain is ecreasin!.' .. GI -eel ! tin5lin5 sens!tion !&oun" /' /outh.G ". G$' bloo" %&essu&e /ust be u% be.!use /' 0ision is blu&&e".G 10. A .lient is e,%e&ien.in5 !n !.ute /'o.!&"i!l in-!&.tion *$I+ !n" I.V. /o&%hine is %&es.&ibe". $o&%hine is 5i0en be.!use it: !. Eli/in!tes %!in6 &e"u.es .!&"i!. (o&klo!"6 !n" in.&e!ses /'o.!&"i!l .ont&!.tilit' b. Lo*ers +ascular resistance, re uces car iac *or-loa , an ecreases m)ocar ial o$)!en eman .. R!ises the bloo" %&essu&e6 lo(e&s /'o.!&"i!l o,'5en "e/!n"6 !n" eli/in!tes %!in ". In.&e!ses 0enous &etu&n6 lo(e&s &esist!n.e6 !n" &e"u.es .!&"i!. (o&klo!" 11. A client comes to the physician&s office for a follow-up visit 4 wee's after suffering a myocardial infarction #()%. The nurse ta'es this opportunity to evaluate the client&s 'nowledge of the prescribed cardiac rehabilitation program. *hich evaluation statement suggests that the client needs more instruction? a. +!lient performs rela,ation e,ercises three times a day to reduce stress.+ b. +!lient&s 24-hour dietary recall reveals low inta'e of fat and cholesterol.+ c. +!lient verbali-es an understanding of the need to see' emergency help if the heart rate increases mar'edly while at rest.+ d. "Client walks 4 miles in 1 hour every day." 1 . The nu&se is e"u.!tin5 ! .lient (ho<s !t &isk -o& .o&on!&' !&te&' "ise!se *CA2+. The nu&se tells the .lient th!t CA2 h!s /!n' &isk -!.to&s. Risk -!.to&s th!t .!n be .ont&olle" o& /o"i-ie" in.lu"e: !. Gen"e&6 obesit'6 -!/il' histo&'6 !n" s/okin5 b. In!.ti0it'6 st&ess6 5en"e&6 !n" s/okin5 c. Obesit), inacti+it), iet, an smo-in! ". St&ess6 -!/il' histo&'6 !n" obesit' 1). 4hi.h o- the -lo(in5 .on"itions /ost .o//onl' &esults in .o&on!&' !&te&' "ise!se *CA2+B a. Atherosclerosis b. 2i!betes $ellitus .. $'o.!&"i!l in-!&.tion ". Ren!l -!ilu&e 14. A client with no 'nown history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. )nspection and palpation reveal absent pulses. paresthesia. and a mottled/ cyanotic/ cold/ and cadaverous left calf. *hile the physician determines the appropriate therapy/ the nurse should0 a. 1lace a heating pad around the affected calf b. levate the affected leg as high as possible c. Keep the affected leg level or slightly dependent d. 2have the affected leg in anticipation of surgery 1A. The nu&se .o&&e.tl' inst&u.ts ! .lient (ith %e&i%he&!l 0!s.ul!& "ise!se th!t st&ess; &e"u.tion te.hniques: !. A&e hel%-ul onl' be.!use the' !ssist in s/okin5 .ess!tion. b. Are helpful because stress stimulates the release of +asoconstrictin! catecholamines. .. A&e hel%-ul be.!use the' "ist&!.t the .lient -&o/ -o.usin5 on .l!u"i.!tion %!in. ". @!0en<t %&o0e" use-ul in .lients (ith %e&i%he&!l 0!s.ul!& "ise!se. 1=. On ! &outine 0isit to the %h'si.i!n6 ! .lient (ith .h&oni. !&te&i!l o..lusi0e "ise!se &e%o&ts sto%%in5 s/okin5 !-te& )1 'e!&s. To &elie0e s'/%to/s o- inte&/ittent .l!u"i.!tion6 ! .on"ition !sso.i!te" (ith .h&oni. !&te&i!l o..lusi0e "ise!se6 the nu&se shoul" &e.o//en" (hi.h !""ition!l /e!su&eB a. .a-in! ail) *al-s

NURSING PRACTICE IV
b. En5!5in5 in !n!e&obi. e,e&.ise .. Re"u.in5 "!il' -!t int!ke to less th!n 1AH o- tot!l .!lo&ies ". A0oi"in5 -oo"s th!t in.&e!se le0els o- hi5h;"ensit' li%o%&oteins *@2Ls+ 1D. A-te& !b"o/in!l su&5e&'6 (hi.h -!.to& (oul" %&e"is%ose ! .lient to "ee% 0ein th&o/bosisB !. The .lient is AI?G t!ll !n" (ei5hs 1 F lb. b. The .lient h!s been %&e5n!nt -ou& ti/es .. The .lient usu!ll' (!lks ) /iles ! "!' . .he client *ill be immobile urin! an shortl) after sur!er). 1F. A .lient (ith 0enous insu--i.ien.' "e0elo%s 0!&i.ose 0eins in both le5s. 4hi.h st!te/ent !bout 0!&i.ose 0eins is !..u&!teB !. V!&i.ose 0eins !&e /o&e .o//on in /en th!n in (o/en b. P&i/!&' 0!&i.ose 0eins !&e .!use" b' "ee% 0ein th&o/bosis !n" in-l!//!tion. .. S.le&othe&!%' is use" to .u&e 0!&i.ose 0eins . .he se+erit) of iscomfort isn/t relate to the si0e of +aricosities. 1?. The nu&se is inst&u.tin5 ! .lient !bout the use o- !ntie/bolis/ sto.kin5s. Antie/bolis/ sto.kin5s hel% %&e0ent "ee% 0ein th&o/bosis *2VT+ b': !. En.ou&!5in5 !/bul!tion to %&e0ent %oolin5 o- bloo". b. P&o0i"in5 (!&/th to the e,t&e/it'. .. Ele0!tin5 the e,t&e/it' to %&e0ent %oolin5 o- bloo" . 1orcin! bloo into the eep +enous s)stem. 0. 4hi.h o- the -ollo(in5 si5ns !n" s'/%to/s su55est th!t ! .lient<s !b"o/in!l !o&ti. !neu&'s/ is e,ten"in5B a. Increase ab ominal an bac- pain b. 2e.&e!se" %ulse &!te !n" bloo" %&essu&e .. Ret&oste&n!l b!.k %!in &!"i!tin5 to the le-t !&/ ". Ele0!te" bloo" %&essu&e !n" &!%i" &es%i&!tions 1. Athe&os.le&osis i/%e"es .o&on!&' bloo" -lo( b' (hi.h o- the -ollo(in5 /e.h!nis/sB !. Pl!ques obst&u.t the 0ein b. 2la%ues obstruct the arter) .. 3loo" .lots -o&/ outsi"e the 0essel (!ll ". @!&"ene" 0essels "il!te to !llo( bloo" to -lo( th&ou5h . The nu&se is %&e%!&in5 to be5in one;%e&son .!&"io%ul/on!&' &esus.it!tion. The nu&se shoul" -i&st: a. #stablish unresponsi+eness b. C!ll -o& hel% .. O%en the !i&(!' ". Assess the .lient -o& ! .!&oti" %ulse ). A .lient (ith ! -o&.e-ul6 %oun"in5 he!&tbe!t is "i!5nose" (ith /it&!l 0!l0e %&ol!%se. This .lient shoul" !0oi" (hi.h o- the -ollo(in5B !. @i5h 0olu/es o- -lui" int!ke b. Ae&obi. e,e&.ise %&o5&!/s c. Caffeine3containin! pro ucts ". Joo"s &i.h in %&otein 1. The nu&se is .!&in5 -o& ! .lient (ith he/i%!&esis .!use" b' ! .e&eb&o0!s.ul!& !..i"ent *CVA+. 4hi.h inte&0ention t!kes hi5hest %&io&it'B !. Pe&-o&/in5 %!ssi0e &!n5e;o-;/otion *RO$+ e,e&.ises b. 2lacin! the client on the affecte si e .. Usin5 h!n" &olls o& %illo(s -o& su%%o&t ". A%%l'in5 !ntie/bolis/ sto.kin5s !s o&"e&e" A. A-te& e,%e&ien.in5 ! t&!nsient is.he/i. !tt!.k *TIA+6 ! .lient is %&es.&ibe" !s%i&in6 ) A /5 P.O. "!il'. The nu&se shoul" te!.h the .lient th!t this /e"i.!tion h!s been %&es.&ibe" to: !. Cont&ol he!"!.he %!in. b. Enh!n.e the i//une &es%onse. .. P&e0ent int&!.&!ni!l blee"in5. . Re uce platelet a!!lutination. =. The %h'si.i!n %&es.&ibes "i5o,in *L!no,in+ -o& ! .lient (ith he!&t -!ilu&e. 2u&in5 "i5o,in the&!%'6 (hi.h ele.t&ol'te i/b!l!n.e /!' %&e"is%ose the .lient to "i5it!lis to,i.it'B !. @'%e&/!5nese/i!

NURSING PRACTICE IV
b. @'%e&.!l.e/i! .. @'%e&n!t&e/i! . &)po-alemia 23. 4efore discharge/ which instruction should the nurse give to a client receiving digo,in #5ano,in%? a. +Ta'e an e,tra dose of digo,in if you miss one dose.+ b. "Call the physician if you have a rapid heart rate." c. +!all the physician if your pulse drops below 67 beats8minute.+ d. +Ta'e digo,in with meals.+ F. 2u&in5 "i5o,in *L!no,in+ the&!%'6 the nu&se shoul" .losel' /onito& the .lient<s: a. Serum potassium an ma!nesium le+els b. U&ine 5lu.ose !n" ketones .. Se&u/ %ot!ssiu/ !n" .&e!tine kin!se *CK+ le0els ". U&ine %ot!ssiu/ !n" CK le0els ?. A .lient is &e.ei0in5 nit&o5l'.e&in oint/ent *Nit&ol+ to t&e!t !n5in! %e.to&is. The nu&se e0!lu!tes the the&!%euti. e--e.ti0eness o- this "&u5 b' !ssessin5 the .lient<s &es%onse !n" .he.kin5 -o& !"0e&se e--e.ts. 4hi.h 0it!l si5n is /ost likel' to &e-le.t !n !"0e&se e--e.t o- nit&o5l'.e&inB !. @e!&t &!te b. Res%i&!to&' &!te c. 4loo pressure ". Te/%e&!tu&e )0. The nu&se !"/iniste&s -u&ose/i"e *L!si,+ to t&e!t ! .lient (ith he!&t -!ilu&e. 4hi.h !"0e&se e--e.t /ust the nu&se (!t.h -o& /ost .!&e-ull'B !. In.&e!se in bloo" %&essu&e b. In.&e!se in bloo" 0olu/e c. Lo* serum potassium le+el ". @i5h se&u/ so"iu/ le0el )1. 2u&in5 su&5e&'6 ! .lient "e0elo%s sinus b&!"'.!&"i!. The %h'si.i!n o&"e&s !t&o%ine sul-!te. 4hi.h o- the -ollo(in5 "oses !n" &outes o- !"/inist&!tion is the nu&se /ost likel' to !"/iniste&B !. 0.= /5 I.$. b. 5 m! I.V. .. /5 I.$. ". /5 I.V. N#UROLO6IC3S#NSOR7 DISORD#RS ) . The .lient is h!0in5 ! lu/b!& %un.tu&e %e&-o&/e". The nu&se (oul" %l!n to %l!.e the .lient in (hi.h %osition -o& the %&o.e"u&eB !. Si"e;l'in56 (ith the %illo( un"e& the hi% b. P&one6 (ith the %illo( un"e& the !b"o/en .. P&one6 in sli5ht;t&en"elenbu&5Cs %osition . Si e3l)in!, *ith the le!s pulle up an hea bent o*n onto the chest )). A /!5neti. &eson!n.e i/!5in5 *$RI+ stu"' is %&es.&ibe" -o& ! .lient (ith ! sus%e.te" b&!in tu/o&. 4hi.h nu&sin5 !.tion is in.lu"e" in the %l!n o- .!&e to %&e%!&e the .lient -o& the testB !. Kee% the .lient on nothin5;b';/outh *NPO+ st!tus -o& = hou&s be-o&e the test b. Remo+in! the metal3containin! ob8ects from the client .. Sh!0e the 5&oin -o& inse&tion o- ! -e/o&!l .!thete& ". Inst&u.t the .lient in inh!l!tion te.hniques -o& the !"/inist&!tion o- the &!"ioisoto%e )1. A nu&se %&o0i"es inst&u.tion to ! .lient (ho is s.he"ule" -o& !n ele.t&oen.e%h!lo5&!/ *EEG+. 4hi.h st!te/ent b' the .lient in"i.!tes ! nee" -o& -u&the& inst&u.tionsB a. 9All me ications nee to be *ithhel on the a) of the test.: b. LThe test (ill t!ke bet(een 1A /inutes !n" hou&sM .. L $' h!i& shoul" be (!she" the e0enin5 be-o&e the testM ". LCol!6 te!6 !n" .o--ee !&e &est&i.te" on the "!' o- the testM )A. The -!/il' o- ! .lient (ith ! s%in!l .o&" in9u&' &ushes to the nu&sin5 st!tion6 s!'in5 th!t the .lient nee"s i//e"i!te hel%. U%on ente&in5 the &oo/6 the nu&se notes th!t the .lient is "i!%ho&eti. (ith ! -lushe" -!.e !n" ne.k !n" .o/%l!ins o- se0e&e he!"!.he.

The %ulse &!te is 10 be!ts>/in !n" the bloo" %&essu&e is !.ts qui.kl'6 sus%e.tin5 th!t the .lient is e,%e&ien.in5: !. S%in!l sho.k b. Pul/on!&' e/bolis/ .. $!li5n!nt h'%e&the&/i! . Autonomic )srefle$ia 9:. The client who sustained an inhalation in;ury arrives in the emergency department. <n assessment of the client/ the nurse notes that the client is very confused and combative. The nurse determines that the client is e,periencing0 a. An,iety b. =ear c. Hypo ia d. 1ain )D. The nu&se is .!&in5 -o& the .lient (ith in.&e!se" int&!.&!ni!l %&essu&e. The nu&se (oul" note (hi.h o- the -ollo(in5 t&en"s in the 0it!l si5ns i- the int&!.&!ni!l %&essu&e is &isin5 !. In.&e!sin5 te/%e&!tu&e6 in.&e!sin5 %ulse6 in.&e!sin5 &es%i&!tions6 "e.&e!sin5 bloo" %&essu&e b. Increasin! temperature, ecreasin! pulse, ecreasin! respirations, increasin! bloo pressure .. 2e.&e!sin5 te/%e&!tu&e6 "e.&e!sin5 %ulse6 in.&e!sin5 &es%i&!tions6 "e.&e!sin5 bloo" %&essu&e ". 2e.&e!sin5 te/%e&!tu&e6 in.&e!sin5 %ulse6 "e.&e!sin5 &es%i&!tions6 in.&e!sin5 bloo" %&essu&e )F. A .lient is bein5 h'%e&0entil!te" b' ! /e.h!ni.!l 0entil!to& to "e.&e!se the .lientCs int&!.&!ni!l %&essu&e *ICP+. On /onito&in5 !&te&i!l bloo" 5!s &esults6 the nu&se (oul" &e%o&t 0!lue outsi"e o- (hi.h o- the -ollo(in5 &!n5esB !. P!O =0 to 100 // @56 P!CO A to )0 // @5 b. P!O =0 to 100 // @56 P!CO )0 to )A // @5 .. P!O F0 to 100 // @56 P!CO )A to 1A // @5 . 2aO; <= to 5== mm &!, 2aCO; ;> to ?= mm &!

NURSING PRACTICE IV )?>100 // @5. The nu&se

)?. A nu&se is .!&in5 -o& ! .lient (ith !n int&!.&!ni!l !neu&'s/ (ho (!s %&e0iousl' !le&t. 4hi.h o- the -ollo(in5 !ssess/ent (oul" not be !n e!&l' in"i.!tion th!t the le0el o.ons.iousness *LOC+ is "ete&io&!tin5B !. Sli5ht slu&&in5 o- s%ee.h b. 2tosis of the e)eli .. $il" "&o(siness ". Less -&equent s%ont!neous s%ee.h 10. A nu&se is .!&in5 -o& ! .lient (ho h!s un"e&5one .&!nioto/' !n" h!s ! su%&!tento&i!l in.ision. The nu&se shoul" %l!.e the .lient to (hi.h o- the -ollo(in5 %ositions %osto%e&!ti0el'B !. @e!" o- be" -l!t6 he!" !n" ne.k /i"line b. @e!" o- be" -l!t6 he!" tu&ne" to the nono%e&!ti0e si"e c. &ea of be ele+ate ?= to @> e!rees, hea an nec- at mi line ". @e!" o- be" ele0!te" )0;1A "e5&ees6 he!" tu&ne" to the o%e&!ti0e si"e 11. A nu&se is %&e%!&in5 ! %l!n o- .!&e -o& ! .lient (ith b&!in !tt!.k *st&oke+ (ho h!s 5lob!l !%h!si!. The nu&se in.o&%o&!tes .o//uni.!tion st&!te5ies into the %l!n o- .!&e be.!use the .lients s%ee.h (ill be: !. Int!.t b. Associate *ith poor comprehension .. Ch!&!.te&iNe" b' lite&!l %!&!%h&!si!s ". R!/blin5 1 . A nu&se is "e0elo%in5 ! %l!n o- .!&e -o& ! .lient (ith ! "i!5nosis o- b&!in !tt!.k *st&oke+ (ith !noso5nosi!. To /eet the nee"s o- ! .lient (ith this "e-i.it6 the nu&se in.lu"es !.ti0ities th!t (ill: !. Increase the clientAs a*areness of the affecte si e. b. En.ou&!5e .o//uni.!tion. .. P&o/ote !"equ!te bo(el eli/in!tion ". P&o0i"e ! .onsistent "!il' &outine 1). A nu&se in the neu&olo5i.!l unit is /onito&in5 ! .lient -o& si5ns o- in.&e!se" int&!.&!ni!l %&essu&e *ICP+. The nu&se &e0ie(s the !ssess/ent -in"in5s -o& ! .lient !n" notes the "o.u/ent!tion o- the %&esen.e o- Cushin5Cs &e-le,. The nu&se "ete&/ines

NURSING PRACTICE IV th!t the %&esen.e o- this &e-le, is obt!ine" b' /e!su&in5 (hi.h o- the -ollo(in5B a. 4loo pressure b. $oto& &es%onse .. Pu%ill!&' &es%onse ". Le0el o- .ons.iousness 11. The nu&se is !ssi5ne" to .!&e -o& ! .lient (ith .o/%lete &i5ht;si"e" he/i%!&esis. The nu&se %l!ns .!&e kno(in5 th!t in this .on"ition: !. The .lient h!s .o/%lete bil!te&!l %!&!l'sis o- the !&/s !n" le5s b. .he client has *ea-ness on the ri!ht si e of the bo ), inclu in! the face an ton!ue .. The .lient h!s lost the !bilit' to /o0e the &i5ht !&/ but is !ble to (!lk in"e%en"entl'. ". The .lient h!s the !bilit' to !/bul!te in"e%en"entl' but is !ble to -ee" !n" b!the sel- (ith out !ssist!n.e 1A. The nu&se h!s inst&u.te" the -!/il' o- ! .lient (ith b&!in !tt!.k *st&oke+ th!t h!s ho/on'/ous he/i!no%si! !bout /e!su&es to hel% the .lient o0e&.o/e the "e-i.it. The nu&se "ete&/ines th!t the -!/il' un"e&st!n"s the /e!su&es to use i- the' st!te th!t the' (ill: !. Pl!.e ob9e.ts in the .lients i/%!i&e" -iel" o- 0ision b. 2is.ou&!5e the .lient -&o/ (e!&in5 e'e5l!sses .. A%%&o!.h the .lient -&o/ the i/%!i&e" -iel" o- 0ision . Remin the client to turn the hea to scan the lost +isual fiel 1=. The nu&se is !ssessin5 the !"!%t!tion o- the .lient to .h!n5es in the -un.tion!l st!tus !-te& ! b&!in !tt!.k *st&oke+. The nu&se !ssesses th!t the .lient is !"!%tin5 /ost su..ess-ull' i- the .lient: !. Gets !n5&' (ith -!/il' i- the' inte&&u%t ! t!sk b. E,%e&ien.es bouts o- "e%&ession !n" i&&it!bilit' .. @!s "i--i.ult' (ith usin5 /o"i-ie" -ee"in5 utensils . Consistentl) uses a apti+e e%uipment in ressin! self 1D. A nu&se is %e&-o&/in5 !n !ssess/ent on ! .lient (ith ! "i!5nosis o- th&o/boti. b&!in !tt!.k *st&oke+. 4hi.h o- the -ollo(in5 !ssess/ent questions (oul" eli.it "!t! s%e.i-i. to this t'%e o- st&okeB !. L@!0e 'ou h!" !n' he!"!.hes in the %!st -e( "!'sBM b. L@!0e 'ou h!" su""en e%iso"es o- %!ssin5 out in the %!st -e( "!'sBM .. L@!0e 'ou &e.entl' been h!0in5 "i--i.ult' (ith seein5 !t ni5ht ti/eBM ". 9&a+e )ou ha an) numbness or tin!lin! or paral)sis feelin!s in an) of )our e$tremities recentl)BM 1F. The nu&se h!s 5i0en su55estions to the .lient (ith t&i5e/in!l neu&!l5i! !bout st&!te5ies to /ini/iNe e%iso"es o- %!in. The nu&se "ete&/ines th!t the .lient nee"s &ein-o&.e/ent o- in-o&/!tion i- the .lient /!kes (hi.h o- the -ollo(in5 st!te/entsB !. LI (ill (!sh /!' -!.e (ith .otton bu"sM b. LICll h!0e to st!&t .he(in5 on the un!--e.te" si"eM c. 9IAll tr) to eat m) foo either +er) *arm or +er) col : ". LI shoul" &inse /' /outh so/eti/es i- toothb&ushin5 is %!in-ulM 1?. The nu&se h!s 5i0en the .lient (ith 3ellCs %!ls' inst&u.tions on %&ese&0in5 /us.le tone in the -!.e !n" %&e0entin5 "ene&0!tion. The nu&se "ete&/ines th!t the .lient nee"s !""ition!l in-o&/!tion i- the .lient st!tes th!t he o& she (ill: a. #$pose the face to col an rafts b. $!ss!5e the -!.e (ith ! 5entle u%(!&" /otion .. Pe&-o&/ -!.i!l e,e&.ises ". 4&inkle the -o&ehe!"6 blo( out the .heeks6 !n" (histle A0. The nu&se is "e0elo%in5 ! te!.hin5 %l!n -o& the .lient (ith 5l!u.o/!. 4hi.h o- the -ollo(in5 inst&u.tions (oul" the nu&se in.lu"e in the %l!n o- .!&eB !. A0oi" o0e&use o- the e'es b. 2e.&e!se the !/ount o- s!lt in the "iet c. #)e me ications *ill nee to be a ministere for the clientAs entire life ". 2e.&e!se -lui" int!ke to .ont&ol in the int&!o.ul!& %&essu&e. A1. The nu&se is %e&-o&/in5 !n !"/ission !ssess/ent on ! .lient (ith ! "i!5nosis o"et!.he" &etin!. 4hi.h o- the -ollo(in5 is !sso.i!te" (ith this e'e "iso&"e&B !. Tot!l loss o- 0ision b. P!in in the !--e.te" e'e .. A 'ello( "is.olo&!tion o- the s.le&! . A sense of a curtain fallin! across the fiel of +ision

NURSING PRACTICE IV A . A .lient &e%o&ts to the he!lth .!&e .lini. to the he!lth .!&e .lini. -o& !n e'e e,!/in!tion6 !n" ! "i!5nosis o- /!.ul!& "e5ene&!tion is /!"e. 4hi.h !ssess/ent question (ill /ost s%e.i-i.!ll' eli.it in-o&/!tion &e5!&"in5 the .lini.!l /!ni-est!tions !sso.i!te" (ith this "iso&"e&B a. 9&a+e )ou ha an) blurre +isionB: b. L2o 'ou h!0e !n' %!in in 'ou& e'eBM .. LA&e 'ou h!0in5 "i--i.ult' seein5 thin5s out o- the si"e o- 'ou& e'esBM ". L2o b&i5ht li5hts bothe& 'ouBM A). An !/bul!to&' .!&e nu&se is %&o0i"in5 inst&u.tions to ! .lient (ho un"e&(ent ! l!se& t&!be.ulo%l!st' -o& the t&e!t/ent o- %&i/!&' o%en;!n5le 5l!u.o/!. 4hi.h st!te/ent i/!"e b' the .lient (oul" in"i.!te !n un"e&st!n"in5 o- the %ost;%&o.e"u&e inst&u.tionsB !. LI (ill &esu/e the 0ision th!t I lost (ithin 1 (eekM b. LIC/ so 5l!" th!t I h!" this t'%e o- su&5e&' be.!use I .!n &esu/e !ll /' !.ti0ities i//e"i!tel'.M c. 9I nee to a+oi acti+ities that cause strainin!.: ". LI .!n li-t ob9e.ts !s lon5 !s the' "o not (ei5h /o&e th!n )A %oun"sM A1. A .lient is e,%e&ien.in5 "'s-un.tion o- the &o"s o- the e'e. The nu&se inte&%&ets th!t this .lient (ill /ost likel' e,hibit (hi.h o- the -ollo(in5 "istu&b!n.es in 0isionB !. Ne!&si5hte"ness b. J!&si5hte"ness c. Ni!ht blin ness ". Colo& blin"ness AA. A .lient (ho h!s 9ust h!" !n e'e e,!/in!tion st!tes th!t the &esults o- the 0ision test in"i.!tes th!t the -o.!l %oint o- the li5ht &!'s ente&in5 the e'es behin" the &etin!. The nu&se inte&%&ets th!t this .lient is &e-e&&in5 to (hi.h o- the -ollo(in5 0isu!l "istu&b!n.esB !. $'o%i! b. &)peropia .. Asti5/!tis/ ". E,o%hth!l/us A=. 2u&in5 ! &outine 0isit to the %h'si.i!nCs o--i.e -o& /onito&in5 o- "i!beti. .ont&ol6 !n ol"e& .lient .o/%l!ins to the nu&se o- 0ision .h!n5es. The .lient "es.&ibes blu&&in5 othe 0ision6 (ith "i--i.ult' in &e!"in5 !n" (ith "&i0in5 !t ni5ht. Gi0en the .lientCs histo&'6 the nu&se inte&%&ets th!t the .lient %&ob!bl' is "e0elo%in5: !. 2et!.he" &etin! b. P!%ille"e/! .. Gl!u.o/! . Cataracts AD. The nu&se notes th!t the %h'si.i!n h!s "o.u/ente" ! "i!5nosis o- P&esb'.usis on the .lientCs .h!&t the nu&se %l!ns the .!&e kno(in5 th!t .on"ition is: !. Tinnitus th!t o..u&s (ith !5in5 b. N'st!5/us th!t o..u& (ith !5in5 .. A .on"u.ti0e he!&in5 loss th!t o..u&s (ith !5in5 . A sensorineural hearin! loss that occurs *ith a!in!
AF. A .lient (ith $enie&eCs "ise!se is e,%e&ien.in5 se0e&e 0e&ti5o. 4hi.h inst&u.tion shoul" nu&se 5i0e the .lient to !ssist in .ont&ollin5 the 0e&ti5oB !. In.&e!se so"iu/ in the "iet b. A+oi su en hea mo+ements .. Lie still !n" (!t.h the tele0ision ". In.&e!se -lui" int!ke to )000 /l ! "!' A?. A nu&se is .!&in5 -o& ! .lient (ith !.ute otitis /e"i!. In o&"e& to &e"u.e %&essu&e !n" !llo( -lui" to "&!in6 the nu&se !nti.i%!tes th!t (hi.h o- the -ollo(in5 (oul" /ost likel' be &e.o//en"e" to the .lientB !. The !"/inist&!tion o- "i%henh'"&!/ine *3en!"&'l+ .!%sules b. A m)rin!otom) .. St&i.t be" &est ". A /!stoi"e.to/' =0. A nu&se is %l!nnin5 to inst&u.t ! .lient (ith .h&oni. 0e&ti5o !bout s!-et' /e!su&es to %&e0ent e,!.e&b!tion o- s'/%to/s o& in9u&'. Te!.hin5 -o& this .lient (ill in.lu"e (hi.h o- the -ollo(in5 st!te/ents. The %!tient: a. Dri+es onl) *hen feelin! of i00iness ha+e not been e$perience for

NURSING PRACTICE IV
se+eral hours. b. Goes to the be"&oo/ !n" lie "o(n (hen 0e&ti5o is e,%e&ien.e" .. Re/o0es th&o( &u5s !n" .lutte& in the ho/e ". Tu&ns the he!" slo(l' (hen s%oken to. =1. The .lient h!s 9ust un"e&5one .o/%ute" to/o5&!%h' s.!nnin5 (ith .ont&!st /e"iu/. The nu&se "ete&/ines th!t the .lient un"e&st!n"s %ost;%&o.e"u&e .!&e i- the .lient 0e&b!liNes to: a. Increase flui inta-e for the a) b. @ol" /e"i.!tions -o& !t le!st 1 hou&s. .. E!t li5htl' -o& the &e/!in"e& o- the "!' ". Rest quietl' -o& the &e/!in"e& o- the "!' = . The nu&se is .!&in5 -o& the .lient in the e/e&5en.' "e%!&t/ent -ollo(in5 ! he!" in9u&'. The .lient /o/ent!&il' lost .ons.iousness !t the ti/e o- the in9u&' !n" then &e5!ine" it. The .lient no( h!s lost .ons.iousness !5!in. The nu&se t!kes qui.k !.tion6 kno(in5 th!t this is .o/%!tible (ith: !. Con.ussion b. Skull -&!.tu&e .. Sub"u&!l he/!to/! . #pi ural hematoma =). The nu&se is %&e%!&in5 to .!&e -o& ! .lient (ho h!s un"e&5one /'elo5&!%h' usin5 oil;b!se" .ont&!st !5ent. The nu&se %l!ns to %osition the .lient on be" &est -o&: a. C to < hour, *ith the hea of be flat b. = to F hou&s6 (ith he!" o- be" ele0!te" 1A to )0 "e5&ees .. to 1 hou&s6 (ith the he!" o- be" -l!t. ". to 1 hou&s6 (ith the he!" o- be" ele0!te" 1A to )0 "e5&ees. SITUATION: A 1A 'e!&;ol" is !"/itte" to the e/e&5en.' &oo/ -ollo(in5 !n !uto !..i"ent (ith ! %ossible s%in!l .o&" in9u&'. The .lient6 A&ison Eilli!n6 is .ons.ious. @e is un!ble to /o0e his le5s o& his !&/s in .o//!n". =1. 4hen t&!ns-e&&in5 ! .lient (ith ! %ossible s%in!l .o&" in9u&'6 (h!t is the /ost i/%o&t!nt .onsi"e&!tion -o& the nu&se to &e/e/be&B !. Su%%o&t the lo(e& e,t&e/ities6 sin.e the' !&e likel' to be (e!k o& %!&!l'Ne". b. E,%l!in (h!t 'ou !&e !bout to "o6 so the .lient .!n !ssist 'ou. .. Su%%o&t the b!.k (ith !""ition!l %illo(s to %&e0ent -u&the& s%in!l t&!u/!. ". Immobili0e the hea an nec- to pre+ent further spinal trauma . =A. 4hi.h o- the -ollo(in5 (oul" be !bsent i- $&. A&ison Eilli!n h!s s%in!l sho.kB !. @'%otension b. &)pertension .. @'%e&the&/i! ". 2&' skin ==. $&. A&ison Eilli!n h!s .o/%lete "est&u.tion o- the s%in!l .o&" !t C);1. Sele.t the /ost i/%o&t!nt !.tion -o& ! nu&se .!&in5 -o& this kin" o- .lient in the !.ute st!5e -ollo(in5 in9u&'. !. Tu&n !n" %osition !t le!st q h. b. I//obiliNe the he!" !n" ne.k c. (aintain a patent air*a) an a e%uate +entilation ". $onito& &en!l out%ut =D. A nu&se in the "e%!&t/ent sto&e noti.es ! 5&ou% o- %eo%le 5!the&e" !&oun" ! %e&son l'in5 on the -loo& h!0in5 ! seiNu&e. The best i//e"i!te &es%onse (oul" be to a. Cra le the personAs hea in )our lap b. Pl!.e so/ethin5 in the %e&sonCs /outh .. @ol" the %e&sonCs !&/ "o(n ". Rest&!in the %!tient =F. 4hi.h t'%e o- seiNu&e is -&equentl' %&e.e"e" b' !n !u&!B !. E!.ksoni!n b. Petit /!l c. (a8or ". Jo.!l =?. 4hi.h o- the -ollo(in5 test -u&nishes the best "i!5nosti. in-o&/!tion !bout the seiNu&eB

NURSING PRACTICE IV
!. Pneu/onen.e%h!lo5&!/ b. #lectroencephalo!ram .. Ce&eb&!l !n5io5&!/ ". Ce&eb&!l to/o5&!%h' D0. 4hen one seiNu&e !-te& !nothe& o..u&s (ithout the .lientCs &e5!inin5 .ons.iousness bet(een seiNu&es6 this is .!lle": !. J&equent seiNu&es b. Jeb&ile seiNu&e c. Status epilepticus ". Petit /!l seiNu&e D1. A nu&se is %e&-o&/in5 ! neu&olo5i.!l e,!/in!tion is !ssessin5 e'e /o0e/ent to e0!lu!te .&!ni!l ne&0es III6 IV6 !n" VI. Usin5 ! -l!shli5ht6 the nu&se (oul" %e&-o&/ (hi.h o- the -ollo(in5 to obt!in the !ssess/ent "!t!B !. Tu&n the -l!shli5ht on the "i&e.tl' in -&ont o- the e'e !n" (!t.h -o& the &es%onse b. Che.k %u%il siNe: then !sk the .lient to look !lte&n!tel' !t the -l!shli5ht (hi.h is lo.!te" eithe& ne!&e& o& -!&the& -&o/ the e,!/ine&s -in5e&. .. Inst&u.t the .lient to look st&!i5ht !he!"8 then shine the -l!shli5ht -&o/ the te/%o&!l !&e! o- the e'e. . As- the client to follo* the flashli!ht throu!h the si$ car inal positions of !a0e. D . A nu&se is %e&-o&/in5 the o.ulo.e%h!li. &es%onse *"ollCs e'es /!neu0e&+ test on !n un.ons.ious .lient. The nu&se tu&ns the .lientOs he!" !n" notes /o0e/ent o- the e'es in the s!/e "i&e.tion !s -o& the he!". The nu&se shoul" !%%&o%&i!tel' "o.u/ent these -in"in5s !s: !. Insi5ni-i.!nt b. No&/!l c. Abnormal ". In.on.lusi0e D). The nu&se is .!&in5 -o& ! .lient (ith ! b&!in tu/o& !n" in.&e!se" int&!.&!ni!l %&essu&e *ICP+. 4hi.h inte&0ention shoul" the nu&se in.lu"e in the %l!n o- .!&e to &e"u.e ICPB !. En.ou&!5e .ou5hin5 !n" "ee% b&e!thin5. b. Position (ith he!" tu&ne" to(!&" si"e o- b&!in tu/o&. c. A minister stool softeners. ". P&o0i"e senso&' sti/ul!tion. D1. A nu&se is "o.u/entin5 nu&sin5 obse&0!tions in the &e.o&" o- ! .lient (ho e,%e&ien.e" ! .loni. seiNu&e. 4hi.h .lini.!l /!ni-est!tion "i" the nu&se /ost likel' note in the %h!se o- the seiNu&eB a. Su en loss of consciousness b. 3&ie- -le,ion o- e,t&e/ities .. Violent e,tension s%!s/ o- the enti&e bo"' ". 3o"' sti--enin5 DA. A nu&se is "e0elo%in5 ! %l!n o- .!&e -o& ! .lient (ith ! "i!5nosis o- e!&l' st!5e AlNhei/e&Cs "ise!se. The %l!n o- .!&e (ill in.lu"e nu&sin5 inte&0entions th!t !""&esses (hi.h o- the -ollo(in5 !s .h!&!.te&isti.s o- e!&l' AlNhei/e&Cs "ise!seB !. Con-usion is .o//on b. 1or!etfulness interferes *ith the ail) routine. .. The .lient /!' (on"e&. ". The .lient /!' be e!sil' -&ust&!te". D=. A nu&se is &e0ie(in5 the &e.o&" o- ! .lient (ith sus%e.te" "i!5nosis o- @un5tin5tonCs "ise!se. The nu&se (oul" e,%e.t to note "o.u/ent!tion o- (hi.h e!&l' s'/%to/ o- this "ise!seB a. 4alance an coor ination problems b. 2i--i.ult' (ith s(!llo(in5 .. A%h!si! ". A5nosi!

DD. A nu&se is %&e%!&in5 -o& the !"/ission o- ! .lient (ith sus%e.te" "i!5nosis ohe&%es si/%le, en.e%h!litis. The nu&se !nti.i%!tes th!t (hi.h "i!5nosti. test (ill be %&es.&ibe" to .on-i&/ this "i!5nosisB !. Lu/b!& %un.tu&e

NURSING PRACTICE IV
b. 4rain biops) .. Ele.t&oen.e%h!lo5&!/ *EEG+ ". Co/%ute" to/o5&!%h' DF. A Th'/e.to/' !..o/%lishe" 0i! ! /e"i!n ste&noto/' !%%&o!.h is %e&-o&/e" in ! .lient (ith ! "i!5nosis o- /'!stheni! 5&!0is. The nu&se "e0elo%e" %osto%e&!ti0e %l!n o- .!&e -o& the .lient !n" in.lu"es (hi.h o- the -ollo(in5 in the %l!nB !. A0oi" !"/iniste&in5 %!in /e"i.!tion to %&e0ent &es%i&!to&' "e%&ession. b. (onitor the chest tube raina!e .. $!int!in int&!0enous in-usion o- l!.t!te" &in5e&Cs solution ". Rest&i.t 0isito&s -o& 1 hou&s &es%e.ti0el'. D?. A .lient !&&i0es in the hos%it!l e/e&5en.' "e%!&t/ent (ith .lose" he!" in9u&' to the &i5ht si"e o- the he!" -&o/ !ss!ult (ith ! b!seb!ll b!t. The nu&se !ssesses the .lient neu&olo5i.!ll'6 lookin5 %&i/!&il' -o& /oto& &es%onse "e-i.its th!t in0ol0e: a. .he left si e of the bo ) b. The &i5ht si"e o- the bo"' .. 3oth si"es o- the bo"' equ!ll' ". C&!ni!l ne&0es onl'6 su.h !s s%ee.h !n" %!%ill!&' &es%onse F0. A nu&se h!s !n o&"e& to be5in !neu&'s/ %&e.!utions -o& ! .lient (ith sub!&!.hnoi" he/o&&h!5e se.on"!&' to !neu&'s/ &u%tu&e. The nu&se (oul" %l!n to in.o&%o&!te (hi.h o- the -ollo(in5 inte&0entions in .ont&ollin5 the en0i&on/ent -o& the .lientB !. Kee%in5 the (in"o( blin"s o%en b. Tu&nin5 on the s/!ll s%otli5ht !bo0e the .lientCs he!" .. $!kin5 su&e the "oo& to the &oo/ is o%en !t !ll ti/es . 2rohibitin! or limitin! the use of a ra io or tele+ision an rea in! F1. A nu&se is %&e%!&in5 the %l!n o- .!&e -o& ! .lient (ho is s.he"ule" to &etu&n -&o/ the &e.o0e&' &oo/ !-te& ! le-t tot!l knee &e%l!.e/ent. The nu&se in.lu"es in the %l!n o.!&e to !ssess the .lientCs neu&o0!s.ul!& st!tus b' /onito&in5: !. The &!n5e o- /otion !t the le-t knee (hen ! .ontinuous %!ssi0e /otion /!.hine is use" b. The %!in le0el !n" .o5niti0e le0el o- the .lient .. 3loo" %&essu&e !n" &es%i&!to&' &!te . Capillar) refill, sensation, color, an pulse of the left foot F . A nu&se is !ssistin5 (ith .!lo&i. testin5 o- !n un.ons.ious .lient. Col" (!te& is in9e.te" into the le-t !u"ito&' .!n!l. The .lient e,hibits e'e .on9u5!te /o0e/ents to(!&" the le-t6 -ollo(e" b' e'e /o0e/ent b!.k to /i"line. The nu&se un"e&st!n"s th!t this in"i.!tes the .lient h!s: !. 3&!in "e!th b. A .e&eb&!l lesion .. A te/%o&!l lesion . An intact brainstem F). A .lient is e,%e&ien.in5 "eli&iu/. The nu&se .on.lu"es th!t the &es%onsible .on"ition o& lesion in0ol0es (hi.h o- the -ollo(in5 !&e!s o- the ne&0ous s'ste/B a. Reticular acti+atin! an cerebral hemispheres b. Li/bi. s'ste/ !n" .e&eb&!l he/is%he&es .. @i%%o.!/%us !n" -&ont!l lobe ". Te/%o&!l lobe !n" -&ont!l lobe F1. A nu&se notes th!t ! .lient (ho h!s su--e&e" ! b&!in in9u&' h!s !n !"equ!te he!&t &!te6 bloo" %&essu&e6 -lui" b!l!n.e6 bo"' te/%e&!tu&e. The nu&se .on.lu"es th!t (hi.h o- the -ollo(in5 !&e!s o- the .lientCs b&!in is -un.tionin5 !"equ!tel'B !. Th!l!/us b. &)pothalamus .. Reti.ul!& !.ti0!tin5 s'ste/ ". Li/bi. s'ste/

(USCULO3 SD#L#.AL: 6>. A client is treated in a physician?s office for a sprained an'le after a fall. @adiographic e,amination

NURSING PRACTICE IV has ruled out a fracture. 4efore sending the client home/ the nurse plans to teach the client to avoid which of the following in the ne,t 24 hours?
!. Restin5 the -oot b. Appl)in! a heatin! pa .. A%%l'in5 !n el!sti. .o/%&ession b!n"!5e ". Ele0!tin5 the !nkle on ! %illo( (hile sittin5 o& l'in5 "o(n F=. A nu&se is .on"u.tin5 he!lth s.&eenin5 -o& osteo%o&osis. 4hi.h o- the -ollo(in5 .lients is !t 5&e!test &isk o- "e0elo%in5 this "iso&"e&B !. A A;'e!&;ol" (o/!n (ho 9o5s. b. A )=;'e!&s;ol" /!n (ho h!s !sth/!. .. A D0;'e!&s;ol" /!n (ho .onsu/es e,.essi0e !l.ohol. . A se entar) C>3)ears3ol *oman *ho smo-es ci!arettes.

FD. A nu&se h!s 5i0en inst&u.tions to ! .lient &etu&nin5 ho/e !-te& knee !&th&os.o%'. The nu&se "ete&/ines th!t the .lient un"e&st!n"s the inst&u.tions ithe .lient st!tes th!t he o& she (ill: !. Resu/e &e5ul!& e,e&.ise the -ollo(in5 "!'. b. St!' o-- the le5 enti&el' -o& the &est o- the "!'. c. Report fe+er or site inflammation to the ph)sician. ". Re-&!in -&o/ e!tin5 -oo" -o& the &e/!in"e& o- the "!'. FF. A nu&se is .!&in5 -o& ! .lient (ho is 5oin5 to h!0e !&th&o5&!%h' (ith ! .ont&!st /e"iu/. The nu&se (ill .he.k (hi.h o- the -ollo(in5B a. Aller!) to io ine or shellfish. b. Abilit' o- the .lient to &e/!in still "u&in5 the %&o.e"u&e. .. 4hethe& the .lient (ishes to 0oi" be-o&e the %&o.e"u&e. ". 4hethe& the .lient h!s !n' &e/!inin5 questions !bout the %&o.e"u&e. F?. A nu&se is one o- se0e&!l %e&sons (ho (itness ! 0ehi.le hit ! %e"est&i!n !t -!i&l' lo( s%ee" on ! s/!ll st&eet. The %e&son is "!Ne" !n" t&ies to 5et u%. The le5 !%%e!&s -&!.tu&e". The nu&se (oul" %l!n to: !. T&' to &e"u.e the -&!.tu&e /!nu!ll'. b. Assist the %e&son to 5et u% !n" (!lk to the si"e;(!lk. .. Le!0e the %e&son -o& ! -e( /o/ents to .!ll !n !/bul!n.e. . Sta) *ith the person an encoura!e the person to remain still.

?0. A .lient h!s ! -ibe&5l!ss *non%l!ste&+ .!st !%%lie" to the lo(e& le5. The .lient !sks the nu&se (hen the .lient (ill be !ble to (!lk usin5 the .!ste" le5. The nu&se &e%lies th!t the .lient (ill be !ble to be!& (ei5ht on the .!ste" le5: !. In 1F hou&s b. In 1 hou&s .. In !bout F hou&s . Eithin ;= to ?= minutes of application ?1. A nu&se h!s 5i0en ! .lient (ith ! le5 .!st inst&u.tions on ! .!st .!&e !t ho/e. The nu&se (oul" e0!lu!te th!t the .lient nee"s -u&the& inst&u.tion i- the .lient /!kes

NURSING PRACTICE IV
(hi.h o- the -ollo(in5 st!te/entsB !. LI shoul" !0oi" (!lkin5 on (et6 sli%%e&' -loo&s.M b. LIC/ not su%%ose" to s.&!t.h the skin un"e&ne!th the .!st.M .. LItCs ok!' to (i%e "i&t o-- the to% o- the .!st (ith ! "!/% .loth.M . 9If the cast !ets *et, I can *armest settin!.: r) it *ith a hair r)er turne to the

? . A .lient (ith ! hi% -&!.tu&e !sk the nu&se (h' 3u.kCs e,tension t&!.tion is bein5 !%%lie" be-o&e su&5e&'6 the nu&seCs &es%onse is b!se" on the un"e&st!n"in5 th!t 3u.kCs e,tension t&!.tion %&i/!&il': !. Allo(s bon' he!lin5 to be5in be-o&e su&5e&'. b. P&o0i"es &i5i" i//obiliN!tion o- the -&!.tu&e site. .. Len5thens the -&!.tu&e" le5 to %&e0ent se0e&in5 o- bloo" 0essels. . 2ro+i es comfort b) re ucin! muscle spasms an fracture immobili0ation. pro+i es

?). A nu&se is e0!lu!tin5 the %in sites o- ! .lient in skelet!l t&!.tion. The nu&se (oul" be le!st .on.e&ne" (ith (hi.h o- the -ollo(in5 -in"in5sB

!. In-l!//!tion b. Serous raina!e

.. P!in !t ! %in site ". Pu&ulent "&!in!5e ?1. A .lient h!s 3u.kCs e,tension t&!.tion on !%%lie" to the &i5ht le5. The nu&se (oul" %l!n (hi.h o- the -ollo(in5 inte&0entions to %&e0ent .o/%li.!tions o- the "e0i.eB !. Gi0e %in .!&e on.e ! shi-t. b. $!ss!5e the skin o- the &i5ht le5 (ith lotion e0e&' F hou&s. c. Inspect the s-in on the ri!ht le! at least once e+er) < hours. ". Rele!se the (ei5hts on the &i5ht le5 -o& "!il' &!n5e;o-;/otion e,e&.ises. ?A. A nu&se is !ssessin5 the .!ste" e,t&e/it' o- ! .lient. The nu&se (oul" !ssess -o& (hi.h o- the -ollo(in5 si5ns !n" s'/%to/s in"i.!ti0e o- in-e.tionB !. 2e%en"ent e"e/! b. 2i/inishe" "ist!l %ulse. c. 2resence of the 9hot spot: on the casts. ". Coolness !n" %!llo& o- the e,t&e/it'. ?=. A .lient h!s sust!ine" ! .lose" -&!.tu&e !n" h!s 9ust h!" ! .!st !%%lie" to the !--e.te" !&/. The .lient is .o/%l!inin5 o- intense %!in. The nu&se ele0!tes the li/b6 !%%lies !n i.e b!56 !n" !"/iniste&s !n !n!l5esi.. The nu&se inte&%&ets th!t this %!in /!' be .!use" b': !. In-e.tion un"e& the .!st b. The !n,iet' o- the .lient

NURSING PRACTICE IV
c. Impaire tissue perfusion ". The &e.ent o..u&&en.e o- the -&!.tu&e. ?D. A .lient is bein5 "is.h!&5e" to ho/e !-te& !%%li.!tion o- ! %l!ste& le5 .!st. The nu&se "ete&/ines th!t the .lient un"e&st!n"s %&o%e& .!&e o- the .!st i- the .lient st!tes th!t he o& she shoul": a. A+oi !ettin! the cast *et.

b. Co0e& the .!ste" le5 (ith (!&/ bl!nkets. .. Use the -in5e&ti%s to li-t !n" /o0e the le5. ". Use ! %!""e" .o!t h!n5e& en" to s.&!t.h un"e& the .!st. ?F. A .lient bein5 /e!su&e" -o& .&ut.hes !sks the nu&se (h' the .&ut.hes .!nnot &est u% un"e&ne!th the !&/ -o& e,t&! su%%o&t. The nu&seCs &es%onse is b!se" on the un"e&st!n"in5 th!t this .oul" &esult in: !. A -!ll !n" -u&the& in9u&' b. In8ur) to the brachial ple$us ner+es. .. Skin b&e!k"o(n in the !&e! o- the !,ill!. ". I/%!i&e" &!n5e o- /otion (hile the .lient !/bul!tes. ??. A nu&se h!s 5i0en ! .lient inst&u.tion !bout .&ut.h s!-et'. The nu&se "ete&/ines th!t the .lient nee"s &ein-o&.e/ent o- in-o&/!tion i- the .lient st!tes: !. Th!t he o& she (ill not use so/eone elseCs .&ut.hes. b. Th!t .&ut.h ti%s (ill not sli% e0en (hen (et. .. The nee" to h!0e s%!&e .&ut.hes !n" ti%s !0!il!ble. ". Th!t .&ut.h ti%s shoul" be ins%e.te" %e&io"i.!ll' -o& (e!&. 100. A nu&se is .!&in5 -o& ! .lient bein5 t&e!te" -o& -!t e/bolus !-te& /ulti%le -&!.tu&es. 4hi.h o- the -ollo(in5 "!t! (oul" the nu&se e0!lu!te !s the /ost -!0o&!ble in"i.!tion o- &esolution o- the -!t e/bolusB !. $ini/!l "'s%ne! b. Clear chest ra io!raph .. O,'5en s!tu&!tion o- FAH ". A&te&i!l o,'5en le0el o- DF //@5

NURSING PRACTICE II NURSING PRACTICE II Community Health Nursing, Care of the Mother an Chil

SU4(I. .&IS .#S. 4OODL#. .O6#.&#R EI.& .&# ANSE#R S&##. .O 7OUR EA.C&#RS, 4RIN6IN6 .&# .#S. 4OODL#. OU. O1 .&# ROO( EILL 4# A 6ROUND 1OR CANC#LLA.ION O1 7OUR #FA(INA.ION PPPP E N 2 PPPP

SU4(I. .&IS .#S. 4OODL#. .O6#.&#R EI.& .&# ANSE#R S&##. .O 7OUR EA.C&#RS, 4RIN6IN6 .&# .#S. 4OODL#. OU. O1 .&# ROO( EILL 4# A 6ROUND 1OR CANC#LLA.ION O1 7OUR #FA(INA.ION PPPP E N 2 PPPP