Mometrix

Question 1

Which need immediate attention

1. Respiration 20
2. HR 122 thready
3. Sunken eyes
4. Temperature 98.9
5. Lethargy
6. Reported vomiting/ diarrhea

Answer 1

2. HR 122 thready
3. Sunken eyes
4. Lethargy
5. Reported vomiting/ diarrhea

Question 2

Hypovolemia/Hypervolemia

1. Orthostatic Hypotension
2. Crackles in the base of lungs
3. Bounding pedal pulse
4. Decreased skin turgor
5. +2 edema bilateral upper extremities

Answer 2

Hypovolemia

1. Orthostatic Hypotension
2. Decreased skin turgor

Hypervolemia
2. Crackles in the base of lungs
3. Bounding pedal pulse
5. +2 edema bilateral upper extremities

Question 3

Apixaban is this type of medication

Used to treat

Answer 3

a novel oral anticoagulant

Nonvalvular atrial fibrillation to reduce the risk of stroke and blood clots

Question 4

Client who stops taking apixaban for their A fib is at risk for what type of stroke?

Secondary to….

Answer 4

Ischemic stroke

Secondary to an embolism

Stopping apixaban (novel blood thinnner) can cause clots to form which can travel to the brain and cause a stroke

Question 5

What is VAN positive mean…

0
1-4
5-15
16-20
21-42

Answer 5

Deficit in vision, aphasia, or neglect (VAN) categories

Large artery stroke

0 (No Stroke)
1-4 Mild
5-15 Moderate
16-20 Moderate/ Severe
21-42 Severe

Question 6

How would a patient get a hemorrhagic stroke?

Answer 6

Head Trauma/ Falls

Question 7

For a suspected ischemic stroke

Which of the following should the nurse consider a priority

1. Blood sugar sample
2. Order CBC, BMP, trophin level
3. Obtain EKG
4. Education on medication compliance
5. CT scan of head
6. Administer IV labetalol

Answer 7

1. Blood sugar sample (Hypo/Hyperglycemia resemble stroke symptoms)
2. CT scan of head (<25 mins arrival ED - Rules out hemorrhagic stroke)
3. Administer IV labetalol ( Contraction for thrombolytics is Systolic BP > 185)

No priority

2. Order CBC, BMP, trophin level
3. Obtain EKG
4. Education on medication compliance

Question 8

newborn’s average blood pressure is ____

Between one month and two years old is ___

Answer 8

New born 64/41

1 month- 2 years = 95/58

Question 9

Most common symptoms with Influenza

1. Fever
2. Cough
3. Diarrhea
4. Loss of appetite
5. Rhinorrhea

Answer 9

Influenza colonizes the Respitory Tract

Fever, Cough, Rhinorrhea

Question 10

Most common symptoms with UTI

1. Fever
2. Cough
3. Diarrhea
4. Loss of appetite
5. Rhinorrhea

Answer 10

Fever

Also, pain / frequent urination
Maybe blood in urine

Question 11

Most common symptoms with gastroenteritis

1. Fever
2. Cough
3. Diarrhea
4. Loss of appetite
5. Rhinorrhea

Answer 11

Diarrhea & loss of appetite

May also have vomiting & abdominal pain

Question 12

Which is a potential nursing action for a 2 year old who had a fever induced seizure and is dehydrated from vomiting & diarrhea

1. Adding safety padding to the sides of the clients bed
2. Request that acetaminophen order be given via rectal suppository
3. Request an order for 1,000mL IV fluid bolus
4. Provide client with juice or popsicle
5. Provide client with cold compression for forehead / neck

Answer 12

Indicated

1. Adding safety padding to the sides of the clients bed
2. Provide client with juice or popsicle
3. Provide client with cold compression for forehead / neck

Not indicated

2. Request that acetaminophen order be given via rectal suppository
3. Request an order for 1,000mL IV fluid bolus (Standard IV bolus for pediatrics = 20 mL / kg over 20 - 30 mins) 1000mL is way too much and dangerous

Question 13

2 year old being discharged for hospital for stroke induced by fever & dehydration. Which statements indicate understanding by mother.

1. My child was diagnosed with epilepsy today.
2. Rectal is the most accurate location to measure my child’s temperature.
3. I will alternate between acetaminophen & Ibuprofen to control my child’s temp.
4. Place a platic biting pad in mouth during seizures to prevent damage.
5. I will monitor my child’s intake of fluids & have him seen again if there is a decrease in wet diapers or crying without tears.

Answer 13

Understanding:

2. Rectal is the most accurate location to measure my child’s temperature.
3. I will alternate between acetaminophen & Ibuprofen to control my child’s temp.
4. I will monitor my child’s intake of fluids & have him seen again if there is a decrease in wet diapers or crying without tears.

Not Understanding:

1. My child was diagnosed with epilepsy today.
2. Place a platic biting pad in mouth during seizures to prevent damage.

Question 14

Children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin.

Due to this serious complication….

Describe it…

Answer 14

Reyes syndrome

Early:
diarrhea, rapid breathing, vomiting, and severe fatigue.

Symptoms such as confusion, seizures, and loss of consciousness need emergency treatment

Brain Swelling/ Damage Most serious complication

Question 15

What duration of apnea in a neonate is of concern?

1. All periods of apena
2. 2 - 3 seconds
3. 6 - 8 seconds
4. > 15 - 20 seconds

Answer 15

4. > 15 - 20 seconds

Periodic breathing are normal in neonates. Usually 2-3 seconds long

If episodes are frequent or accompanied by Pallor, cyanosis, bradycardia, or hypotonia alert physician

Question 16

Following a Lumbar puncture client has sever headaches lasting >24 hrs & not relieved by bedrest or fluids.

Which intervention does the nurse anticipate

1. Bedrest 3 days
2. Opiod analgesia
3. Epidural blood patch
4. IV fluids

Answer 16

3. Epidural blood patch

Persistent headaches indicate a hole in the Dura Mater, Epidural Blood Patch creates a Blood Clot to “seal the hole”

Headaches occur in 1/5 post Lumbar Puncture aka spinal tap

Used to diagnose bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis.

Bleeding around the brain, known as subarachnoid hemorrhage.

Question 17

HbA1c levels

Pre-diabetic
Diabetic

*must occur on 2 separate occasions

Answer 17

Pre-diabetic: 5.7 - 6.4
Diabetic: > 6.5

Question 18

Describe Parkinsons gait

Answer 18

Slight flexion of hips & knees
Short shuffling steps
Trunk leaning forward
No arm swing

Question 19

RN team leader has a staff of 1 LPN & 2 CNA’s. Which assignment would you give to the LPN

1. Dressing change on foot ulcer
2. Insert Foley catheter
3. Enema as prep for radiological procedure
4. Bed bath for four clients
5. Checking vital signs

Answer 19

LPN

1. Dressing change on foot ulcer
2. Insert Foley catheter

CNA

3. Enema as prep for radiological procedure (YES, they can give enemas)
4. Bed bath for four clients
5. Checking vital signs

Question 20

State Naegele’s rule for estimating pregnancy

When would be the due date for a client whose last menstrual cycle started June 10
Ended June 14

Answer 20

Naegeles rule states:
Date of onset of (LMP -Last menstrual period) + 9 months + 7 days

June 10th + 9 months = March 10th

March 10th + 7 days = March 17th

Question 21

Immune system attacks the nerves.
The condition may be triggered by an acute bacterial or viral infection.

Early: weakness and tingling in the feet and legs that spread to the upper body. Paralysis can occur. (Lung paralysis)

Special blood treatments (plasma exchange and IV immunoglobulin therapy) can relieve symptoms.

Physical therapy is needed.

Answer 21

Guillain barré syndrome

Question 22

autoimmune disease that occurs when the body’s immune system mistakenly attacks and destroys the pancreas’ insulin-producing beta cells.

Name the disease

Answer 22

DM type 1

Question 23

In _____ arthritis, the body’s immune system attacks its own tissue, typically in the hands and feet. In some people, the condition can damage body systems including the skin, eyes, lung, heart and blood vessels.

Answer 23

rheumatoid

Question 24

Hashimoto disease describe:

Describe disease in general.

How you contract it?

Symptoms/ Complications

Treatment

Answer 24

Hashimoto is an Auto Immune disorder that attacks the Thyroid (butterfly shapped organ Located below Adam’s Apple)

Contracted Auto Immune

S&S: Same as hypothyroidism (Tired, Sleepy, muscle weakness & aches)

Complications: Goiter - which can cut off airway
Myxedema coma: Exposure to Stress, Cold, Infection or Sedation

Treatment: levothyroxine aka Synthroid

Question 25

Client with schizophrenia has frequent hallucinations and is becoming withdrawn. Which are appropriate interventions to hallucinations 1. Communicate frequently and present to reality 2. Use distraction techniques 3. Ask client to describe hallucinations 4. Encourage the client to participate in reality-based activities, ie. Playing Cards 5. Tell client to ignore hallucinations

Answer 25

1. Communicate frequently and present to reality 3. Ask client to describe hallucinations (Helps determine if Client or Others are at risk due to the hallucinations) 4. Encourage the client to participate in reality-based activities, ie. Playing Cards Do Not Use distraction techniques Tell client to ignore hallucinations

Question 26

Ischemic stroke ( From Clot ) in the Right Hemisphere. What type of problems do you anticipate?

Answer 26

Left sided paralysis and visual disturbances

Question 27

Raynauds disease 35 yr female. Which is appropriate education? 1. Stop smoking 2. Wear gloves outside during cold weather 3. Handle foods from the refrigerator or freezer for brief periods 4. Avoid calcium channel blockers 5. Avoid beta blockers 6. Avoid birth control pills 7. Avoid vasodilatadors

Answer 27

Raynaud’s disease is intermittent digital arteriolar vasoconstriction, affects hands & feet: Result Ulceration or Gangrene 1. Stop smoking 2. Wear gloves outside during cold weather 3. Handle foods from the refrigerator or freezer for brief periods 5. Avoid beta blockers 6. Avoid birth control pills It's the opposite 4. Avoid calcium channel blockers 7. Avoid vasodilatadors Calcium channel blockers & vasodilatadors improve symptoms of Raynaud’s disease

Question 28

Flumazenil is....

Answer 28

a benzodiazepine antagonist typically used in overdose emergencies. Benzodiazepine overdose and postoperative sedation from benzodiazepine anesthetics

Question 29

Client mistakenly takes 4, 80mg doses of baclofen (to relieve muscle spasms) instead of his 4, 10mg dose. The overdose results in a overdose and pronounced CNS depression. Which of the following does the nurse anticipate 1. Administer Naloxone 2. Administer atropine 3. Supportive care only 4. Administer flumazenil

Answer 29

3. Supportive care only There is no antidote to muscle relaxants such as: Carisoprodol (Soma), Cyclobenzaprine (Flexeril), Metaxalone (Skelaxin), Methocarbamol (Robaxin), Baclofen (Lioresal) 2. Give atropine for Bradycardia 4. Give flumazenil for Benzodiazepine OD

Question 30

Carisoprodol Cyclobenzaprine Metaxalon Methocarbamol

Answer 30

Carisoprodol (Soma), Cyclobenzaprine (Flexeril), Metaxalone (Skelaxin), Methocarbamol (Robaxin), Baclofen (Lioresal

Question 31

Brain damage can happ3n from birth but is more often due to lack of oxygen than from compression of the skull. During birth mother has a narrow boney Pelvis. What is the most likely result? 1. Cerebral Palsy 2. Intracranial hemorrhage 3. Cranial molding 4. Epilepsy

Answer 31

3. Cranial molding

Question 32

____ can occur before, during, or shortly after birth, or in the first few years of life, when the brain is still developing. The majority of cases (85%–90%) are congenital, which is related to events before or during birth. A congenital disorder of movement, muscle tone, or posture. Exaggerated reflexes, floppy or rigid limbs, and involuntary motions. Medications: Valium, Ativan, Dilantin, and Versed.

Answer 32

Cerebral Palsy

Question 33

4 yr old child with autism reaches for a stuffed animal and says "bunny". Which of the following is the best example of Incidental Teaching? 1. Nurse asks, "What color is the bunny?" And waits for response before giving the child the toy 2. Nurse states, "that's right, it's a bunny" and gives child the toy 3. Nurse gives child toy without comment, because child correctly ID the toy 4. Nurse states, "before you get the bunny, you need to answer some questions "

Answer 33

1. Nurse asks, "What color is the bunny?" And waits for response before giving the child the toy Incidental teaching involves using a child's interest as teaching opportunities

Question 34

Which vaccine is needed <12 hrs after birth? 1. Polio 2. Heptavalent pneumococcal Conjugate 3. Hep B 4. Rotavirus

Answer 34

Hep B. It can be passed from mother to children during birth Vaccine consists of 3 doses. One at birth, second 1 - 2 months, third about 24 weeks.

Question 35

If mother test positive for Hep B what interventions are done to the child

Answer 35

1. Monovalent hepB vaccine 2. HepB immune globulin <12 hrs after birth

Question 36

TBI treated in ICU Which interventions does the nurse anticipate 1. Elevate HOB 2. Admin Ox maintain PaO2 >85mmHg 3. Maintain neutral alignment of head 4. Admin sedative to reduce Agitation 5. Maintain body temp below normal

Answer 36

1. Elevate HOB 3. Maintain neutral alignment of head 4. Admin sedative to reduce Agitation Not 2. Admin Ox maintain PaO2 >85mmHg - Should be maintain >90 5. Maintain body temp below normal (Maintain body at normal temperature)

Question 37

Rumack-Matthew nomogram....

Answer 37

Serum acetaminophen concentration, in relation to the time after ingestion, to assess potential hepatotoxicity after a single, acute ingestion of acetaminophen.

Question 38

15 yr old took bottle of Tylenol (Acetaminophen) 5 hrs prior to arrival at ED. Serum level is 180mcg/ mL Which of the following interventions does the nurse anticipate 1. Antidote: 72 hr N-acetylcysteine (NAC) protocol 2. Supportive care 3. GI decontamination with activated charcoal 4. Monitor hepatic function 5. Psychiatric consultation

Answer 38

1. Antidote: 72 hr N-acetylcysteine (NAC) protocol 2. Supportive care 4. Monitor hepatic function 5. Psychiatric consultation 3. GI decontamination with activated charcoal - Only with in 1 hr of ingestion.

Question 39

Acute spinal cord edema due to spinal cord injury. Drug to best control edema? 1. Aspirin 2. Mannitol 3. Morphine 4. Methylprednisone

Answer 39

Methylprednisone Is a steroidal Anti-inflammatory which reduces edema Mannitol is an osmotic diuretic to control brain edema

Question 40

Central catheter is inserted for administration of parental nutrition. X-ray shows the catheter tip is in the right Atrium. Which action is correct 1. Hold infusion and notify MD 2. Gently withdraw catheter 2-3 " 3. Begin the infusion catheter is placed correctly. 4. Gently insert catheter 2-3"

Answer 40

1. Hold infusion and notify MD Superior vena cava is the correct placement

Question 41

Which is correct for a toxic (not caustic) substance in the right eye. 1. Posistion client on their left side with head flat on surface 2. Irrigate with bulb syringe tip about .5" above eye. 3. Flush for 5 minutes 4. Hold eye open while flushing 5. Hold emesis basin against left side of clients face to contain the irrigant

Answer 41

2. Irrigate with bulb syringe tip about .5" above eye. 4. Hold eye open while flushing Incorrect: 1. Posistion client on their left side with head flat on surface (Place client on right side with head elevated 20°) 3. Flush for 5 minutes (mometrix says 1 minute) 5. Hold emesis basin against left side of clients face to contain the irrigant

Question 42

Stages of wound repair Profileration, Maturation, Inflammation, Hemostasis 1st stage: First few minutes platelets seal off vessels, Vasoconstriction, Thrombin stimulates clotting mechanism forming fibrin mesh 2nd over 1 - 4 days inflammatory response & phagocytosis occurs 3rd Over 5 - 20 days. Fibroblasts produce collagen & granulation tissue starts to form 4th. After 21 days - 2 years. Collagen tightens to reduce scars. Tissue gains tensile strength

Answer 42

Hemostatis 1st stage: First few minutes platelets seal off vessels, Vasoconstriction, Thrombin stimulates clotting mechanism forming fibrin mesh Inflammation 2nd over 1 - 4 days inflammatory response & phagocytosis occurs Profileration 3rd Over 5 - 20 days. Fibroblasts produce collagen & granulation tissue starts to form Maturation 4th. After 21 days - 2 years. Collagen tightens to reduce scars. Tissue gains tensile strength

Question 43

An epileptic taking phenytoin will be educated about these long-term SE 1. Gingival hypertrophy 2. Hirsutism 3. Hypertrophy of facial subcutaneous tissue 4. Dementia 5. Anemia

Answer 43

1. Gingival hypertrophy 2. Hirsutism 3. Hypertrophy of facial subcutaneous tissue Long-term use of phenytoin includes condition call "Dilantin facies" characterized by Gingival hypertrophy, hirsutism (hair growth on unexpected areas of the body, such as on the face, chest, and back) and Facial SQ fat loss. Additionally, they may develop osteoporosis, Vitamin D is prescribed. Clients with low albumin (renal disease or malnutrition) may have more severe side effects

Question 44

Client taking anticholinergic (benztropine mesylate) aka Cogentin to relieve tremors & muscle spasms associated with Parkinsons disease are advised to avoid 1. Overheating 2. Overeating 3. Excessive fluid intake 4. Skipping meals

Answer 44

Overheating Anticholinergics "dry you up" and affect the ability to sweat

Question 45

Which is correct when taking a telephone order 1. Write down orders directly into clients record as given 2. Write orders in their entirely and read back to confirm 3. Repeat each order 1 at a time and confirm each before proceeding 4. Insist the physician email or fax a copy of the orders for confirmation

Answer 45

2. Write orders in their entirely and read back to confirm Repeating each order and confirmation before proceeding may cause MD to lose their train of thought

Question 46

Alzheimer's patient has repeatedly eloped by walking out the front door at night. Which of the following might be helpful 1. Hang curtain over the front door 2. Place a latch at the top or bottom of the door. 3. Lock client into their room. 4. Place motion detector with loud alarm on clients bedroom door 5. Place bed restraints on client

Answer 46

1. Hang curtain over the front door 2. Place a latch at the top or bottom of the door. NOT A motion detector with loud alarm will scare client and make them want to escape

Question 47

Type of cancer that kills most women between 15 - 34

Answer 47

Breast also highest in 35 - 54 Breast cancer is more aggressive & harder to detect in young women due to denser breast tissue

Question 48

Eye opening, verbal response, and motor response are all the criteria for this scale. What are the "brackets" in this scale

Answer 48

Glasgow coma scale 16 = Fine 15 - 13 = mild head injury 9 - 12 = Moderate head injury <8 = Severe head Injury 3 - 8 = Coma

Question 49

Client has episodes of Constipation with fecal impaction. The nurse assisting with bowels training regimen will include which interventions 1. Scheduled toileting 2. Stool softeners 3. High Fiber Diet 4. Daily Laxatives 5. Periodic enemas 6. Routine exercise

Answer 49

1. Scheduled toileting 2. Stool softeners 3. High Fiber Diet 6. Routine exercise Not 4. Daily Laxatives 5. Periodic enemas

Question 50

Best body mechanics for moving a heavy medication cart 1. Push cart both hands, head up and back straight 2. Pull cart 1 hand leaning slightly forward 3. Push cart with shoulders 4. Pull cart with 1 hand, head up and back straight

Answer 50

Push cart both hands, head up and back straight Avoid pulling or twisting when moving items. Stand close to item

Question 51

Tracheostomy client needs these teachings before discharge 1. Bowel care 2. Pulmonary hygine 3. Dietary supplements 4. Tracheostomy care 5. Exercise program

Answer 51

1. Bowel care 2. Pulmonary hygine 4. Tracheostomy care Bowel care is needed due to client cannot "bear down" for Valsalva maneuver & may need daily stool softeners

Question 52

Nulliparous client is fully effaced and dilated 3cm after 12 hrs of mild contractions at home. How long should it take to get to 10 cm dilation

Answer 52

7hrs Nulliparous dilate at a rate of 1 cm per hour The latent phase of stage 1 usually last 10- 14 hrs the client went through this phase and now is in the active phase

Question 53

Client had 4 pregnancies 1 miscarriage at 12 weeks 2. Still born at 34 weeks 3. Healthy son at 38 weeks 4. Healthy daughter at 40 weeks What is her Gravida / Para number

Answer 53

Gravida 4 Para 3 Gravida = confirm3d pregnancies Para = number of births after 20 weeks

Question 54

What is a concern of using Naloxone on a longtime opiod addict?

Answer 54

Withdrawal & Seizures

Question 55

What is a normal TUG (Timed up & go) What is considered a fall risk

Answer 55

Normal 7 - 10 seconds Fall risk >14

Question 56

Which is most appropriate for stage II pressure ulcer with moderate exudate 1. NS on guaze (Wet-to-Dry) 2. Transparent film 3. Hydrocolloid 4. Hydrogel

Answer 56

Hydrocolloid - contains gelling agents to absorb exudate Wet - to - Dry No longer recommended Disrupt the graduation process. Transparent is used to IV ports Hydrogels are designed to hydrate dry wounds Not for Exudate

Question 57

Is it ever appropriate to "milk" blood clots out of the tubing of a JP drain before emptying it?

Answer 57

Yes, this is how one removes blood clots

Question 58

Which B vitamin does a woman need to start taking before she gets pregnant to prevent neural tube defects

Answer 58

B9 folate

Question 59

Which are Contradicted for Parkinsons patient who has been prescribed levodopa (Precursor to Dopamine) helps with ADL's 1. Narrow angle glaucoma 2. Macular degeneration 3. Pregnancy 4. Melanoma 5. Cataracts

Answer 59

1. Narrow angle glaucoma 3. Pregnancy 4. Melanoma Also not for clients with psychosis & monitor if there is a heart problem

Question 60

How long is the incubation period for measles? When can a person with measles pass it to another person (how long into the disease)

Answer 60

Incubation period 7 - 21 days May spread measles 4 days prior to rash & 4 days after

Question 61

Match the following Brain stem, Frontal Lobe, Cerebellum, Occipital, Parietal, Temporal Changes in mood & personality, as well as hemiparesis Visual disturbances & Hallucinations Loss of memory, speech abnormalities, and lack of coordination Loss of sensation, difficulty with fine motor skills, Loss of half body awareness Lack of balance and coordination Dysphagia, facial pain, weakness and cranial nerve dysfunction

Answer 61

Frontal Changes in mood & personality, as well as hemiparesis Occipital Visual disturbances & Hallucinations Temporal Loss of memory, speech abnormalities, and lack of coordination Parietal Loss of sensation, difficulty with fine motor skills, Loss of half body awareness Cerebellum Lack of balance and coordination Brain stem Dysphagia, facial pain, weakness and cranial nerve dysfunction

Question 62

Study macule, papule, nodule, patch in your nursing class stuff

Answer 62

Infact study all of that stuff

Question 63

11 yr old autistic is hospitalized. When parents not present he hits his head on the wall, screams, get violent. Which is the most effective method to control his behavior 1. Ask the parents for advice 2. Ask physician for a sedative 3. Place child in restraints 4. Ask for psych referal

Answer 63

Ask the parents for advice

Question 64

Cranial molding is a common, abnormal head shape in newborns that occurs when pressure is applied to the baby's head during childbirth. Cause the skull bones to shift Treatments

Answer 64

Helmet therapy to reconform head shape