Term
| a client presents to the walk in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client? |
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Definition
| use caution while driving or performing hazardous activities |
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Term
| a client has just been diagnosed with cerebral aneurysm. In planning discharge teaching to the client what instructions should be delivered by the nurse to the client? |
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Definition
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Term
| A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help the clients with tension headaches? |
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Definition
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Term
| the nurse is caring for a client with a cerebral aneurysm why does the nurse limit the interaction of visitors or family members with the client with an aneurysm |
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Definition
| the stimulation can increase intracranial pressure ICP or trigger a seizure |
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Term
| a client is prescribed warfarin client teaching has included instructions to avoid a diet rich in foods contaaining vitamin k what sources of food should the nurse instruct the client to avoid? |
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Definition
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Term
| a client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give to this client? |
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Definition
| Identify and avoid factors that participitate or intensify an attack |
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Term
| you are caring for a client admitted with a stroke Imaging studies indicate an embolus partially obstructing the right caratoid artery what type of stroke do you know this client has? |
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Definition
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Term
| while making your initial rounds after coming on shift you find a client thrashing about in bed complaining of severe headache. The client tells you the pain is behind the right eye , which is red and tearing. What type of headache would you suspect the client of having? |
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Definition
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Term
| a family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting the nurse knows that when a client experiences a stroke on the right side of the brain common deficits include what? |
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Definition
left sided hemiplegia
tendacy to distractibility
neglect of objects and people on the left side |
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Term
| a 76 year old male client is brought to the clinic by his daughter the daughter states that her father has had two transiet ischemic attacks in the past week the physician orders caratoid angiography and the report reveals that the cartoid artery has been narrowed by atherosclerotic plaques what treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? |
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Definition
balloon angioplasty of the cartoid artery followed by stent placement
caratoid endarterectomy |
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Term
| the nurse is completeing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for migraine headache? |
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Definition
red wine
nausea
mensturation
prolonged positioning |
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Term
| a client who complains of recurring headaches accompanied by increased irrability photophobia and fatique is asked to track the headache symptoms and occurence on a calendar log. Which is best nursing rationale for this action? |
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Definition
| migraines often coincide with menstural cycle |
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Term
| when providing teaching to a client who reports tension headaches which of the following instructions would be the most beneficial to prevent onset symptoms? |
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Definition
| perform stretching exercises and frequent position change |
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Term
a client who has experienced an initial transiet ischemic attack states "im glad it wasnt anything serious" which is the best nursing response to this statement?
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Definition
| tia is a warning sign lets talk about lowering your risks |
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Term
| a client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce th risk of cerebralvascular accident the nurse anticipates the medical treatment to include which of the following |
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Definition
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Term
| a client is brought to the emergency department with symptoms of cerebralvascular accident the nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? |
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Definition
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Term
| a client with a cerebralvascular accident is having difficulty with eating food on the plate which is the best nursing action to be taken? |
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Definition
| perform a vison field assesment |
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Term
| a client has been found unresponsive at a home for an undertermined period of time a CVA is suspected and the family is demanding a clot buster be used to restore functioning. The nurse knows that succesful use of TPA in an client with CVA requires which of the following? |
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Definition
prescence of an ischemic stroke
administer within 3 hpurs of onset symptoms |
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Term
| the nurse is assisting a client with a right sided brain infarction to transfer from the wheelchair to the bed which is the best placemnet of the wheelchair to facilitate this transfer? |
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Definition
| wheelchair placed on the right side of the bed facing the foot |
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Term
| following the use of a thrombolytic agent in the management of CVA client which is the priority nursing assesment? |
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Definition
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Term
| the client with hemipeligia is ata risk for impaired walking. Which nursing intervention would best assist this clieny in preventing complications associated with lower extremity impairment? |
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Definition
| use of high top tennis shoes throughout the day |
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Term
| which of the following goals is the priority in the care planning of a client with CVA who is being transferred to a rehabilitation unit? |
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Definition
| to prevent contractures and joint deformities |
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Term
| which nursing assesment finding is most indicative of a hemorrhagic stroke? |
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Definition
| symptoms evolving over past 24 to 48 hrs |
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Term
| a video flouroscopy has determined that the appropriate diet for the client with a left CVA should include honey thickened liquids which of the following is the priority nursing diagnosis for this client? |
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Definition
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Term
| the client with a cerebral aneursym asks the nurse whats the big fuss over a headach which is the best response from the nurse regarding to a cerebral aneursym? |
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Definition
| your physician wants to evaluate the location and condition of the aneurysm |
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Term
| a client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm which assessment data provides the most important information in preparing for the nursing care of this client? |
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Definition
| grade V on the hunt hess scale |
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Term
| a client prescribed sumatriptan(Imitrex) for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? |
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Definition
| I use to prevent migraines |
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Term
| a client with atrial fibrillation is placed on coumadin to reduce the potential of developing a CVA the international normalized ratio INR is 1.5 what does this finding indicate to the nurse? |
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Definition
| coumadin will be increased |
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Term
| a client is admitted into the ICU with a diagnosis of CVA. Which assessment by the nurse provides the most significant finding in differentaiatiang between ischemic and hemorrhagic stroke? |
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Definition
| a unit of fresh frozen plasma infusing |
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Term
| a client admitted with weakness expressive aphasia and right hemianopia the brain MRI reveals infarct. the nurse understands these symptoms to be suggestive of which of the following findings? |
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Definition
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Term
| a client has experienced a TIA and presents eith cartoid bruits. Which is the priority action to be take by the nurse following a bilateral cartoid endarctomy? |
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Definition
| anticipate need for endotracheal intubation |
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Term
| you are the nurse caring for the client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condiotion is in inital stages? |
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Definition
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Term
| you are caring for a client with shock. You are concerened about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client in shock? |
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Definition
| Arterial blood gas findings |
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Term
| you are the nurse caring for a client with shock accompanied by lung congestion How would you positon this client? |
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Definition
| semi fowlers with lower extremities raised to approximately 15 degrees |
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Term
| you are a nursing stduent preparing to care for an ICU client with shock. Ypur instructor asks you to name the different categories of shock. Which of the following is a category of shock? |
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Definition
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Term
| you are caring for a client who is in neurogenic shock You know that this is a subcategory of what kind of shock? |
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Definition
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Term
| you are assessing a 6 year old little girl in the ed who was brought in by the mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing She is vasodialated hypotension and has broken out in hives. What do you suspect is wrong with this client? |
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Definition
| she is having a allergic reaction and going into analphalactic shock |
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Term
| you are caring for a client in the compensation stage of shock. You know that one of the bodys mechanisms of compensation in this stage of shock is the renin angiotension aldostorone system. What does this system do? |
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Definition
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Term
| you are caring for a client in shock deteriating you are infusing IV fluids and giving medications as ordered. What type of medications are you mosy likely giving to this client? |
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Definition
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Term
| a patient presents to the ed for shock. At what point in shock does the nurse know that metaboliv acidosis is going to occur? |
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Definition
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Term
| the nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emeergency department. The client has numerous fractures internal abdominal injuries and large lacerations on the head and torso. The family arrives and seeks update on the clients condition a family memeber asks what causes the body to go into shock Given the clients condition which statement is most correct? |
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Definition
| the client is in shock because the blood volume has decresed in the system |
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Term
| the nurse is evaluating a client in the ICU to identify improvemnt in the clients condition which outcome does the nurse note as the result of inadequate compensatory mechanism? |
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Definition
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Term
| a client with a spinal cord injury the nurse caring for a client realizes that the client is at risk for which type of shock? |
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Definition
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Term
| a client presents to the community health office experiencing rapidly increasing symptoms of analphylatic shock which nursing action would be completed first? |
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Definition
| administer an epinepherine injection |
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Term
| the nurse is reviewing diagnostic lab work of a client developing shock which labatory result does the nurse note as a key in determining the type of shock? |
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Definition
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Term
| a nurse educator is teaching students the type of shocks and associated causes. Which combination of shock type and causative factors are correct? |
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Definition
hypovelimic shock; blood loss
cardiogenic shock; myocardinal infactrion
anaphlatic shock'nuts
septic shock; infection |
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Term
| the nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? |
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Definition
| increased arterial oxygenation |
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Term
| which compensatory mechanism during the first stage of shock is the nurse most correct to identify as responsible for stabilization of fluid balance? |
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Definition
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Term
| the nurse is caring for a client who has progressed to the decompasation stage of shock which intravenous medication does the nurse anticipate as prophlatic means to prevent complications? |
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Definition
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Term
| the nurse is obtaining physician orders which inclue a pulse pressure. The nurse is most correct to report which of the following? |
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Definition
| the differences between the systolic and dialstolic pressure |
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Term
| the nurse is reporting the current nursing assessment to the physician. Vital signs 97.2F pulse 68 thready respiration 28 bp 102/78 and pedal pulses palpable the physician asks for the pulse pressure which would the nurse report? |
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Definition
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Term
| the nurse is caring for a a client with highly pigmented skin. Which assessment techniques is used to evaluate cyanosis? |
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Definition
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Term
| the seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmanary artery pressure which statement made by the seasoned nurse reflects the most pertinent information regaurding circulation? |
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Definition
| the pulmanary artery pressure provides information about pressure on the left side of the heart |
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Term
| a nurse is initiating intravenous theraphy for a client who is in shock which ratio of fluid lost is anticpated? |
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Definition
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Term
| the registered nurse is recieveing a client from the emergency room on a dopamine drip the registered nurse asks the nurse to prepare the room for the client. The practical nurse obtains an IV pump sets bed arranges the furniture and places towels and a gown in the bathroom which other pice of equiptment is essential? |
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Definition
| an automatic blood pressure monitoring machine |
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Term
| the nurse is administering a medication to the client with a positive inotrophic effect. Which action of the medications does the nurse anticipate? |
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Definition
| increase the force myocardinal contraction |
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Term
| the nurse is caring for a client diagnosed with hypovelimic shock which outcome would be the best evidence of an improvement in client condition? |
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Definition
| alertneess in level of consciousness |
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Term
| the nurse is performing hourly assesments on an client in the compensation stage of shock in documenting the hourly urine output of 40ml hr from the foley cathetar which nursing action is appropriate? |
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Definition
| recordd 40ml as the hourly output |
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Term
| the nurse is planning care for a client diagnosed with cardiogenic shock which nursing intervention is most helpful to decrease myocardinal oxygen consumption? |
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Definition
| maintain activity restriction to bedrest |
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Term
| the community health nurse finds the client collapsed outdoors. The nurse assess that the client is shallow breathing and has a weak pulse the 911 is called by the neighbor which nursing action is helpful while waiting for the client ambulance? |
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Definition
| elevate the legs higher then the heart |
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Term
| the nurse is assisting the physician with placing a ventricular device which assessment finding would confirm the successful implementation? |
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Definition
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Term
| you are the nurse caring for a client in septic shock you know to closely monitor your client. What finding would you observe when the clients condition is in it initial stage? |
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Definition
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Term
| you are caring for a client who has a premature ventricular contractions what sign or symptom is observed in this client? |
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Definition
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Term
| a pacemaker is the treatment of chice for what cardiac dysrhythimia? |
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Definition
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Term
| the staff educator is teaching a classin dyrrhymias which statement is correct for defibrilation |
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Definition
| it is used to eliminate ventricular dysrhythimas |
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Term
| your client has just been diagnosed with a dysrhythymias the clients ask you to explain normal sinus rhythm what would you explain is the characteristics of normal sinus rhythym? |
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Definition
| the sinoatrial (SA) node initiates the impulse |
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Term
| you are taking a pre nursing pharmacology class. Today you are learning about antidysrhythymic drugs. What drug is a potassium channel blosker? |
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Definition
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Term
| you are caring for a client with atrial fibrillation what procedure would be recommeneded if drug therapies did not control dysrhythimia |
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Definition
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Term
| elective cardioversion is similat to defibrillation except thay electrical stimulation wants to discharge until an R wave appearsm Pacemakers. What does this prevent? |
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Definition
| disrupting the heart during the critical period of ventricular repolorization |
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Term
| you enter your clients room and find him pulseless and unresponsive what would be the treatment of chocie for this client? |
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Definition
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Term
| your client has returned to the floor with a transthoracic pacemaker ready to be connected. Ypu know that a transthoracic pacemaker used in what situation? |
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Definition
| transthoracic pacemakers are used in a client who has had open heart surgery |
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Term
| the nurse os caring for clients on the telementary unit which nursing considerations best represents concerns of altereed rhytmic patterns? |
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Definition
| altered patterns frquently affect the hearts ability to pump blood effectively |
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Term
| the nurse is caring for a client with dysrhythimia. While assessing the data in the history of the chart the nurse anticpates the cause of the dysrrhythymia to be which of the following? |
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Definition
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