Assess 2 Flashcards
Which priority assessment finding should the clinic nurse discuss with the health care provider for Diabetes?
high blood sugar (hyperglycemia) in the blood stream (viscosity of the blood)
polyuria (increased urine output), polydipsia (increased thirst), and polyphagia (increased hunger) Weight loss (type 1)
Glucosuria
Which statement by the client should the nurse evaluate as a good understanding of the disease process of Diabetes I?
Chronic disorder of the pancreas (type 1)
Absolute lack of insulin secretion for DM I due to autoimmune destruction of pancreatic islet cells and secretes and releases enzymes for chemical digestion of nutrients
- What should the nurse include in the discharge teaching on blood glucose levels?
Fasting blood glucose > 126 mg/dL (x 2) – hyperglycemia
Which statement by the client should the nurse evaluate as a good understanding of the disease process of DM I?I (4)
- Target cells become unresponsive to insulin (defective insulin receptor function); blood glucose levels rise
- Cells cannot use the Insulin the pancreas makes
- Pancreas secretes more insulin; hypersecretion leads to beta cell exhaustion and death
- Eventual deficiency in insulin secretion + insulin resistance
What should the nurse include in the discharge teaching for type I?
-Dietary restrictions
- Exercise
- Insulin therapy via Insulin pump
What should the nurse include in the discharge teaching for type II?
Healthy diet and exercise can reverse insulin resistance
- Oral hyperglycemics and Insulin
Which statements by the client should the nurse evaluate as a good understanding of the teaching provided on if person does not stick to the regimen for diabetes? (5)
- Cardiovascular damage – heart disease
Nervous system damage
Kidney disease
Blindness
Numbness/tingling in feet or hands
How should the nurse analyze this statement? Endocrine function of pancreas is not working
Beta cells does not produce enough Insulin
How should the nurse analyze this statement? Cells cannot use the Insulin the pancreas makes
- Pancreas secretes more insulin; hypersecretion leads to beta cell exhaustion and death
- Eventual deficiency in insulin secretion + insulin resistance
What action should the nurse include in the care plan to assess a possible complication from DMI?
Diabetic Ketoacidosis - serious symptom
Which priority assessment finding should the clinic nurse discuss with the health care provider for diabetes?
when have you had problems?
Do you have a family history of diabetes or obesity
What action should the nurse take next? How should the nurse response for rapid-acting,
Administer 0.5 to 1 unit/kg/dose 5 minutes or just before meals.
Take your insulin 5 minutes before meals.
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided for rapid- acting insulin?
0.5 to 1 unit/kg/dose 5 minutes or just before meals.
What action should the nurse take next? How should the nurse response for short-acting,
Administer less than 10 units - 30 minutes before meals
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided for onset, peak, and duration of short- acting insulin?
Onset 30 minutes to 1 hour.
Peaks in 2-4 hours.
Lasts 6-8 hours.
What are some rapid acting insulins?
Lispro (human analog) (Humalog)
human Insulin aspart (rDNA origin) (NovoLog)
What assessment finding should the nurse expect for someone with moderate hypoglycemia? Nervousness, hunger, headache, shakiness, dizziness, confusion, weakness, diaphoresis (sweating/moist skin).
Nervousness, hunger
headache
shakiness/dizziness, weakness
confusion
diaphoresis (sweating/moist skin).
How should the nurse respond to the client’s condition with BS<70?
For moderate hypogycemia,
treat with Treat with 3-4 glucose tablets
3 oz. regular soda
1 T sugar or honey
5-6 hard candy
Give 4-8 oz milk and half a cheese sandwich (this is the best answer because it will not allow them to crash)
What assessment finding should the nurse expect for someone with severe hypoglycemia?
Confusion, combativeness, unresponsiveness, coma.
Which nursing action should nurse take next for severe hypoglycemia?
Treat with glucagon 1M and/or dextrose 5 IV drip or 50 IV push
What action might the nurse take next after Alpha- glucosidase inhibitors is used?
May be used with insulin, sulfonylureas and biguanides.
What assessment finding should the nurse expect as a possible complication from alpha-glucosidase inhibitors?
ADR: Abdominal pain, flatulence, diarrhea.
may increase risk of hypoglycemia when used with sulfonylureas or insulin
Which statement by the client should the nurse recognize as effectiveness of the medication and goal of alpha-glucosidase inhibitors?
Inhibit the enzyme from the pancreas that breaks down complex carbohydrates into glucose.
What are examples of alpha-glucosidase inhibitors?
acarbose (Precose) and miglitol (Glyset)
How should the nurse respond if a child’s growth is well below the standard for a specific age?
Refer to endocrinologist
Which risk factors of a child should the nurse expect to find upon review of the client’s medical record for GH deficiency?
Child is short for stature/low percentile
Growth deficiency may be diagnosed, and dwarfism can result
Which client statement should the nurse interpret as GH replacement is having its desired effects?
GH replacement – Drug of Choice – Somatropin (Genotropin)
Several years of tx can increase height (growth)
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided on pituitary GH deficiency?
Has the same amino acid as HGH
Promotes bone growth at the epiphyseal plates of long bones
Must be given before fusing of the epiphysis occurs
Several years of tx can increase height (growth)
What action should the nurse include in the care plan to assess a possible complication from GH replacement?
prolonged use can cause DM because it increase serum in blood, so refer to endocrinologist
Which priority assessment finding should the clinic nurse discuss with the health care provider for hypothyroidism?
Decreased T4 and elevated TSH levels- primary
Lack of TSH secretion- secondary
lack of TRH (Free T4 and serum TSH are low)- tertiary
What assessment findings should the nurse expect with primary hypothyroidism?
(primary and five findings)
Decreased T4 and elevated TSH levels
Lethargy, apathy, memory impairment, slow speech, edema in eyelids and face
What assessment finding should the nurse expect with secondary hypothyroidism?
Lack of TSH secretion-
What assessment finding should the nurse expect with tertiary hypothyroidism?
lack of TRH (Free T4 and serum TSH are low)
Which priority assessment finding should the clinic nurse discuss with the health care provider when seeing severe hypothyroidism in children?
Congenital Cretinism in children
Which priority assessment finding should the clinic nurse discuss with the health care provider when seeing severe hypothyroidism in adults?
Myxedema in adults
What should the nurse include in the discharge teaching of when the full benefits of synthroid will kick in?
It take a few weeks – up to 3 weeks to see the full benefits from the drug
Which statement by the client should the nurse recognize as effectiveness of the medication and goal of the synthroid?
It take a few weeks – up to 3 weeks to see the full benefits from the drug
will reverse the effects of Lethargy, apathy, memory impairment, slow speech, edema in eyelids and face
What action should the nurse include in the care plan to assess a possible complication from synthroid?
Tachycardia, irregular heart rate, hypertension, nervousness, weight loss, diarrhea, heat intolerance and excess fatigue, slow speech, hoarseness or slow pulse bone density.
Which statement by the client should the nurse recognize as the client needing additional/further teaching for Synthroid ?
I take it in the morning
What should the nurse include in the discharge teaching for synthroid? (3)
lifelong use
Causes insomnia
Take with plenty of water to avoid gagging.
Which statement by the client should the nurse evaluate as a good understanding of the increase in circulating T4 and T3 levels? (3)
Graves disease or thyrotoxicosis
Most common type of hyperthyroidism
Caused by hyperfunction of the thyroid gland
Which statement by the client should the nurse recognize as the effectiveness of the medication and goal of the therapy? (3)
I do not have any more palpitations
I do not feel as hot anymore
I am not perspiring as I did before I am not as anxious, nervous, or irritable as I did before
Which statement by the client should the nurse evaluate as a good understanding of the disease process of the adrenal medulla?
Adrenal medulla- Produces epinephrine and norepinephrine
Which statement by the client should the nurse evaluate as a good understanding of the disease process of the adrenal cortex?
Adrenal cortex- Produces glucocorticoids (cortisol), Mineralocorticoids (aldosterone)
What secretion causes Addison’s disease?
Glucocorticoid hyposecretion
What secretion causes Cushing syndrome?
Glucocorticoid hypersecretion
What assessment findings should the nurse expect for side effects of high or prolonged glucocorticoid use? (3)
Cushing’s syndrome
Upper body obesity, abnormal fat deposits in face (moon face) and trunk (dowager’s or buffalo hump)
increased blood sugar
How should the nurse analyze this statement? I am having HTN, euphoria, decreased extremity size and psychosis
Addisonian crisis
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided on long term glucocorticoid use? (3)
adrenal atrophy (loss of adrenal gland function), muscle wasting, osteoporosis
Which lifestyle risk factors of PUD should the nurse expect to find upon review of the client’s medical record? (5)
Alcohol
Smoking tobacco
Caffeine
Drugs (corticosteroids, N S A I D s, platelet inhibitors)
N S A I D s (most common cause in those who are not infected with H. pylori)
Excessive psychological stress
Which general risk factors of PUD should the nurse expect to find upon review of the client’s medical record? (3)
Infection with Helicobacter pylori
Close family history of P U D
Blood group O
What assessment finding should the nurse expect with H. Pylori?
Primary cause of peptic ulcers
Gram-negative bacterium will release 13CO2
- What should the best plan by the nurse include for H. Pylori suspicion?
Noninvasive test and Administering 13C urea
What assessment finding should the nurse expect with non-H. Pylori? related causes of PUD?
Secretion of excess gastric acid
inadequate mucus secretion
N S A I D s
What should the nurse include in the discharge teaching on PPI endings?
end in “zole”
ex: Prilosec (omeprazole)
What should the nurse include in the discharge teaching about PPI’s? (2)
Reduce acid better
Have a longer DOA
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided on H2-receptor antagonists?
I will take B to avoid deficiency when taking Zantac or Tagamet
How should the nurse analyze this: client is missing vitamin B?
patient may be taking H2-receptor antagonists?
What should the best plan by the nurse include for PUD?
best combination PPI & triple Abx
What action should the nurse take next after taking antacids such as sucralfate?
give H2-receptors one hour after
Which statement by the client should the nurse evaluate as a good understanding of the teaching on mucosal protective drugs?
I will take H2-receptors one hour after the antacid because the drug coats the gastric lining from the gastric acids
What action should the nurse include in the care plan to assess a possible complication from Misoprostol (Cytotec)? (2)
Gastric distress from long-term NSAIDs therapy
Category X- Sometimes terminate pregnancy
Which assessment finding should be of concern to the nurse to tell the client to not use this drug Misoprostol (Cytotec)?
pregnancy possibility and confirmed pregnancy
Which client statement should the nurse interpret as the PUD treatment is having its desired effects?
H. pylori infection eliminated, bacteria eradicated, and ulcers heal more rapidly, prevent recurrence
Which statement by the client should the nurse evaluate as a good understanding of the teaching on how the PPI works?
reduces acid secretion in stomach by binding irreversibly to enzyme H+, K+, and ATPase
What action should the nurse include in the care plan to assess a possible complication from PPI’s?
Use short term only 4-8 weeks of therapy for ulcers and GERD
What should the nurse include in the discharge teaching for PPI’s?
on an empty stomach before breakfast with antacids optional and swallowed, not chewed
What should the nurse include in the discharge teaching for PPI’s? How to take, and ADR’s
on an empty stomach before breakfast with antacids optional and swallowed, not chewed
Which assessment finding should be of concern to the nurse to tell the client not to use PPI’s
Use of more than two months and pregnant
Which statement by the client should the nurse evaluate as a good understanding of the disease process and the drug?
Full effect can take several days to weeks and must take consistently and ulcer can completely heal
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided on PUD?
I will take the drug consistantly
I will notify the HCP if my gastric discomfort worsens after several weeks
I will report any emesis
I will return periodically for lab work
Which statement by the client should the nurse recognize as effectiveness of the medication and goal of therapy of PUD?
Promotes ulcer healing
Healing should occurs in 4-8 weeks and pain subsides after 10 days
Ulcers can remain in remission longer
Which statement by the client should the nurse recognize as effectiveness of the medication and goal of therapy
H. Pylori can have a very high recurrence if H. Pylor is not eradicated
Wha should the best plans by the nurse be to treat a patient with vomiting, diarrhea, and/or constipation?
Antiemetics
Emetics
Antidiarrheals
Laxatives
What assessment finding should the nurse expect in dietary habits when a client has constipation
Lack of fiber
Chronic laxative use
Insufficient water intake
What assessment finding should the nurse expect in lifestyle habits when a client has constipation
Fecal/bowel obstruction
Neuro disorder
Ignoring urge to defecate
Lack of exercise
Various drugs
What are some priority questions a nurse should ask the client prior to administration of constipation meds?
How have your bowel movements been?
Have you been taking any laxatives?
Which statement by the client should the nurse recognize as effectiveness of the medication and goal of Docusate Sodium/Colace/mineral oil?
Prevent constipation and
Decrease straining during defecation
Which client statement should the nurse interpret as the stool softener is having its desired effects?
Lowers surface tension
Promotes water accumulation in intestine and stool
Emulsify and lubricate feces for easier passage
What should the nurse include in the discharge teaching?
Nausea vomiting and diarrhea should make you stop taking the medication
Cramping is serious
Any of these indication should make you ask your provider
Which statement by the client should the nurse evaluate as a good understanding of laxative uses?
Promotes soft stool
Cathartics promote soft to water stool with cramping (Metamucil)
Purgatives promote water stool with cramping
What are some types of laxatives?
Osmotic (saline
Stimulant (irritants)
Bulk-forming
Emollient (stool softener)
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided for laxatives?
Take with enough water to prevent obstruction
Which priority assessment finding should the clinic nurse discuss with the health care provider?
Do you have cramping
Which assessment finding should be of concern to the nurse to tell the client to not use this drug?
Psyllium may decrease the absorption and effects of warfarin, digoxin, nitrofurantoin, antibiotics, tricyclic antidepressants, carbamazepine, and salicylates.
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided? Name and bulk-forming medication and MOA
Psyllium mucilloid
Swells and increases size of fecal mass
How should the nurse respond to a patient who has undiagnosed abdominal pain, intestinal obstruction, or fecal impaction?
Stop or don’t take the Metamucil and notify provider
Which statement by the client should the nurse evaluate as a good understanding of the adverse reactions of bulk forming laxatives?
Absorbs water into intestines
Increases bulk and peristalsis
Promotes large, soft stools
Which statement by the client should the nurse evaluate as a good understanding of the adverse reactions of bulk forming laxatives?
Cramps
N/V
Farting/diarrhea
Insufficient fluid intake causes intentional obstruction
What assessment finding should the nurse expect in DM 2 patients taking psyllium muccilloid?
Reduction of serum glucose levels
Which assessment finding should be of concern to the nurse to tell the client to not use this drug?
Psyllium may decrease the absorption and effects of warfarin, digoxin, nitrofurantoin, antibiotics, tricyclic antidepressants, carbamazepine, and salicylates.
How should the nurse respond? I have severe diarrhea, what treatments are there?
Diphenoxylate with Atropine (Lomotil)
What are medications for mild diarrhea?
Loperamide (Imodium)
Bismuth subsalicylate (Pepto-Bismol)
Psyllium preparations (adjunct)
Probiotic supplements (Lactobacillus)
Which statement by the client should the nurse evaluate as a good understanding of the disease process of constipation?
Helps with symptoms, but not with pain, no driving
Which statement by the client should the nurse evaluate as a good understanding of the disease process?
Helps with symptoms, but not with pain, no driving
What should the nurse include in the discharge teaching for Diphenoxylate??
Doesn’t have analgesic properties
Drug is well tolerated at normal doses
Some ADRs are dizziness, drowsiness, and do not operate heavy machinery
Which risk factors of IBS should the nurse expect to find upon review of the client’s medical record?(4)
Spastic colon or mucous colitis
Ulcers in the lower GI with cramping, bloating, and gas
Constipation alternating with diarrhea and mucous in stool
At least three days / past three months
Recurrent abdominal pain
How should the nurse respond when a patient can’t swallow and has a nonfunctioning GI tract?
TPN
What should the best plan by the nurse include if a patient is malnourished and have dysphagia and has a functioning GI tract?
NG tube for short term
Peg/G tube for long term
What should a client understand about a G tube?
Longer term treatment where a tube is surgically placed into the client’s stomach
Which nursing action should nurse take with G tubes?
Don’t crush enteric coated drugs into G-tubes
Flush routinely to maintain latency
If drug form is a pill can cannot be crushed, contact the physician
What is also known as hyperalimentation?
TPN
What demonstrates a good understanding by the client about the difference between peripheral and central TPN and how they are administered?
Peripheral veins are for short-term and central is for long term and they are both
What action should the nurse include in the care plan to assess a possible complication from TPN?
Use an infusion pump
Change rates gradually and avoid abrupt discontinuation
Remove from fridge 30 minutes prior to hanging
How should the nurse respond to the client’s condition of irritation at the TPN site
Make sure to bring the solution up to room temp before hanging
What should the nurse include in the discharge teaching for successful TPN feeding?
Use the pump for precision
Change rates gradually and abrupt discontinuation of TPN
Don’t put in cold infusions
Can cause hyperglycemia
Which statement by the client should the nurse evaluate as a good understanding of the teaching provided about why the patient can get hyperglycemic?
The solution has lots of sugar
What assessment finding should the nurse for enteral feedings?
Skin turgor and mucous membranes
What action should the nurse take next after an enteral feeding?
Provide water between bolus feedings
Clean the area around the insertion site
Clean the equipment between each feeding
Refrigerate any feeding not needed for a feeding
What should the nurse include in the discharge teaching?
Consume small amounts of water if allowed
Teach patient to monitor for dry mouth on lips, or tenting, for dehydration
