Other Flashcards
Hyperthyroidism
Hyperthyroidism presents with findings such as ____?
–> Heat Intolerance
–> Palpitations
–> Weight Loss
Grave’s Disease
A nurse is reviewing the electronic health record (EHR) of a client who has Graves disease and findings of exophthalmos. Which location should the nurse expect to find exophthalmos?
Over right or left eye
Exophthalmos is abnormal protrusion of the eyeball which is due to edema in the extraocular muscles and increased fatty tissue behind the eye.
Grave’s Disease
A nurse in a provider’s office is reviewing the health record of a client who is being evaluated for Graves disease. The nurse should identify that what laboratory result is an expected finding?
Decreased thyroid-stimulating hormone (TSH).
In the presence of Graves disease, low TSH is an expected finding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated. In the presence of Graves disease, elevated thyrotropin receptor antibodies, elevated free thyroxine index, and elevated triiodothyronine are expected findings.
Hip Arthroplasty: Post-op care
A nurse is providing postoperative care for a client following a total hip arthroplasty. What should the nurse review with the client?
–> Provide a raised toilet seat for the client
–> Use an abductor pillow when turning the client
–> Instruct the client on the use of an incentive spirometer
When taking actions, the nurse should provide a raised toilet seat for the client to avoid hip flexion of 90 degrees which cause dislocation of the operated hip. The nurse should place an abductor pillow in between the client’s legs when turning to prevent dislocation of the operated hip. The nurse should also instruct the client to perform incentive spirometry exercises to promote alveolar expansion and avoid postoperative respiratory complications.
Hip Arthroplasty: Post-op care
A nurse is providing teaching for a client who had a total hip arthroplasty. What information should the nurse include?
–> Clean the incision daily with soap and water
–> Remain at a 90 degree angle when sitting
–> Use a raised toilet seat
When taking actions, the nurse should instruct the client to clean the incision daily with soap and water to prevent an infection. The client should remain no more than 90 degree angle flexion when sitting and externally rotate the toes to avoid dislocation of the hip. The client should use a raised toilet seat to prevent extreme flexion of the hip which can cause dislocation.
Client education:
- Use raised toilet seats, and assistive items (long-handled shoehorn, dressing sticks) to prevent strain on the prosthesis/flexion > 90 degrees.
- Follow position restrictions to avoid dislocation.
- Use straight chairs with arms.
- Use an abduction pillow or regular pillow, if prescribed, between the legs while in bed (and with turning, if restless, or in an altered mental state).
- Externally rotate the toes.
- Avoid flexion of hip greater than 90°.
- Avoid low chairs.
- Do not cross the legs.
- Do not internally rotate the toes.
- Avoid turning to the operative side, unless prescribed.
- Anticoagulant medications (warfarin, aspirin) can be required for several weeks after surgery.
Hip Arthroplasty
What should a nurse monitor for new hip dislocation?
- acute onset of pain
- reports hearing “a pop”
- internal or external rotation of the affected extremity
- shortened affected extremity.
Hypovolemia
What are expected vital sign findings of hypovolemia (fluid volume deficit - FVD)
- hypothermia (hypovolemia)
- hyperthermia (dehydration)
- tachycardia
- thready pulse
- hypotension
- orthostatic hypotension
- decreased central venous pressure
- tachypnea (increased respirations)
- hypoxia
Hypovolemia
What are expected lab findings for hypovolemia?
- HCT: increased
- Urine specific gravity: > than 1.030
- Na: > 145
- BUN: > 25
- Increased protein, electrolytes, glucose
Hypovolemia
The nurse is reviewing the data on the client who has hypovolemia. The nurse should identify which of the following findings is a manifestation of hypovolemia?
- Increased HCT
- Decreased urine output
- Increased Na
Hypovolemia
The nurse is performing an assessment on the client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings?
- Hyperthermia
- Orthostatic hypotension
- Decreased skin turgor
Dehydration
The nurse is planning care for the client who is admitted to an acute care facility with dehydration. What actions should the nurse include in the plan?
- monitor the client’s respiratory rate, oxygen saturation and administer supplemental oxygen as prescribed, check the client’s urinalysis, CBC, and electrolytes, and alert the provider for a urine output less than 30 mL/hr
- measure the client’s weight daily at same time of day using the same scale, observe for nausea and vomiting, assess for blood pressure for postural hypotension, and encourage the client to change positions slowly and to use the call light and ask for assistance before getting out of bed
- check the client’s neurologic status, observe level of gait stability, assess heart rhythm, initiate, and maintain IV access, provide oral and IV rehydration therapy as prescribed, monitor I&O, and encourage fluids as tolerated
Hypokalemia
What are expected GI findings due to hypokalemia?
- decreased motility
- hypoactive bowel sounds
- abdominal distention
- constipation
- ileus
- N/V
- anorexia
Hypothyroidism
Hypothyroidism is characterized by what manifestations?
- fatigue (sleeping up to 16hr/day)
- irritability
- intolerance to cold
- constipation
- weight gain w/o increased caloric intake
- pallor
- thick, brittle fingernails
- depression/apathy
- joint/muscle pain
- low BP, low HR, dysrhythmias
- slow thought process/speech
- hypoventilation/pleural effusion
- thickening of skin
- hair loss/thinning eyebrow hair
- dry/flaky skin
- swelling in face, tongue, hands, feet
- decreased taste/smell
- hoarse speech
- abnormal menstrual periods
- decreased libido
Anaphylactic Reaction
What meds are expected to be administered during anaphylaxis?
- epinephrine
- bronchodilators
- antihistamines
Also provide respiratory support (O2, albuterol) & notify provider
Renal Calculi
Nephrostomy Tube Care
- monitor output from drains/catheters for expected color/amount
- notify provider if urine is decreased or absent in client w/ external pouch
- Secure external drainage catheter - notufy provider if it becomes dislodged or removed
- monitor urinary output in pouch/drains
