Exam 2 401 Flashcards
The urine of a client is dark and foamy. What would the nurse suspect?
Cholecystitis
Measles, TB, and varicella are all requiring what type of precautions
Airborne
What are clinical manifestations of sepsis
Fever
Tachypnea
Tachycardia
Hypotension
Elevated wbc
Altered mental status/confusion
What are the stages of infectious disease process
Incubation (no symptoms)
Prodromal (nonspecific symptoms)
Acute illness (pronounced symptoms)
Convalescent (symptoms subside)
Patients who present with sepsis criteria and after fluid resuscitation their MAP is less than 65 serum lactate greater than 2 are considered to be clinically in what?
Septic shock
Clinical manifestations of TB
Blood tinged sputum with cough
Weight loss
Low appetite
Night sweats
Drycough
Fatigue
Low grade fever
Risk factors for UTIs
Pregnancy
Urinary tract obstruction or calculi
Females
Congenital malformation
Urinary stasis
Chronic disorders: diabetes mellitus
Menopause
Long term catheter use
Multiple sex partners
Lack of water intake
Diagnostic studies for UTIs
Clean catch Urine samples
Urinalysis
Gram stain, urine culture and sensitivity and wbc count
Clinical manifestations of cellulitis
Redness, warmth, edema and tenderness to the skin area.
Tight glossy stretched skin non elevated borders.
Interventions for conjunctivitis
Infection control strategy education
Antibiotics
Eye irrigation, warm washcloth
Photophobia management
Warm compress, cool compress, soaking eyelids
Clinical manifestations of otitis media
Pain in ear.
Hearing difficulties
Fever
Fluid draining from ear
Irritability in young children
Clinical manifestations of influenza
Fever cough inflammation of mucus membranes headache and malaise.
What education will the nurse provide regarding the flu vaccine
Recommend for All people over 6mo
Changes annually
Vulnerable populations; infants, young children, people over 65
Interventions for otitis media
Avoid over treating with antibiotics by educating that it can work itself out without meds within a few days
Never irrigate an ear
Antipyretics
Analgesics
Calm
Environment
Skin cancer risk factor
Sun or UV exposure
Expected lab results for Leukemia
Decreased platelets
Decreased leukocytes
Decreased erythrocytes
Risk factors for prostate cancer
Increased incidence with age.
African American males
Diet high in dairy or processed meat.
Obesity
Firefighters
Genetic and hereditary.
Having a vasectomy
What vague Clinical manifestations would you expect with cancer
Weight loss
Fatigue
Fever
Pain
Skin changes
Clinical manifestations of iron deficiency anemia
Headache
Pallor
Lethargy
Fatigue
Sob
Intolerance to cold
Glossitis
Cheilosis
Pica
Stomach irritation
Expected lab results for iron deficiency anemia
Low RBCs
Smaller, pale, and misshapen RBCs (hyperchromic, microcytic)
Clinical manifestations of sickle cell disease
Pain- Vaso-occlusive crisis
Sob
Fatigue
Infections
Vision changes
Nursing interventions for sickle cell disease
Promote oxygenation to alleviate sickling
Hydration
Pain management
Blood transfusions
Bed rest
Nutrition management
3 Stages of inflammation
Vascular and cellular response
Exudate production
Reparative phase
5 cardinal manifestations of inflammation
Erythema
Heat
Swelling
Pain
Possible impaired function
Important diagnostic test to detect presence of inflammation would be
ESR-
C-reactive proteins
What kind of pain management would a patient with sickle cell receive
Around the clock or PCA morphine
Nursing interventions for cellulitis
Pain management
Antibiotic and analgesic administration
Wound care
Elevate limb
What actions would the nurse take when following droplet precautions
Standard precautions plus…
Place patient in private room or with similar diagnosis
Wear mask
Place surgical mask on patient when outside of room
Who should get a colonoscopy
Age 45-75
Every 10 years
What are some symptoms of patients with decreased H&H
Fatigue
SOB
Arrhythmias
Dizziness
Chest pain
Cold hands and feet
Interventions for appendicitis
Keep npo
Monitor temp q4h
Pain management
No laxatives or enemas
No heat on abdomen
What are general concerns for patients with ulcerative colitis
Bleeding
Nutrition status,electrolytes
Anemia
Impaired function
Skin integrity
Emotional concerns
Where is mc burneys point
Lower right quadrant
Nursing interventions with cholecystitis
Education-avoid fatty foods
Pain management
Monitor weight-Is& Os
NG tube to low suction
Fowler position
What are some expected lab values for glomerulonephritis
Elevated creatinine
Elevated BuN
Decreased GFr
Electrolyte imbalance
Risk factors for PUD
Stress
H pylori
NSAID misuse
What are signs that an infection has triggered an inflammatory response
Vasodilation, increased capillary permeability
Hypercoagulability
Fever
Tachycardia, tachypnea
Erythema
Pain
Swelling
Precautions a nurse would take caring for a patient with Tb
Airborne precautions
Private room with negative airflow
Mask patient during transport
Inform all personnel having contact with patient of diagnosis
Assist visitors with appropriate masking before entering
Is a gown required for droplet precautions
Not unless you are coming into contact with bodily fluids
Latent TB is contagious
True or false
False.
