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Adult Health Nursing II > HESI Review > Flashcards

HESI Review Flashcards

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1
Q

Pneumonia Nursing Assessment

A

Tachypnea, shallow respirations with accessory muscles

Productive cough with pleuritic pain

Rapid, bounding pulse

Pain and dullness to percussion

Increased fremitus

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2
Q

Nursing Interventions for Pneumonia

A

Assess sputum

TCDB q2h

Humidity, suctioning, physiotherapy

Fluids

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3
Q

Early Signs of Cerebral Hypoxia

A

Irritability and restlessness

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4
Q

COPD Hints

A

Compensation occurs over time, ABGs are altered

Hypoxemia and hypercapnia

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5
Q

Normal pH

A

7.35–7.45

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6
Q

Normal PCO2

A

35–45 mmHg

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7
Q

Normal PO2

A

80–100 mmHg

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8
Q

Normal HCO3

A

21–28 mEq/L

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9
Q

Pathophysiology of Chronic Bronchitis

A

Chronic sputum with cough production

Chronic hypoxemia, cor pulmonale

Increase in mucus, cilia production

Increase in bronchial wall thickness

Higher incidence in smokers

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10
Q

Assessment of Chronic Bronchitis

A

Generalized cyanosis

“Blue bloaters”

Right-sided heart failure

Distended neck veins

Crackles

Expiratory wheezes

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11
Q

Nursing Interventions for Chronic Bronchitis and Emphysema

A

Lowest FiO2 possible to prevent CO2 prevention

Monitor for S/S of fluid overload

Teach pursed lip breathing and diaphragmatic breathing

Teach tripod position

Bronchodilators and anti-inflammatory agents

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12
Q

Pathophysiology of Emphysema

A

Reduced gas exchange surface area

Increased air trapping

Cigarette smoking, exposure, genetic

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13
Q

Assessment of Emphysema

A

Barrel chest

Pursed lip breathers

Wheezes

Pulmonary blebs on radiograph

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14
Q

Precipitating Factors for Asthma

A

Mucosal edema

Increased work of breathing

Beta blockers

Respiratory infection

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15
Q

Assessment of Asthma

A

Dyspnea, wheezing, chest tightness

Assess precipitating factors

Medication history

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16
Q

Nursing Interventions for Asthma

A

Administer bronchodilators

Administer fluids and humidification

ABGs

Ventilatory patterns

C-PAP and Bi-PAP

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17
Q

Nursing Assessment of Pulmonary Tuberculosis

A 
Fever with night sweats
Anorexia, weight loss
Malaise, fatigue
Cough, hemoptysis
Repeated URIs
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18
Q

Drug Therapy for Tuberculosis

A

Drug therapy is usually long-term

DO NOT skip doses

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19
Q

Chest Tubes

A

If it becomes disconnected, immediately place end of tube in a container of sterile water

Cover client with a dry sterile dressing taped on three sides

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20
Q

Typical Daily Urine Output

A

1500–2000 mL

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21
Q

Nephrotoxic Drugs

A

Salicylates, antibiotics, NSAIDs, ACE inhibitors, angiotensin receptor blockers

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22
Q

Nursing Assessment for Acute Kidney Injury

A

Alterations in urinary output

Edema, weight gain

Change in mental status

Hematuria

Dry mucous membranes

Drowsiness, headache, muscle twitching, seizures

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23
Q

Primary Extracellular Ions

A

Sodium and chloride

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24
Q

Primary Intracellular Ions

A

Potassium and phosphate

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25
Q

Risk Factors for Acute Kidney Inury

A 
Chronic kidney disease
Older age
Massive trauma
Major surgical procedures
Extensive burns
Cardiac failure
Sepsis
Obstetric complications
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26
Q

Nursing Interventions for Acute Kidney Injury

A

Monitor intake and output

Weigh daily

Report any change in fluid volume status

Adequate protein intake

Monitor electrolyte status

Potassium and sodium restriction

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27
Q

Signs/Symptoms of Hyperkalemia

A

Dizziness

Weakness

Cardiac irregularities

Muscle cramps

Diarrhea

Nausea

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28
Q

Nursing Assessment for Chronic Renal Failure

A

History of renal disease, hypertension, diabetes

Edema, pulmonary edema

Decreasing urinary function (hematuria, proteinuria, cloudy urine, oliguria, anuria)

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29
Q

Nursing Interventions for Chronic Renal Failure

A

Restrict protein

Monitor serum electrolyte levels

Weigh daily, strict I&O

Check for JVD and edema

Low-protein, low-sodium, low-potassium, low-phosphate diet

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30
Q

Nursing Assessment for Urinary Tract Obstructions

A

Pain

Fever, chills, NVD, abdominal distention

Changes in voiding pattern (dysuria, hematuria, urgency, frequency, hesitancy, incontinence)

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31
Q

Nursing Interventions for Urinary Tract Obstructions

A

Administer analgesics and alpha-adrenergic blockers

Moist heat to painful area

High oral fluid intake

Strain all urine

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32
Q

Nursing Assessment for Benign Prostatic Hyperplasia

A

Increased frequency of voiding with a decrease in amount

Nocturia

Hesitancy

Terminal dribbling

Acute urinary retention

Bladder distention

Recurrent UTIs

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33
Q

Nursing Interventions for Benign Prostatic Hyperplasia

A

Observe color and content of urinary output

Monitor for signs of hemorrhagic or hypovolemic shock

Increase fluid intake to 3000 mL/day

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34
Q

Causes of Angina

A

Atherosclerotic heart disease

Hypertension

Coronary artery spasm

Hypertrophic cardiomyopathy

Physical exertion, cold temperatures

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35
Q

Nursing Assessment of Angina

A

Pain, dyspnea, tachycardia, palpitations, nausea, vomiting, fatigue, diaphoresis, pallor, weakness, syncope, dysrhythmias

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36
Q

Nursing Interventions for Angina

A

Provide immediate rest, take vital signs, record an ECG

Administer no more than three nitroglycerin tablets 5 minutes apart

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37
Q

Antianginals

A

Nitrates (nitroglycerin, isosorbide)

Beta Blockers (propranolol)

Calcium Channel Blockers (verapamil, nifedipine)

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38
Q

Nursing Assessment of MI

A

Sudden onset of pain in the lower sternal region

Rapid, irregular, and thready pulse

Decreased LOC

Cardiac dysrhythmias

Cardiogenic shock or fluid retention

Troponin

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39
Q

Nursing Interventions for MI

A

Obtain vital signs and ECG

Administer oxygen

Keep in semi-Fowler’s position

Bed rest for 12 hours

MONA: morphine, oxygen, nitroglycerin, aspirin

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40
Q

Nursing Assessment of Arterial Insufficiency

A

Associated with Raynaud’s, Buerger’s, diabetes, acute occlusion

Smooth, shiny, cool skin

Loss of hair

Thickened nails

Pallor on elevation

Decreased or absent pulses

Sharp pain increases with walking and elevation

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41
Q

Nursing Assessment of Venous Insufficiency

A

Brown pigment around ankles

Warm

Pulses are normal

Persistent aching, full feeling, dull sensation

Relieved when horizontal

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42
Q

Antihypertensives

A

Alpha-Adrenergic Blockers (Prazosin, Terazosin)

Beta Blockers (Metaprolol, Propranolol)

Vasodilators (Hydralazine)

Angiotensin II Receptor Antagonists (Losartan)

ACE Inhibitors (Captopril)

Calcium Channel Blockers (Nifedipine)

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43
Q

Anticoagulants

A

Heparin

Warfarin

Antiplatelet agents (Clopidogrel)

LMWH (Enoxaparin)

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44
Q

Nursing Interventions for Peripheral Vascular Disease

A

Monitor extremities at designated intervals

Encourage rest at first sign of pain

Encourage elevation

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45
Q

Nursing Assessment of Abdominal Aortic Aneurysm

A

Bruit

Abdominal or lower back pain

May feel heartbeat in abdomen

Symptoms of rupture: hypovolemic or cardiogenic shock with sudden, severe abdominal pain

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46
Q

Assessments Required within the First Few Hours of Abdominal Aortic Dissection

A

Vital sings every hour

Neurologic vital signs

Respiratory status

Urinary output

Peripheral pulses

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47
Q

Nursing Assessment for Thrombophlebitis

A

Calf tenderness, redness or pain

Edema and warmth in extremity

Functional impairment of the extremity

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48
Q

Heparin

A

Antagonist: protamine sulfate

Laboratory: PTT or aPTT

Keep 1.5 to 2.5 times normal control

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49
Q

Warfarin

A

Antagonist: vitamin K

Laboratory: PT

Keep 1.5 to 2.5 times normal control

INR therapeutic level usually 2–3

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50
Q

Nursing Interventions for Thrombophlebitis

A

Observe client for bleeding

Monitor laboratory data

Antiembolic stockings

Advise bedrest

Monitor for pulmonary embolus

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51
Q

Nursing Assessment of Heart Failure

A

Left-sided: dyspnea, orthopnea, crackles, cough, fatigue, confusion, restlessness

Right-sided: peripheral edema, weight gain, distended neck veings, hepatomegaly, ascites

High BNP levels indicate heart failure

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52
Q

Digitalis

A

Side effects are increased when client is hypokalemic

Negative chronotropic effect (slows heart rate); hold if pulse rate is less than 60 or greater than 120

Digitalis toxicity includes bradycardia, tachycardia, nausea, vomiting, headache

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53
Q

Nursing Interventions for Heart Failure

A

Monitor vital signs every 4 hours

Assess for hypoxia

Auscultate lungs

Elevate HOB

Observe for signs of edema

Limit sodium intake

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54
Q

Nursing Assessment of Endocarditis

A

Fever, chills, malaise, night sweats, fatigue, murmurs, symptoms of heart failure, atrial embolization

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55
Q

Nursing Assessment of Pericarditis

A

Sudden, sharp, severe pain in substernal region

Pericardial friction rub heart best at left lower sternal border

Fever

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56
Q

Nursing Interventions for Endocarditis

A

Monitor hemodynamic status

Encourage client to to maintain good hygiene

Instruct client to inform dentist and other health providers of history

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57
Q

Nursing Interventions for Pericarditis

A

Provide rest and maintain position of comfort

Administer analgesics and anti-inflammatory drugs

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58
Q

Nursing Assessment for Valvular Heart Disease

A

Pericardial effusion with possible tamponade that required pericardiocentesis

Fatigue, dyspnea, orthopnea, hemoptysis and pulmonary edema, murmurs, angina

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59
Q

Nursing Interventions for Valvular Heart Disease

A

Teach the necessity for prophylactic antibiotic therapy before any invasive procedure

Need for lifelong anticoagulant therapy with mechanical valve replacement

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60
Q

Nursing Assessment for Hiatal Hernia and GERD

A

Heartburn after eating that radiates to arms and shoulders

Feeling of fullness and discomfort after eating

Positive diagnosis determined by fluoroscopy, barium swallow, or gastroscopy

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61
Q

Nursing Interventions for Hiatal Hernia and GERD

A

Encourage small, frequent meals

Sit up while eating

Stop eating 3 hours before bedtime

Elevate HOB

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62
Q

Antiulcer Drugs

A

Antacids (aluminum hydroxide)

Histamine-2 Antagonists (cimetidine)

PPIs (lansoprazole)

Prokinetic drugs

Antiemetics

Cough suppressants

Stool softeners

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63
Q

Nursing Assessment of Peptic Ulcer Disease

A

Determine presence of melena

Potential complications include hemorrhage, perforation, obstruction)

EGD, barium swallow, gastric analysis

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64
Q

Nursing Interventions for Peptic Ulcer Disease

A

Determine symptom onset and how symptoms are relieved

Monitor stools

Encourage small, frequent meals

Teach that dumping syndrome may occur postoperatively

Teach symptoms of GI bleedng

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65
Q

Clinical Manifestations of GI Bleeding

A

Pallor

Dark, tarry stools

Bright-red or coffee-ground emesis

Abdominal mass or bruit

Decreased BP, rapid pulse, cool extremities, increased respirations

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66
Q

Nursing Assessment of Crohn’s Disease

A

Abdominal pain in right lower quadrant

Diarrhea, steatorrhea, weight loss

Constant fluid loss

Low-grade fever

Weight loss, anemia, malnutrition

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67
Q

Nursing Interventions for Crohn’s Disease

A

Provide well-balanced, low-residue, low-fat, high-protein, high-calorie diet

Provide complete bowel rest

Administer aminosalicylates, antimicrobials, corticosteroids, immunosuppressants, biologic therapy

Weigh at least twice a week

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68
Q

Nursing Assessment of Ulcerative Colitis

A

Diarrhea, abdominal pain and cramping

Intermittent tenesmus and rectal bleeding

Liquid stools containing blood, mucus, and pus

Weakness and fatigue, anemia

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69
Q

Nursing Interventions for Ulcerative Colitis

A

Avoid caffeinated beverages, smoking, pepper, and alcohol

Provide complete bowel rest

Administer corticosteroids, antidiarrheals, biologic treatments

Monitor I&O and serum electrolytes

Weigh at least twice a week

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70
Q

Nursing Assessment of Diverticular Disease

A

Left lower quadrant pain

Increased flatus

Signs of intestinal obstruction (constipation/diarrhea, abdominal distention, anorexia, low-grade fever)

Barium enema or colonoscopy positive for diverticular disease

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71
Q

Nursing Interventions for Diverticular Disease

A

Well-balanced, high-fiber diet unless inflammation is present, in which client will be NPO followed by low-residue foods

Bulk-forming laxatives

Increase fluids to 3 L/day

Monitor I&O and bowel elimination

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72
Q

Mechanical Bowel Obstruction

A

Due to disorders outside the bowel (hernia, adhesions) by disorders within the bowel (tumors, diverticulitis) or by blockage of the lumen in the intestine

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73
Q

Nonmechanical Bowel Obstruction

A

Due to paralytic ileus

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74
Q

Nursing Assessment of Intestinal Obstruction

A

Sudden onset of abdominal pain, tenderness, or guarding

Distention

Increased peristalsis when obstruction first occurs, then paralytic ileus causes absent peristalsis

Bowel sounds are high pitched early and diminished late

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75
Q

Nursing Interventions for Intestinal Obstruction

A

Maintain client NPO with IV fluids and electrolyte therayp

Monitor I&O

Implement NG intubation

Assess abdomen regularly for distention, rigidity, change of status in bowel sounds

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76
Q

Diet to Prevent Bowel Cancer

A

Eat more cruciferous vegetables (cabbage family)

Increase fiber intake

Maintain average body weight

Eat less animal fat

77
Q

Recommendations for Early Detection of Colon Cancer

A

Digital rectal examination every year after 40

Stool blood test every year after 50

Colonoscopy or sigmoidoscopy every 10 years after the age of 50

78
Q

Nursing Assessment of Colorectal Cancer

A

Rectal bleeding

Change in bowel habits

Sense of incomplete evacuation, tenesmus

Abdominal pain, nausea, vomiting, weight loss, cachexia

Abdominal distention or ascites

History of polyps

79
Q

Nursing Interventions for Colorectal Cancer

A

Bowel preparation (GoLYTELY)

High-calorie, high-protein diet

High-fiber

80
Q

Nursing Assessment of Cirrhosis

A

Weakness, malaise

Anorexia, weight loss

Palpable liver early

Jaundice

Fruity breath

Bruising, erythema

Gyencomastia

81
Q

Clinical Manifestations of Jaundice

A

Yellow skin, sclera, or mucous membranes

Dark-colored urine

Chalky or clay-colored stools

82
Q

Laboratory Findings for Cirrhosis

A

Elevated bilirubin, AST, ALT, alkaline phosphatase, PT, and ammonia

Decreased Hgb, Hct, electrolytes, potassium, sodium, and albumin

83
Q

Nursing Interventions for Cirrhosis

A

Bleeding precautions

Monitor fluid and electrolyte status daily

Restrict protein, low sodium, low potassium, low fat, high carbohydrate

84
Q

Nursing Assessment of Hepatitis

A

Fatigue, malaise, weakness, anorexia, nausea, vomiting

Jaundice, dark urine, clay-colored stools

Myalgia, joint pain

Dull headaches, irritability, depression

Abdominal tenderness in right upper quadrant

Elevations of ALT, AST, alkaline phosphatase, bilirubin

85
Q

Nursing Interventions for Hepatitis

A

High-calorie, high-carbohydrate diet with moderate fats and proteins

Administer interferon, nucleoside and nucleotide analogs, protease inhibitors, and antiemetics as prescribed

Adhere to personal hygiene

Promote rest

86
Q

Nursing Assessment for Acute Pancreatitis

A

Severe midepigastric pain radiating to back

Abdominal guarding, boardlike abdomen

Elevated temperature, tachycardia, decreased BP

Bluish discoloration of flanks (Grey Turner) or umbilicus (Cullen)

Elevated amylase, lipase, triglycerides, and glucose levels

87
Q

Nursing Assessment for Chronic Pancreatitis

A

Continuous burning or gnawing abdominal pain

Recurring attacks of severe upper abdominal and back pain

Ascites

Steatorrhea, diarrhea

Weight loss

Jaundice, dark urine

S/S of DM

88
Q

Nursing Interventions for Acute Pancreatitis

A

Maintain NPO status

Hydromorphone or fentanyl as needed

Antacids, H2 receptor blocking drugs, anticholinergics, PPIs

Monitor for neuromuscular manifestations of hypocalcemia

Place in semi-Fowler position

Lean forward to reduce pain

89
Q

Nursing Interventions for Chronic Pancreatitis

A

Administer hydromorphone, fentanyl, morphine as needed

Monitor stools for number and consistency

Bland, low-fat diet

Monitor for S/S of DM

90
Q

Nursing Assessment for Cholecystitis and Cholelithiasis

A

Pain, anorexia, vomiting, or flatulence following fried, spicy, or fatty foods

Fever, elevated WBCs, and other signs of infection

Abdominal tenderness

Jaundice and clay-colored stools (blockage)

Elevated liver enzymes, bilirubin, and WBCs

91
Q

Nonsurgical Management of Cholecystitis

A

Low-fat diet

Decompression of the stomach via NG tube

Medications for pain and clotting if required

92
Q

Nursing Assessment of Hyperthyroidism

A

Enlarged thyroid gland

Weight loss, increased appetite, diarrhea, heat intolerance, tachycardia, increased systolic blood pressure, diaphoresis, nervousness

Exophthalmos

T3 and T4 elevated

93
Q

Nursing Interventions for Hyperthyroidism

A

Observe for signs of thyroid storm

High-calorie, high-protein, low-caffeine, low-fiber diet

PTU and methimazole

94
Q

Normal Serum Calcium

A

9.0–10.5

95
Q

Chvostek Sign

A

Twitching of upper lip after a tap over the facial nerve

96
Q

Trousseau Sign

A

Carpopedal spasm after BP cuff is inflated

97
Q

Nursing Assessment for Hypothyroidism

A

Fatigue, weigh gain

Thin, dry hair and thick, brittle nails

Bradycardia, hypotension

Cold intolerance, weight gain, dull emotions and mental processes

Low T3, low T4

98
Q

Nursing Interventions for Hypothyroidism

A

Bowel elimination plan to prevent constipation

Avoid sedating the client

99
Q

Corticosteroids

A

Hydrocortisone, prednisone, dexamethasone, methylprednisone

100
Q

Nursing Assessment for Addison’s Disease

A

Fatigue, weakness, weight loss, anorexia, postural hypotension

Hypoglycemia, hyponatremia, hyperkalemia, hyperpigmentation

101
Q

Nursing Interventions for Addison’s Disease

A

Take vital signs frequently

Monitor I&O and weigh daily

Administer IV glucose with parenteral hydrocortisone during crisis

Monitor serum electrolyte levels

Reduce stress

102
Q

Addisonian Crisis

A

Vascular collapse–administer IV fluids rapidly until stabilized

Hypoglycemia–administer IV glucose

Reverse crisis by administering parenteral hydrocortisone

Aldosterone replacement–administer fludocortisone acetate with simultaneous administration of sodium chloride

103
Q

Nursing Assessment of Cushing Syndrome

A

Moon face, truncal obesity, buffalo hump, abdominal striae, muscle atrophy

Hyperglycemia, hypernatremia, hypokalemia

104
Q

Nursing Interventions for Cushing Syndrome

A

Encourage to protect from exposure to infection

Provide low-sodium diet, encourage consumption of foods that contain vitamin D and calcium

Take steroids with meals to prevent gastric irritation

105
Q

Clinical Characteristics of Type I DM

A

Results from progressive loss of autoimmune-based destruction of beta cells

Can become hyperglycemic and ketosis-prone relatively easily

106
Q

Clinical Characteristics of DKA

A

Serum glucose of 250 or above

Ketonuria in large amounts

Arterial pH of < 7.3 and HCO3 < 15

Nausea, vomiting, dehydration, abdominal pain, Kussmaul’s respirations, acetone odor to breath

107
Q

Treatment of DKA

A

Isotonic IV fluids 0.9% NaCl until BP is stabilized

Slow infusion by IV pump of regular insulin

Careful replacement of potassium

108
Q

Pathophysiology of Type II DM

A

Results from either inadequate production of insulin by the body or lack of sensitivity to the insulin being produced

Can develop HHNKS

109
Q

Clinical Characteristics of Hyperosmolar Hyperglycemic Nonketotic Syndrome

A

Hyperglycemia greater than 600

Plasma hyperosmolality

Dehydration

Changed mental status

Abent ketone bodies

110
Q

Treatment of Hyperosmolar Hyperglycemic Nonketotic Syndrome

A

Usualy with isotonic IV fluid replacement and careful monitoring of potassium and glucose levels

IV insulin until blood glucose stabilizes at 250

111
Q

Nursing Assessment of Diabetes

A

Retinopathy

Angina, dyspnea, HTN

Hair loss, poor perfusion, pallor

Edema, UTI, renal failure, diabetic nephropathy

Nighttime diarrhea, gastroparesis

Impotence, vaginal dryness, vaginal infections, menstrual irregularities

112
Q

Rapid Acting Insulin

A

Human insulin lispro aspart

Give within 15min of meal

113
Q

Short Acting Insulin

A

Regular insulin

May be given IV

114
Q

Intermediate Acting Insulin

A

Isophane insulin

Combines rapid acting regular insulin with intermediate acting NPH

115
Q

Long Acting Insulin

A

Glargine

Give once daily at bedtime

116
Q

Hyperglycemia

A

Polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, syncope

Encourage water intake

Check blood glucose frequently

Assess for ketoacidosis

117
Q

Hypoglycemia

A

Headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around the mouth

Treat immediately with a complex carbohydrate (glucose gel, fruit juice, jelly beans, gum drops)

Check blood glucose (may seize if < 40)

118
Q

Nursing Assessment of Rheumatoid Arthritis

A

Fatigue, generalized weakness, weight loss, anorexia, morning stuffiness, bilateral inflammation of the joints, joint deformity

119
Q

Diagnosis of Rheumatoid Arthritis

A

Elevated ESR

Positive rheumatoid factor

Presence of antinuclear antibody

Arthroscopic examination

Abnormal synovial fluid

C-reactive protein

120
Q

Nursing Interventions for Rheumatoid Arthritis

A

Moist heat

Provide periods of rest after periods of activity

Avoid overexertion

Encourage use of assistive devices

121
Q

NSAIDS

A

Aspirin, ibuprofen, indomethacin, ketorolac, naproxen, celecoxib

May cause GI symptoms

Hepatotoxic

Check liver/renal labs and CBC

122
Q

Nursing Assessment of Lupus

A

Dry, scaly rash on upper face or upper body

Joint pain, fever, nephritis, pleural effusion, pericarditis, abdominal pain, photosensitivity, HTN

123
Q

Nursing Interventions for Lupus

A

Avoid exposure to sunlight

Monitor and instruct client in administration of steroids

124
Q

Nursing Assessment of Osteoarthritis

A

Joint pain that increases with activity and improves with rest

Morning stiffness

Asymmetry of affected joints

Crepitus

Limited movement

Joint enlargement and bony nodules

125
Q

Nursing Interventions for Osteoarthritis

A

Weight-reduction diet

Use correct posture and body mechanics

Encourage rest

126
Q

Nursing Assessment of Osteoporosis

A

Kyphosis of the dorsal spine

Loss of height

Back pain

Pathologic fractures

Compression fracture of spine

Postmenopausal white women are at highest risk

127
Q

Nursing Interventions for Osteoporosis

A

Keep bed in low position

Provide assistance with ambulation

Diet high in protein, calcium, and vitamin D; discourage alcohol and caffeine

Hormone replacement therapu

128
Q

Fat Embolism

A

Greatest risk 36 hours after a fracture

Initial symptom is confusion due to hypoxemia

Petechial rash

129
Q

5 Ps of Neurovascular Functioning

A

Pain

Paresthesia

Pulse

Pallor

Paralysis

130
Q

Nursing Assessment of Joint Replacement

A

Joint pathology (OA, rheumatoid arthritis, fracture)

Pain not relieved by medication

Poor ROM in the affected joint

131
Q

Nursing Interventions for Amputations

A

Change dressing as needed

Monitor for signs of infection

Position client to relieve edema and spasms at residual limb site

Elevate residual limb for the first 24 hours postoperatively (only on one pillow)

Keep residual limb in extended position, and turn client to prone position three times a day to prevent contracture

132
Q

Nursing Assessment of Glaucoma

A

Early signs include increase in IOP > 22 mmHg and decreased accommodation; often painless and symptom free

Late signs include loss of peripheral vision, seeing halos, decreased visual acuity, headache or eye pain

Diagnostic tests include tonometer to measure IOP, gonioscopy

133
Q

Nursing Interventions for Glaucoma

A

Administer eye drops as prescribed

Orient client to surroundings

Avoid activities that may increase IOP

134
Q

Medications for Glaucoma

A

Parasympathomimetics (pilocarpine)

Beta-Adrenergic Receptor-Blocking Agents (careolol, levobunolol)

Carbonic Anhydrase Inhibitors (acetazolamide)

135
Q

Nursing Assessment of Cataracts

A

Early signs: blurred vision, decreased color perception, photophobia

Late signs: diplopia, reduced visual acuity, clouded pupil

Diagnosis with ophthalmoscope, slit-lamp biomicroscope, keratometry

136
Q

Nursing Interventions for Cataracts

A

Fall prevention is very important

Warn not to put pressure or rub on the eye

137
Q

Nursing Assessment for Altered State of Consciousness

A

Glasgow Coma Scale (Max 15, Min 3)

Neurologic vital signs (pupil size, limb movement, BP, temperature, pulse, respirations)

Assess skin integrity and corneal integrity

Check bladder for fullness, auscultate lungs, and monitor cardiac status

138
Q

Nursing Interventions for Altered State of Consciousness

A

Maintain adequate respirations, airway, and oxygenation

Provide nutritional and fluid and electrolyte support–NPO until responsive

Prevent complications of immobility and thrombus formation

Monitor and evaluate the vital sign changes–if temperature elevates, take quick measures to decrease it because fever increases cerebral metabolism and can cause cerebral edema

139
Q

Nursing Assessment of Head Injury

A

Unconsciousness or disturbances in consciousness

Vertigo, seizures, ataxia, abnormal posturing

Confusion, delirium, disorientation

Symptoms of increased ICP (change in LOC is most important indicator)

Changes in vital signs (slowed respirations, increase/decrease in pulse, rising BP, rising temperature)

Headache, vomiting, pupillary changes

140
Q

Nursing Interventions for Head Injury

A

Maintain adequate ventilation and airway

HOB at 30-45 degrees

Neurologic vital signs q2h

Avoid activities that increase ICP

141
Q

Medications for Head Injury

A

Hyperosmotic agents (Mannitol, Urea)

Steroids (Dexamethasone, Methylprednisone)

Barbiturates

142
Q

Nursing Assessment of Spinal Cord Injury

A

Assess breathing pattern and auscultate lungs

Check neurologic vital signs

Assess abdomen for girth, bowel sounds, distention

Assess temperature

143
Q

Nursing Interventions for Spinal Cord Injury

A

Maintain a patent airway

High-dose corticosteroids

Assess for respiratory failure

Evaluate for hypotension, bradycardia, paralysis, bowel and bladder distention

Watch for paralytic ileus

144
Q

Nursing Assessment of Brain Tumor

A

Headache that is more severe on awakening

Vomiting not associated with nausea

Papilledema with visual changes

Behavioral and personality changes

Seizures

145
Q

Nursing Interventions for Brain Tumor

A

Elevate HOB 30-40 degrees

Similar to increased intracranial pressure interventions

146
Q

Craniotomy Preoperative Medications

A

Corticosteroids to reduce swelling

Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate)

Agents to reduce seizures (phenytoin)

Prophylactic antibiotics

147
Q

Nursing Assessment of Multiple Sclerosis

A

Visual or swallowing defects

Gait disturbances

Unusual fatigue, weakness, or clumsiness

Numbness, speech disturbances, impaired bowel/bladder control

Usually begin in the upper extremities with weakness progressing to spastic paralysis

148
Q

Nursing Interventions for Multiple Sclerosis

A

Encourage rest periods

Voiding schedule

Adequate fluid intake, high-fiber foods, and a bowel regimen

ACTH, cortisone, cyclophosphamide, immunosuppressive drugs

149
Q

Nursing Assessment for Myasthenia Gravis

A

Diplopia, ptosis, masklike affect

Weakness of laryngeal and pharyngeal muscles (choking, food aspiration, difficulty speaking)

Muscle weakness improved by rest

Respiratory failure, bladder and bowel incontinence

150
Q

Myasthenic Crisis

A

Attributed to disease worsening

Associated with undermedication

More difficulty swallowing, diplopia, ptosis, dyspnea

151
Q

Cholingergic Crisis

A

Attributed to anticholinesterase overdosage

Diaphoresis, diarrhea, fasciculations, cramps, marked worsening of symptoms

152
Q

Treatment of Myasthenia Gravis

A

Diagnosis made by positive Tensilon test

Pyridostigmine bromide

Can cause cholingergic crisis

153
Q

Nursing Interventions for Myasthenia Gravis

A

Conserve energy as much as possible

Administer cholinergic drugs as prescribed

TCDB every 4-6 hours

154
Q

Nursing Assessment of Parkinson Disease

A

Rigidity of extremities

Masklike facial expressions with associated difficulty in chewing, swallowing, and speaking

Drooling

Tremors at rest, “pill-rolling” movement

Emotional lability

155
Q

Nursing Interventions for Parkinson Disease

A

Schedule activities later in the day

Encourage activities and exercise

Eliminate environmental noise

Serve a soft diet

Antiparkinson drugs

156
Q

Antiparkinson Drugs

A

Anticholinergics (atropine)

Dopamine Replacements (levodpa)

Monoamine Oxidase Type B Inhibitors (selegiline)

COMT Inhibitors (entacapone)

157
Q

Nursing Assessment of Guillain-Barre Syndrome

A

Paresthesia

Muscle weakness of legs progressing to the upper extremities, trunk, and face

Paralysis of the ocular, facial, and oropharyngeal muscles

Increasing pulse rate and disturbances in rhythm

Transient HTN

Weakness or paralysis in intercostal and diaphragm muscles

158
Q

Nursing Interventions for Guillain-Barre Syndrome

A

Monitor for respiratory distress and initiate mechanical ventilation if necessary

159
Q

Hemorrhagic Stroke

A

Caused by a slow or fast hemorrhage into the brain tissue, often related to HTN

160
Q

Embolic Stroke

A

Caused by a clot that has broken away from a vessel

Often related to atherosclerosis

161
Q

Behavior with Left Hemisphere Disruption

A 
Slow
Cautious
Anxiety
Depression
Sense of guilt
Feeling of worthlessness
Worries over future
Quick anger and frustration
162
Q

Behavior with Right Hemisphere Disruption

A 
Impulsive
Unaware of neurological deficits
Confabulates
Euphoric
Constantly smiles
Denies illness
Poor judgment
Impaired sense of humor
163
Q

Nursing Assessment of Stroke

A 
Change in LOC
Paresthesia, paralysis
Aphasia, agraphia
Memory loss
Vision impairment
Bowel/bladder dysfunction
Behavioral changes
164
Q

Nursing Interventions for Stroke

A

Control HTN

Maintain proper body alignment when in bed

Perform full ROM four times a day

Analyze bladder elimination pattern

Steroids administered to decrease cerebral edema and retard permanent disability

165
Q

Apraxia

A

Inability to perform purposeful movements in the absence of motor problems

166
Q

Dysarthria

A

Difficulty articulating

167
Q

Nursing Assessment for Anemia

A

Pallor, fatigue, exercise intolerance, lethargy, orthostatic hypotension

Tachycardia, heart murmurs, heart failure

Signs of bleeding

Cool skin, cold intolerance

168
Q

Diagnostic Tests for Anemia

A

Hgb < 10

Hct < 36%

RBCs < 4 x 10^12

Bone marrow aspiration positive for anemia

169
Q

Nursing Interventions for Anemia

A

Alternate periods of activity with periods of rest

Eat more iron, folic acid, and vitamin B12 rich foods

Take iron on empty stomach, take with vitamin C

Sickle cell crisis is precipitated by hypoxia

Stools may turn black

170
Q

Administration of Iron

A

DO use z-track method, air bubble to avoid withdrawing medication into subcutaneous tissue

DON’T use deltoid muscle, massage injection site

171
Q

Acute Myelogenous Leukemia

A

Involves inability of leukocytes to mature

Can occur at any time in the life cycle

Onset is insidious

Poor prognosis; cause of death tends to be infection

172
Q

Chronic Myelogenous Leukemia

A

Results from abnormal production of granulocytic cells

Occurs in young to middle-aged adults

Poor prognosis

Oral antineoplastic agents (hydroxyura, interferon, gleevec)

173
Q

Acute Lymphocytic Leukemia

A

Abnormal leukocytes are found in blood-forming tissue

Occurs in children (most common childhood cancer)

Prognosis is favorable

174
Q

Chronic Lymphocytic Leukemia

A

Increased production of leukocytes and lymphocytes

Occurs after age 35

Favorable prognosis

Most clients are asymptomatic and are never treated

175
Q

Nursing Assessment for Leukemia

A

Tendency to bleed

Anemia

Infection

GI distress

176
Q

Nursing Interventions for Leukemia

A

Monitor WBC count daily

Monitor vital signs frequently

Teach importance of infection control

177
Q

Nursing Assessment for Hodgkin Disease

A

Enlarged lymph nodes

Anemia, thrombocytopenia, elevated leukocytes, decreased platelets

Fever, increased susceptibility to infections

Anorexia, weight loss

Malaise, bone pain

Night sweats, pruritus, pain

178
Q

Nursing Interventions for Hodgkin Disease

A

Protect client from infection

Observe for signs of anemia

Provide adequate rest

Encourage high-nutrient foods

179
Q

Nursing Assessment of Benign Tumors of the Uterus

A

Menorrhagia (most important factor related to benign uterine tumors)
Dysmenorrhea
Uterine enlargement
Low back pain and pelvic pain

180
Q

Nursing Assessment of Uterine Prolapse, Cystocele, and Rectocele

A

Uterine Prolapse: dysmenorrhea, dyspareunia, pressure, protrusions, fatigue, low backache

Cystocele: incontinence, urinary retention, cystitis

Rectocele: constipation, hemorrhoids, sense of pressure/need to defecate

181
Q

Nursing Interventions for Hysterectomy

A

Administer enema and douche as ordered

Avoid rectal thermometers or tube

Encourage ambulation

Monitor urinary output

Maintain adequate fluid intake

Notify physician of elevated temperature, swelling of suture line, or foul-smelling vaginal drainage

182
Q

Nursing Assessment of Ovarian Cancer

A

Asymptomatic in early stages

Laparotomy is primary tool for diagnosis/staging

Pelvic discomfort, low back pain, weight change, abdominal pain, nausea/vomiting, constipation, urinary frequency

183
Q

Nursing Interventions for Ovarian Cancer

A

Major emphasis on early detection

184
Q

Nursing Assessment of Breast Cancer

A

Hard lump (not freely movable and not painful)

Dimpling of skin

Retraction of nipple

Discharge from nipple

Pain and ulcerations

185
Q

Nursing Interventions for Breast Cancer

A

Assess lesion (size, location, shape, consistency, fixation, lymph node involvement)

Monitor for bleeding

Avoid BP, injections, venipuncture in arm of surgery

186
Q

Nursing Assessment of Testicular Cancer

A

Early signs are subtle and go unnoticed

Lump or swelling (painless) on the testicle

Low back pain, weight loss, fatigue

187
Q

Nursing Interventions for Testicular Cancer

A

Observe for hemorrhage

Encourage genetic counseling

Counsel that sexual functioning is usually not affected

188
Q

Nursing Assessment of Prostate Cancer

A

Asymptomatic if confined to gland

Symptoms of urinary obstruction

Elevated PSA

Definitive diagnosis by biopsy

189
Q

Nursing Interventions for Prostate Cancer

A

Teach importance of early detection

Prepare client for radiation therapy

Provide preoperative bowel preparation

Adult Health Nursing II (22 decks)

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