Med-surg 3 Flashcards
Glasgow Coma Scale (GSC) score
What are the 3 factors to determine?
What score is considered OK?
Eye opening
Motor response
Verbal response
13-15, less than 8 need to intubate
Brudzinski sign
Babinski sign
Medical sign that can indicate meningitis
Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed
Kernig sign
their back with their hips and knees flexed at 90-degree angles, and then slowly extending one knee at a time. A positive Kernig’s sign is indicated by pain, resistance, or an inability to extend the knee past 135 degrees, or in severe cases, past 90 degrees.
babinski sign
-Plantar reflex
A client admitted with a diagnosis of AKI. What interventions should the nurse include in this plan? SATA
1. Provide meticulous skin care.
2. Reposition every 2 hours.
3. Maintain a high carbohydrate, high protein diet.
4. Provide foods low in phosphate.
5. Monitor intake and output.
6. Give IV medications in smallest volume allowed.
1,2,4,5,6
The leading cause of death from acute renal injury is infection, so meticulous skin care and aseptic technique are critical. Repositioning every 2 hours will help to prevent pressure ulcers.
Clients in acute renal injury have high phosphorus levels and low calcium levele,so they need foods low in phosphorus.
Monitor intake and output. The client cannot handle excess fluid at this time. This is also why all IV meds should be administered in the smallest possible volume allowed.
A client report a sharp pain, rated 10/10, radiating from the right flank around to the lower right abdomen. What s/s?
1. Glomerulonephritis
2. Renal lithiasis
3. Nephrotic syndrome
4. Acute kidney injury
2
=kidney stone
Which medication prescription should the nurse question for a client diagnosed with nephrotic syndrome?
1. Ibuprofen
2. Enalapril
3. Prednisone
4. Cyclophosphamide
1
NSAIDs can cause acute interstitial nephritis and acute tubular nephritis. The client with nephrotic syndrome currently has damage to the micro blood vessels in the kidneys.
Which data supports the diagnosis of glomerulonephritis?
SATA
1. Malaise
2. Blood pressure – 160/92
3. 24 hour urinary output – 960 mL
4. Costovertebral angle tenderness
5. Urine specific gravity of 1.040
1,2,4,5
Malaise-general feeling of discomfort
The normal range of urine specific gravity ranges from 1.005 to 1.030. An elevated urine specific gravity of 1.040 is reflective of highly concentrated urine.
3- The normal range for a 24 urinary output is 800-2000 mL.
COPD can cause your lungs to produce #1 leading to #2.
Not all coughs are effective in clearing excess mucus from, uncontrolled coughing causes airways to collapse and spasm, trapping mucus.
1)excess mucus
2)frequent coughing
They need to controlling their coughing
What residual volume indicates the pt likely not absorbing the tube feeding?
More than 200mL for tow consecutive check
More than 500mL at 6 hurs
Myasthenia gravis (MG)
s/s?
Weakness muscle
Ptosis(dropping eye)
Decrease eyelid movements
Diplopia
Double vision
Cholinergic crisis
s/s?
Diarrhea
Increase urination
Nausea and vomiting
Chest tube
If there are 2 tubes upper and bottom, what is the upper tube for?
upper: air
bottom:fluid
Remember, air rises and fluid settles down lower
Which of the following should the nurse teach regarding nutrition for a pt with celiac disease?
a) Glute is a protein found in wheat and oats
b) A gluten-intolerant person can eat food that is made with barley or rye
c) Fruits can be eaten on a gluten-free diet
d) Gluten causes inflammation of the large intestines
e) Accidentally eating gluten may result in abdominal pain and diarrhea
a,c,e
What preferred lab value would the nurse expect to see the HCP prescribed for a pt admitted with generalized malnutrition?
a) Albumin
b) Prealbumin
c) Iron
d) Calcium
b
a-It can take weeks to drop
a) What is Lactase deficiency and what causes in the body?
b) which statement understand teaching?
1:I can still eat cheese and yogurt
2:I should take a daily calcium and vitamin D supplement
3:My lactase enzyme supplement should be taken with meals containing dairy
4 This means that I have developed an allergy to milk
1,2,3
Asthma requires follow up
a) appears agitated
b) audible wheezing bilaterally
c) peak flow readings are 65-70%
a,b,c
agitated suggests potential exacerbation
Wheezing indicates bronchospasm and airway resistance
PEF reding less than 70% of baseline indicates respiratory distress
A pt with COPD and limited mobility, what physiological responses to prolonged immobility should the nurse assess?
a) Inc insulin production
b) Dec RBC production
c) Dec nitrogen exertion
d) Inc calcium excretion
d
leads to the breakdown of bone tissue. This results in calcium exertion and put the pt at risk for fractures
A client with a right below-the-knee amputation (BKA). The client responds, “What is the purpose of the compression sock on my stump?” Which statement by the nurse is appropriate
a) The compression sock on the stump will increase your balance when crutch walking
b) Phantom limb pain will decrease by applying the compression sock tightly around the stump
c) A compression sock is applied to shape the stump smaller and rounder on the bottom
c
Amputation
a) Post-ope
Limb should what position?
b) BKA, what positon pt recommended?
c) Phatom pain, what to teach?
a) lie complete flat
b) prone opsition
c) diversional activity (hobbies, exercise) first then pain medication
A client’s skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see? SATA
a) Pain
b) Foot drop
c) Muscle spasm
d) Bone displacement
e) Itching under the straps
a,c,d
The purpose of traction is to stabilize and realign bone fractures and reduce pain.
A nursing instructor is presenting a discussion on nephrotoxic medications. Which class of medications would the instructor discuss?
1. Opioids
2. Antidiabetic
3. Corticosteroids
4. Aminoglycoside
4
Aminoglycoside antibiotics are nephrotoxic. Nephrotoxic medications can cause damage to the kidneys. Examples of aminoglycoside antibiotics are tobramycin, gentamicin, streptomycin, and paromomycin.
