Module 5 Comprehensive Flashcards
The nurse understands that knowledge of appropriate laboratory values is important. The nurse asks a group of nursing students to state the appropriate ranges for potassium, magnesium, calcium, sodium, phosphorus, pH, CO2, and HCO3.
- Potassium: 3.5 - 5.0
- Magnesium: 1.8 - 3.0
- Calcium: 8.5 - 10.5
- Sodium: 135 - 145
- Phosphorus: 2.5 4.5
- pH: 7.35 - 7.45
- CO2: 35 - 45
- HCO3: 22 - 26
Compare and contrast hyperkalemia and hypokalemia symptoms.
Hypokalemia symptoms include confusion, EKG changes, cardiac dysrhythmias, muscle cramps, shallow respirations, polyuria, and polydipsia. Whereas, hyperkalemia symptoms include EKG changes, cardiac arrest, respiratory distress, muscle cramps, stomach cramps, and diarhea.
Compare and contrast hyponatremia vs. hypernatremia symptoms.
Hyponatremia symptoms include stupor, coma, confusion, headache, edema, apprehension, and feeling of impending doom. In contrast, hypernatremia symptoms include seizures, coma, fever, tachycardia, hypotension, dry mucous membranes, polydipsia, and headache.
Compare and contrast hypocalcemia and hypercalcemia symptoms.
Hypocalcemia symptoms include bone pain, osteomalacia, positive Chvostek sign, positive Trousseau sign, numbness and tingling, muscle cramps, hyperactive reflexes, and tetany. In contrast, hypercalcemia produces symptoms of renal calculi, renal insufficiency, osteoporosis, stupor, coma, loss of muscle tone, shortened QT, and AV blocks.
The nurse understands that hypocalcemia can have serious adverse effects. When caring for a client with suspected hypocalcemia the nurse understands that these two non-invasive tests can assist in identifying a client with hypocalcemia?
Positive Chvostek and Trousseau signs are indicative of hypocalcemia.
The nurse understands that signs of fluid volume excess in patients include:
- Rapid weight gain
- Edema in the arms, legs, and face
- Swelling in the abdomen
- Cramping, headache, and stomach bloating
- Shortness of breath
- Hypertension
- CHF
The nurse understands that signs of fluid volume deficit include:
- Altered mental status
- Weakness
- Thirst
- Weight loss (depending on the severity of fluid volume deficit)
- Concentrated urine
- Decreased urine output
- Dry mucous membranes
- Sunken appearance of the eyes
- Sunken fontanels in infants
- Weak pulse
- Tachycardia
A pediatric client age 7 years old presents to the ED with a suspected fracture. The nursing assessing the client in triage understands that the most likely fracture type that this client is experiencing is a:
A greenstick fracture which is due to the fact that a child’s bones at this age have some degree of flex due to the cartilage ossification process that is occurring and the bone salts that have not fully impregnanted the tissue yet. Therefore the bone will bend and crack rather than fully breaking. Think of a green tree branch.
The nurse understands that the fracture identified in this image is called a
Comminuted fracture
The nurse understands that the fracture identified in this image is known as a
Transverse fracture
The nurse understands that the fracture identified in the image below is described as a
Spiral fracture
The nurse understands that the facture identified in the image below is described as a
Segmental fracture
Atrophy is a
decrease in cell size
Hypertrophy is a
increase in cell size
Hyperplasia is a
increase in the number of cells
Metaplasia is a
replacement of adult cells
Dysplasia is a
deranged cell growth of a specific tissue
How does blood flow through the heart?
Blood flows through the heart in the following pathway:
- Superior/ inferior vena cava
- right atrium
- Tricuspid valve
- right ventricle
- pulmonary semilunar valve
- pulmonary artery
- lungs for oxygenation
- pulmonary vein
- left atrium
- mitral valve (aka bicuspid valve)
- left ventricle
- aortic valve
- aorta
- systemic circulation
The nurse understands that when a client reports hypotension as a side effect from his recent increase in blood pressure medication dosage this would mean the blood pressure is:
Hypotension means the blood pressure is low. This can result in fainting, fatigue, and falls. BP readings are typically less than 90/60 to be classified as hypotension.
A client in the hospital who has been on bed rest for the last 4 days rises from a lying position to standing. Upon standing the client experiences a syncopal episode (passes out) and falls to the floor. The nurse understands that what has most likely happened to this client?
The client has orthostatic hypotension. To assist in confirmation of this the client should have their blood pressure checked in the lying, sitting, and standing positions. The client should be advised to not get out of the bed or chair without assistance.
What is hypertension?
Hypertension is a sustained elevation in blood pressure that will result in end organ damage and vessel changes. Normal systolic blood pressure (top number) should be less than 120 and normal diastolic blood pressure (bottom number) should be less than 80.
What is a cardiac tamponade?
A rapid filling of the pericardial sac which compresses the heart
What symptoms would the nurse anticipate in a client with a suspected cardiac tamponade?
Anxiety, chest pain, difficulty breathing, increased heart rate, JVD, low SBP (systolic blood pressure), and muffled heart sounds.
What treatment is preformed for a cardiac tamponade and what would occur if treatment is delayed or not completed?
Pericardiocentesis is performed for treatment and if not completed the patient will progress to circulatory shock and impending death
What is a pericardial effusion?
A pericardial effusion is an accumulation of fluid in the pericardial cavity from inflammation or infection.
What is the most serious complication of a pericardial effusion?
Cardiac Tamponade from the increased pressure the fluid accumulating in the pericardial sac is placing on the heart
What symptoms would the nurse anticipate in a patient diagnosed with a pericardial effusion?
- Chest pain
- Feeling faint
- Chest fullness
- Shortness of breath
- Difficulty breathing when lying flat
What symptoms would the nurse anticipate in a client diagnosed with right sided heart failure?
- Fatigue
- Pitting edema in lower extremities
- JVD
- Anorexia
- GI complaints
- Weight gain
- Ascites
- Enlarged liver and spleen
What symptoms would the nurse anticipate in a client diagnosed with left-sided heart failure?
- Fatigue
- Confusion
- Restlessness
- Cyanosis
- Orthopnea
- Exertional shortness of breath
- Tachycardia
- Chronic cough
- Wheezes, crackles, blood tinged sputum
What is a normal EF and what is considered abnormal?
EF is an ejection fraction which is determined by how much blood in the ventricle is pumped out with each beat.
- Normal is 50% to 75%
- 41% to 49% is borderline and symptoms of HF may occur with activity
- Heart failure symptoms will be present at rest and activity with a EF of 40% or less. These patients are also at a higher risk for complications
What would alert the nurse that a client may be experiencing a STEMI?
- ST elevation on EKG
- Elevated cardiac enzymes (cardiac markers such as troponin)
- Abrupt onset of symptoms
- Severe and crushing pain in the chest
- Pain may radiate to the left jaw or left neck.
- GI symptoms of nausea and vomiting
- Fatigue / weakness
- Tachycardia, anxiety, restlessness, feelings of impending doom
- Pale, cool, and moist skin
In a client diagnosed with shock the nurse would anticipate the following symptoms:
- Altered level of consciousness
- Pale or bluish discoloration of the skin
- Cool and moist skin
- Restlessness or irritability
- increased thirst
- Rapid and weak pulse (Tachycardia = HR greater than 100 beats a min)
- Rapid breathing (Tachypnea = rate greater than 24 breaths a minute)
- Nausea or vomiting
A client is experiencing anaphylactic shock related to a peanut allergy. What treatment should the nurse rapidly administer?
Anaphylactic shock should be treated with epi administered as quickly as possible. The nurse should additionally call 911 if he/she is not in the hospital and maintain an open airway in the client. Keep in mind that anaphylactic shock is a type of distributive shock.
Cardiogenic shock is failure of the heart to pump blood sufficiently to meet the body’s demands. An acute event that result in cardiogenic shock would be?
Myocardial infarction (MI), cardiac contusion, and sudden change from sinus rhythm to an arrhythmia such as ventricular fibrillation.
A client presents to the emergency department after an MVA in which the femoral artery has been severed. The nurse understands that this client is most at risk for this type of shock:
Hypovolemic shock due to a diminished blood volume resulting in inadequate filling of the vascular compartment. This type of shock occurs after 15 to 20% blood loss.
The nurse understands that a client experiencing a cardiac tamponade is at risk for this type of shock?
Obstructive shock which results in elevated right heart pressure because of impaired right ventricular function. Signs of right-sided heart failure will occur. This would include symptoms such as elevated CVP and jugular venous distention
What is the pacemaker of the heart?
- A. SA Node
- B. AV Node
- C. Bundle of HIS
- D. Purkinje Fibers
The SA node is the pacemaker of the heart.
The nurse understands that treatment of bacterial sinusitis will include a prescription for what class of medications?
A bacteria infection will be treated with antibiotic medications.
The nurse understands that a diagnosis of the common cold is caused by infections that are typically _________ and therefore treatment would include what recommendations?
The nurse understands that the common cold is typically caused by a virus and therefore treatment includes rest, fluids, antipyretics (fever reducing medications), decongestants, and antihistamines.
The nurse understands that epiglottitis is inflammation of the epiglottis (flap of cartilage that covers the airway during swallowing). The nurse would anticipate the following symptoms in a client with epiglottitis:
- Fever
- Sore throat
- Drooling
- Stridor
- Shortness of breath
- Tripod condition (air hunger)
The nurse understand that the priority treatment in a client with epiglottis is:
- Keep the child calm
- Have trach kit at bedside
- Minimize crying
- Monitor the airway
Croup is an upper airway infection that is caused by viral infections. The nurse understands that croup will produce what symptoms in a child?
- Barking cough
- Stridor
- Cold symptoms
The nurse understands that croup is treated by
- Cool humidified air
- Antipyretics for fever
- Possibly steroid medication if symptoms warrant the need
The nurse understands that in a pneumothorax the patient will exhibit these symptoms because the entire lung has collapsed due to air in the pleural space.
- Chest pain
- Increased respirations
- Shortness of breath (dyspnea)
- Asymmetry of the chest
- Tension pneumothorax - deviation of the trachea
The treatment of a tension pneumothorax involves the insertion of a large bore needle or chest tube what action should the nurse immediately take if the patient pulls out a chest tube and a sucking chest wound is noted?
The nurse should immediately apply an occlusive dressing such as Vaseline gauze.
The nurse understands that there are three types of pneumothoraxes. The nurse can describe these three types as:
- Spontaneous Pneumothorax - occurs when an air-filled blister on the lung surface ruptures
- Traumatic Pneumothorax - caused by penetrating or nonpenetrating injuries
- Tension Pneumothorax - occurs when the intrapleural pressure exceeds atmospheric pressure
The nurse understands that asthma is a chronic disorder of the airways which is characterized by bronchial hyperresponsiveness, airway inflammation, and airway remodeling. When exposed to a trigger such as allergens, exercise, or infection the client will have the following symptoms:
- Cough
- Chest tightness
- Wheezing
- Increase in respiratory rate
The nurse understands that the correct treatment for an asthma attack is:
The correct treatment is to provide quick acting relief medications beta 2 adrenergic agonists (albuterol), avoid triggers, potentially administer steroid medications or racemic epi in severe attacks.
In a client with DIC what symptoms will the patient experience simultaneously?
DIC will result in the client experiencing both bleeding and clotting simultaneously.
The nurse understands that hemorrhaging in DIC is the result of?
In DIC a client will have excessive clotting to the point that all clotting factors are used in the body. Since there will then be no clotting factors left the patient will begin to hemorrhage.
What symptoms would the nurse anticipate in a client dx with DIC?
The nurse should anticipate that the client will have petechiae, purpura, excessive bleeding from any wound, excessive bleeding from IV or catheter insertion, and excessive widespread clotting.
A client has been diagnosed with mononucleosis and asks the nurse what caused this infection. The nurse understands that mononucleosis is the result of?
Mononucleosis is the result of the Epstein–Barr virus. This is passed from person to person most commonly through bodily fluids, especially saliva.
The nurse is educating a family on their child’s dx of mononucleosis. The child plays football (high impact sport) and the parents would like to know if their child will be able to play in the game scheduled for this weekend. The nurse will educate the family that high-impact sports in patients with mono pose what risk?
Mononucleosis causes enlargement of the spleen which places a client at high risk for rupture of the spleen from the impact that can occur in sports such as football.
The nurse understands that the gallbladder is located in this quadrant of the abdomen?
Right upper quadrant
The nurse understands that the liver is located in this quadrant of the abdomen?
Right upper quadrant
The nurse understands that the pancreas is located predominately in this quadrant of the abdomen.
Left upper quadrant
The spleen is located predominately in this quadrant of the abdomen?
Left upper quadrant
The appendix is located in this quadrant of the abdomen?
Right lower quadrant
The rectum is located in this quadrant of the abdomen?
Left lower quadrant
The nurse is assigned to care for a client with c-diff during her shift. Prior to entering the clients room the nurse understands that all clients with c-diff have these two things in common?
These patients all have copious amounts of foul smelling, watery diarrhea and a history of broad spectrum antibiotic usage.
The nurse understands that c-diff is highly contagious and is easily transferred from patient to patient. The nurse understands that hand hygiene can prevent infections from spreading. How should the nurse perform hand hygiene after caring for a patient with c-diff?
The nurse should only** wash her hands with soap and water. The nurse should **never use alcohol based hand sanitizer since this will not kill the c-diff spores.
List potential complications of appendicitis?
Perforation (rupture), peritonitis, sepsis, localized periappendiceal abscess formation
What is the treatment for appendicitis?
Treatment for appendicitis is surgery.
The nurse is caring for a patient with appendicitis. The patient reports that the right lower quadrant pain has suddenly been relieved. What should the nurse suspect has happened?
The nurse should expect the appendix has ruptured.
List common symptoms associated with appendicitis.
Abrupt onset with pain originally at the epigastric or periumbilical that then localizes to the lower right quadrant. Nausea, vomiting, RLQ tenderness, rebound tenderness, elevated WBC count, and fever.
A client has symptoms of belching, nausea, burning pain in the chest, dry cough, and heartburn. The physician has dx with client with GERD. What medication treatment should should the nurse anticipate in this patient?
The nurse should anticipate antacids and proton pump inhibitors (PPI’s).
The nurse understands that this sphincter is weak in patients with a diagnosis of GERD?
Lower esophageal sphincter
The nurse is caring for an infant with severe projectile vomiting, weight loss, constipation, fatigue, excessive hunger, and a lump in abdomen. The physician tells the patient’s parents that the child has pyloric stenosis and failure to thrive. The parents begin to cry after the physician leaves and asks what they did wrong and why their infant is not gaining weight? The nurse says …
The nurse says that pyloric stenosis is a condition in which the opening between the stomach and small intestine (duodenum) thickens. This thickening will prevent food from entering the small intestine where most of the nutrients are absorbed. This means that no matter how much you feed your child the child will vomit the food up because it cannot move through the intestines. This is not your fault. You did nothing wrong, the cause of this disorder is unknown. Your child will need surgical correction of the problem.
Describe pancreatitis.
Pancreatitis is an inflammation of the pancreas. The pancreas is a long, flat gland that sits tucked behind the stomach in the upper abdomen. In acute pancreatitis the inflammation is brought on by premature activation of pancreatic enzymes and is reversible.
List potential causes of pancreatitis.
Potential causes of pancreatitis include gallstones, ETOH, hyperlipidemia, infections, cystic fibrosis, diabetes, medications, abdominal trauma or surgery.
The nurse is caring for a client with acute pancreatitis and knows that lab testing can be utilized as a part of the diagnosis of pancreatitis. What lab results would indicate acute pancreatitis?
Elevated serum amylase and lipase three or more times the upper limit of normal,
The nurse anticipates what treatment plan to be ordered by the physician in acute pancreatitis?
Acute pancreatitis treatment includes IV fluids, nasogastric tube insertion, and NPO (nothing by mouth). The patient will also require pain relief and electrolyte replacement.
The nurse is explaining cirrhosis to a patient and states that this diagnosis best described as?
Cirrhosis is the end-stage of chronic liver disease, in which much of the functional liver tissue has been replaced by fibrous tissue. Common causes include alcohol, viral hepatitis, toxic reactions to drugs/chemicals, biliary obstruction, hemochromatosis, Wilson disease, and NAFLD (Nonalcoholic fatty liver disease).
The nurse understands that liver failure is the most severe consequence of liver disease. This occurs either suddenly or gradually depending on cause. The nurse knows possible causes of liver failure include?
Causes include a reaction to a medication, high doses of acetaminophen or paracetamol, hepatitis infection, alcohol abuse, and advanced fatty liver. Sudden fulminant hepatitis which is a sudden damage to the liver such as with overdoses of medications like Tylenol.
In a client diagnosed with liver failure the nurse would anticipate symptoms to include:
Sweet odor on breath, jaundice, RUQ pain, ascites, nausea, vomiting, malaise, confusion, sleepiness, deficiency in fat-soluble vitamins, fatty stools, gynecomastia, menstrual irregularities, spider angiomas, and tremors. Fulminant hepatitis - symptoms include elevated ammonia levels, convulsions, confusion, a flapping tremor, and coma.
List potential complications of liver failure.
Potential complications of liver failure include liver cirrhosis, cancer of liver, liver failure, hepatic encephalopathy, portal hypertension, glomerulonephritis, and death.
List the cranial nerves, cranial nerve functions, and how to test each:
- CN I - Olfactory - smell
- CN II - Optic - Vision, test snellen chart.
- CN III - Oculomotor - Eye movements upward, medial, downward, and up and in.
- CN IV - Trochlear - eye movement down and in.
- CN V - Trigeminal - Facial touch sensation/ clench teeth.
- CN VI - Abducens - Eye movement side to side.
- CN VII - Facial - Taste on anterior 2/3 of tongue. Responsible for smile, crease forehead, and puff cheeks.
- CN VIII - Vestibulocochlear / Acoustic - hearing, whisper test, weber, rinne tests.
- CN IX - Glossopharyngeal - Controls muscles in oral cavity for speech and swallowing, taste on posterior 1/3 of tongue. Test gag reflex, ask patient to say “ah” watch for soft palate rise. Test taste.
- CN X - Vagus - responsible for digestion, heart rate, and respiratory rate. Ask patient to say “ah” and watch for soft palate rise.
- CN XI -Spinal Accessory - Shoulder shrug
- CN XII - Hypoglossal - Tongue movements
A patient has presented to the clinic today who’s family reports he has developed increasing difficulty with walking resulting in several falls at home. Upon assessment the nurse notes a pill roll tremor, difficulty starting ambulation, and difficulty with suddenly stopping or changing directions with ambulation. What diagnosis does the nurse anticipate the patient will have further referral to a neurologist to accurately diagnose?
The nurse anticipates the patient may have Parkinson’s Disease based on his current symptoms. Other symptoms include stooped posture, mask like face, back rigidity, forward tilt of trunk, reduced arm swing, short shuffling gait, and dementia. A neurologist will determine if the patient meets the absolute inclusion criteria for diagnosis of Parkinson’s Disease since there is no definitive test for Parkinson’s Disease.
A 40 year-old female with symptoms of chronic fatigue, diplopia, dysphagia, muscle weakness, chronic pain, and incontinence of urine was recently diagnosed with MS (Multiple Sclerosis). The patient would like to better understand her condition by knowing what is happening in her body to result in her current symptoms. What would be the best response by the nurse?
Multiple Sclerosis (MS) is a demyelinating disease of the central nervous system. Some nerve axons in the body are covered in a fatty substance called a myelin sheath that acts as an insulation that helps impulses travel more rapidly over longer distances. When the myelin is damaged or breaks down the impulses can no longer travel as they should because the impulses are slowed which results in the symptoms experienced in MS.
The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The patient’s family asks the nurse what a hemorrhagic stroke means. How would the nurse best respond?
A hemorrhagic stroke means that there is bleeding into the brain tissues which is placing pressure on the tissues of the brain. The pressure builds up because the skull does not allow for expansion. This pressure is reducing the ability of the brain tissues affected to receive the oxygen and nutrients they need. This type of stroke is typically caused by blood vessels rupturing from head injuries, aneurysms, or arteriovenous malformations.
The nurse is caring for a client diagnosed with an ischemic stroke. The family asks the nurse to explain what this diagnosis means. How would the nurse best respond?
An ischemic stroke is caused by an interruption of the blood flow in the brain typically from a blood clot. The blockage created by the blood clot means that the area of the brain tissue past the blockage is unable to receive the oxygen and nutrients it needs to survive.
A patient has been diagnosed with a transient ischemic attack (TIA, mini stroke). The patient asks the nurse what a “mini-stroke” is and why treatment is important if all the symptoms have resolved. What would be the best response by the nurse?
A “mini-stroke” is also known as a transient ischemic attack. This type of stroke is caused by a temporary clot. The temporary clot caused a lack of oxygen and nutrients to the area past the clot which is why you experienced your symptoms. The clot was temporary and when blood flow resumed the tissues affected by the lack of blood flow were able to receive oxygen and nutrients again so your symptoms resolved. Treatment with anticoagulants is very important because you are at a very high risk for a ischemic stroke due to your history of having a “mini-stroke.”
The nurse understands that early recognition of a stroke can save a persons life and reduce long term negative effects associated with a stroke. What symptoms of a cerebral vascular accident (CVA) would the nurse teach a group of clients about to promote early presentation for treatment?
The nurse should teach the clients that the following symptoms can indicate a stroke is occurring:
- Facial droop
- Arm weakness
- Slurred speech
- Sudden confusion
- Sudden difficulty speaking (finding correct words)
- Sudden difficulty understanding speech
- Sudden dizziness, loss of balance, lack of coordination
- Sudden numbness of the face or one side of the body
- Difficulty seeing
- Sudden severe headache
Time is brain tissue so the patient should present as soon as possible!
What treatment can a person having an ischemic stroke receive within a three hour window that can significantly improve their symptoms and outcome?
TPA (Tissue plasminogen activator) may be given to someone having an ischemic stroke because it is a clot buster. This medication should never be given to someone having a hemorrhagic stroke.
Compare expressive vs receptive aphasia as a complication of a stroke.
Expressive aphasia - the patient knows what they want to say, but they have trouble saying or writing what they mean. The message will come out garbled or will not make any sense.
Receptive aphasia - the patient hears the voice or sees the print, but then they cannot make sense of the words.
What is the difference between benign paroxysmal positional vertigo and Meniere disease?
Benign paroxysmal positional vertigo (BPPV) is triggered by certain changes in head position, such as tipping the head up, down, or side to side. It results in a spinning sensation and dizziness. It’s rarely serious unless it increases the risk of falling. The episodes are typically brief (less than one minute) and resolve spontaneously. Meniere’s disease is a disease of unknown causes that affects the membranous labyrinth of the ear. Symptoms include fluctuating episodes of tinnitus, feelings of ear fullness, and violent rotary vertigo that often renders the person unable to sit or walk.
A new nurse on the neurological intensive care unit understands that the master gland of the human body is:
Pituitary gland
A patient presents with symptoms of fatigue, puffiness around the eyes, irritability, thinning hair, dry skin, weight gain, and cold intolerance. The nurse expects the patient’s symptoms indicate which endocrine disorder?
Hypothyroidism which can be diagnosed by laboratory testing of T3, T4, and TSH levels. Testing of thyroid autoantibodies such as TPO (thyroid peroxidase antibodies) which are indicative of a autoimmune causes of hypothyroidism (Hashimoto’s disease). If thyroid cancer or goiters are suspected a thyroid scan, CT, MRI, ultrasound, or fine needle biopsy will be completed.
A patient presents with symptoms of anxiety, restlessness, difficulty sleeping, exophthalmos, tachycardia, weight loss, silky hair, and heat intolerance. The nurse suspects that the patient’s symptoms indicate a diagnosis of:
Hyperthyroidism which will be diagnosed by laboratory testing of T3, T4, and TSH. Laboratory testing of autoimmune causes of hyperthyroidism may include testing thyroid-stimulating immunoglobulins (TSI) and/or TSH receptor antibodies (TRAb). Graves disease is an autoimmune disorder resulting in hyperthyroidism.
A patient is suspected of having a diagnosis of Graves Disease. What symptoms would the nurse anticipate in this patient?
The nurse should anticipate exophthalmos, headaches, nervousness, emotional instability, weight loss, thyroid goiter, sweating, tachycardia, nausea, diarrhea, oligomenorrhea, muscle weakness, and tremors. Graves disease is an autoimmune disorder. Treatment can include beta-blockers, radioactive iodine therapy, anti-thyroid medications, and/or surgical removal of the thyroid gland.
A group of nursing students is discussing the difference between type 1 diabetes and type 2 diabetes. The nursing instructor knows the students understand the difference between these two diabetes types when the students state:
Type 1 diabetes requires insulin because the patient’s pancreas produces little to no insulin. This diabetes type occurs more frequently in children and is the result of autoimmune destruction of the pancreas. Type 2 diabetes is more common in adults. This is an acquired disorder in which the body cannot use insulin correctly because not enough insulin is being produced or insulin resistance.
The nurse understands that a diagnosis of diabetes can be obtained from blood testing. What would be considered blood levels indicative of diabetes?
Normal fasting blood glucose: 70 - 99 mg/dL Normal hemoglobin A1C test: below 5.7% Diabetes fasting blood glucose: above 126 mg/dL Diabetes hemoglobin A1C test: 6.5% or higher
List potential symptoms of diabetes:
Polyuria - increased urination Polydipsia - increased thirst Polyphagia - increased hunger Dry mouth Fatigue Vision changes Difficulty healing Yeast infections Numbness in extremities End organ damage
A patient with a history of diabetes presents with symptoms of fatigue, increased thirst, increased urination, rapid deep breathing, flushed skin, dry skin, fruity-smelling breath, high blood glucose, nausea, and vomiting. The nurse understands that the patient may progress to confusion or loss of consciousness as this complication of diabetes progresses:
The patient is presenting with symptoms of DKA (Diabetic Ketoacidosis). DKA develops when the body doesn’t have enough insulin to allow blood sugar into the cells for use as energy. So, the liver breaks down fat for fuel. This process produces acids called ketones. When too many ketones are produced too rapidly, they can build up to dangerous levels in the body.
Treatment of DKA includes:
Administration of fluids, replacement of electrolytes, and administration of insulin.
A patient diagnosed with diabetes should be taught the symptoms of hypoglycemia. An adverse effect of medications used to treat diabetes is hypoglycemia. What symptoms would the nurse teach a client indicate hypoglycemia?
Symptoms of hypoglycemia include a blood glucose less than 70 mg/dL, tachycardia, fatigue, pale skin, shakiness, anxiety, sweating, hunger, irritability, and tingling around lips, tongue, or cheek. As hypoglycemia worsens confusion, visual disturbances, seizures, and loss of consciousness will occur.
A nurse is teaching a patient and their family treatment for hypoglycemia. What teaching should be included on this topic?
If hypoglycemia occurs oral treatment is preferred unless IV treatment is absolutely necessary. Oral treatment includes eating/drinking 15 to 20 grams of fast-acting carbohydrates. These are sugary foods without protein or fat that are easily converted to sugar in the body such as glucose tablets/ gel, fruit juice, regular soft drinks, honey, and sugary candy. A blood glucose level should be rechecked in 15 minutes. If the blood glucose is within normal limits the patient should eat a snack or meal that has complex carbs to stabilize the body glycogen stores. If hypoglycemia is severe and the patient is unresponsive or unable to follow commands a glucagon injection or IV glucose may be administered for treatment.
List potential complications of diabetes that all patients should be educated on:
Peripheral neuropathy Retinopathy, cataracts, glaucoma PVD Renal damage (nephropathy) Diabetic foot ulcers Hearing impairment Cardiovascular disease End organ damage
A patient has been diagnosed with a first-degree burn (superficial partial-thickness). What would the nurse anticipate finding upon assessment of this patient’s burns?
The nurse should anticipate finding a burn that only involves the outer layers of the epidermis. The burn will appear red, painful, dry to the touch, and may have mild edema present. Hint: Think of a sunburn.
A patient has been diagnosed with a second-degree partial thickness burn. What would the nurse anticipate finding upon assessment of this patient’s burns?
The nurse should anticipate that the epidermis and varying areas of the dermis will be involved. The burn will appear red and moist with blistering noted. The patient will complain of extensive pain.
A patient has been diagnosed with a second-degree full-thickness burn. What would the nurse anticipate finding upon assessment of this patient’s burns?
The nurse should anticipate that the epidermis and dermis are involved. The burn will appear edematous, mottled pink/red with tissue paper-like blisters. There may be waxy white areas present. These burns are typically very painful but may have some areas without sensation.
A patient has been diagnosed with a third-degree full-thickness burn. What would the nurse anticipate finding upon assessment of this patient’s burns?
The nurse should anticipate that the client will have involvement of the epidermis, dermis, subcutaneous, and potentially muscle and bone. The burn area will appear very edematous and have areas of waxy white, yellow, deep brown, black, tan, or red areas. There is no sensation in this burn tissue because all the nerve endings are no longer present.
The nurse educator is asking a group of nursing students about the purpose of the Renin-Angiotensin-Aldosterone mechanism. The nurse educator knows that the students understand the purpose when they state?
The Renin-Angiotensin-Aldosterone mechanism is a series of actions responsible for short and long-term management of blood pressure. You can remember this more easily if you remember that the medical terms for blood pressure abnormalities include hypotension and hypertension. The Renin-Angiotensin-Aldosterone mechanism also includes a similar part of the words with -tensin.
The nurse is caring for a client with polycystic kidney disease. The nurse understands that this is:
Polycystic kidney disease (PKD) is an inherited disorder in which clusters of cysts develop primarily within the kidneys, causing the kidneys to enlarge and lose function over time. Keep in mind these cysts are noncancerous. They are similar to other cysts in the body. The cysts are round sacs containing fluid.
The nurse is caring for a patient who presented to the emergency department with symptoms of severe flank pain that is moving toward the pelvic area, urinary frequency, urinary urgency, nausea, and vomiting. The patient’s UA results indicate hematuria. The nurse understands that the most likely diagnosis is?
Renal calculi (renal stone, kidney stone) which is a crystalline structure that forms form components of the urine. The most common type of stone is calcium stones.
The nurse understands that a client with chronic renal failure must be placed into the correct stage of chronic renal failure as this affects the treatment recommendations. A client with a GFR of 20 would be identified as stage:
The client would be staged as having a severe reduction of renal function. The stages of renal failure are identified as follows:
- Mild reduction of GFR to 60 to 89 mL/min/1.73 m2
- Moderate reduction of GFR to 30 to 59 mL/min/1.73 m2
- Severe reduction in GFR to 15 to 29 mL/min/1.73 m2
- Kidney failure with a GFR < 15 mL/min/1.73 m2, with a need for renal replacement therapy
The nurse understands that client education is very important to client care. In discussing chronic renal failure with a client what would the nurse include as potential causes?
Potential causes include hypertension, diabetes, polycystic kidney disease, obstructions of the urinary tract, glomerulonephritis, cancer, autoimmune disorders, disease of the heart/lungs, and chronic usage of pain medications.
A client with chronic renal failure has updated lab results that indicate a GFR of 10 mL/min/1.73 m2. The nurse understands that this is identified as renal failure and that the treatment for end-stage chronic renal failure that will prevent the build-up of waste in the body is?
The patient requires diaylasis to remove body wastes. If diaylasis is not preformed the client will not live because waste will build up in the body such as excess potassium which will result in cardiac arrest.
A client is being diagnosed with urinary incontinence which is the involuntary loss of urine. The nurse understands that the different types of urinary incontinence include:
- Stress incontinence: involuntary loss of urine from increased intra-abdominal pressure such as when coughing, sneezing, laughing or lifting objects.
- Urge incontinence: involuntary loss of urine associated with a strong desire to void (urgency).
- Overflow incontinence: involuntary loss of urine that occurs when the patient is unable to completely empty the bladder which leads to an overflow of urine, that then leaks out unexpectedly.
- Mixed incontinence: this is a combination of stress and urge incontinence.
Compare and contrast hypospadias and epispadias.
- Hypospadias is the termination of the urethra opening in males on the ventral surface (bottom) of the penis. See figure A.
- Epispadias is the termination of the urethra opening on the dorsal surface (top) of the penis. See figure B.
A male infant has been diagnosed with cryptorchidism. The nurse understands that this means the client:
This means the client has an undescended testicle. The testicle may be in the abdominal cavity, inguinal canal, or high scrotal area. The testes should have descended into the scrotum during the 7th to 9th month of gestation. If the testicle does not move into the scrotum by 3 months of age surgical treatment will be completed after the patient reaches 6 months.
An infant is 6 months old and cryptorchidism has persisted since birth. The parents have presented the child for a presurgical screening appointment. The parents ask the nurse why they cannot just leave the cosmetic problem of the testicle not being in the scrotum as it is rather than having surgery at this young age? What is the best response by the nurse?
The best response of the nurse is to educate the parents that this is not just a cosmetic issue. If the testicle is left in the incorrect location this can cause a sequelae of events with potential complications that include infertility, malignancy, psychological effects, and an approx 10 fold increase risk of testicular torsion.
A patient presents with sudden onset of severe pain rated 10/10 and testicular edema. The patient reports that he was running across the field in a football game and was inadvertently hit in the genital area. The nurse understands that the patient may have a diagnosis of _____________ which is a medical emergency and requires prompt treatment.
The client may have testicular torsion which is a twisting of the testicle. When the testicle rotates it will twist the spermatic cord and compress the vessels supplying blood. Surgical treatment is necessary or the testicle may not be salvageable. This could result in infertility.
A female client presents with symptoms of copious amounts of a green/yellow frothy malodorous discharge. The patient reports mild pruritus over the labia. The internal vaginal exam reveals an edematous cervix with strawberry spots. The most likely cause of this patient’s symptoms is?
The symptoms of this patient indicate a trichomoniasis infection. This is an anaerobic protozoan that feeds on the vaginal mucosa and ingests bacteria and leukocytes. This infection is typically treated with Flagyl unless there is a contraindication to this medication.
A male client presents with symptoms of dysuria and a dripping creamy yellow discharge from the urethra. What is the most likely STD that this patient has?
The symptoms of this patient align with gonorrhea. Most women are asymptomatic, however, when symptoms are present they could include pelvic pain, bleeding between periods, spotting after intercourse, and a yellow-white vaginal discharge.
A male client presents to the outpatient client with symptoms of testicular pain, dysuria, and a greyish faint yellow discharge from the urethra. The nurse knows that the most likely STD causing these symptoms is?
The nurse understands that these symptoms correlate with a chlamydia infection. This STD is frequently asymptomatic in both males and females.
A female client has recently been diagnosed with HPV. The client states that she is lucky because this is not the type of HPV that causes genital warts so she has nothing to worry about. How should the nurse respond to this statement?
Although, the HPV type you have contracted may not cause genital warts at this time the most serious complication of HPV is cancer. Cancer can result in areas that are infected with the HPV cells such as the cervix, oropharynx, anus, penis, vagina, and vulva. Cancerous cells on the cervix can be removed. You will need to maintain regular screening visits to check for precancerous and cancerous cells.
A client reports to the client with symptoms of painful blisters in the genital area. Some of these blisters have developed into ulcerations. The client reports that this happens periodically and she has had 3 occurrences of these blisters over the last 4 months. The nurse understands that the most likely diagnosis is?
The most likely diagnosis is HSV 2 (herpes simplex virus type 2, genital herpes). This virus will result in painful outbreaks of these blisters followed by periods of the patient appearing asymptomatic. The client can transmit this infection at all times not only during symptomatic outbreaks.
HPV increases a female’s risk for
cervical cancer
Undescended testicles place a client at risk for
infertility, malignancy, testicular torsion, and psychological effects
Describe how a UTI will present differently in an elderly client compared to a young adult.
The elderly client may have symptoms of mental status changes compared to the dysuria, urinary frequency, and urinary urgency that the young adult may experience
Symptoms of breast cancer include
a lump (mass), nipple discharge, dimpling of skin, changes in skin texture, and nipple retraction
Brittle hair, hair loss, dry skin, and weight gain are all potential symptoms of this endocrine disorder
hypothyroidism
Medication class found OTC that frequently results in GI ulcerations
NSAIDs
Symptoms of testicular torsion include
sudden, severe pain and swelling in the testicle
________ sided heart failure is characterized by JVD, weight gain, dependent edema, and increased venous pressure.
right-sided
A client with a history of a thyroid disorder presents with thinning hair, bradycardia, thickened, nonpitting edema of the skin, and is unresponsive. The patient’s family member reports the patient was very sick with COVID and stopped taking the ordered thyroid medication due to nausea. The nurse understands that the most likely diagnosis is _______ from this thyroid disorder:
myxedema coma related to the client’s hypothyroidism that was triggered by the client’s infection and stopping the thyroid medication (levothyroxine)?
The three most common symptoms in diabetic patients are
polyuria, polydipsia, and polyphagia
The nurse is assessing the cranial nerves of a client and suspects damage to this cranial nerve when swallowing is abnormal and gag reflex response is abnormal.
CN lX Glossopharyngeal
A class of medication that causes a decrease in stomach acid.
Proton-pump inhibitors or antacids. (Tums or Nexium)
Describe the medication treatment options for influenza.
Tylenol, ibuprofen, decongestants, etc. Antibiotics would not be utilized for viral infections.
Death can result from mononucleosis (mono) as a complication of what occurring
a rupture of an enlarged spleen
The nurse understands that pancreatitis symptoms would include (name at least 2) and pancreatitis would be indicated by these lab tests being three times the upper limit of normal?
Amylase and lipase. Symptoms would include epigastric pain, bloating, fat in the stool, indigestion, nausea, vomiting, loss of appetite, weight loss, fever, tachycardia, hypotension, abdominal tenderness, respiratory distress, increase thirst, poor urine output, and ascites.
Explain what is happening in DIC to cause both bleeding and clotting in a patient.
There is so much clotting occurring that all clotting factors are being used and therefore uncontrolled bleeding occurs.
The nurse understands that symptoms of a dissecting abdominal aortic aneurysm include:
The nurse understands that symptoms of a dissecting abdominal aortic aneurysm include:
a sudden onset of pain described as a tearing or ripping sensation in the abdomen, decreasing blood pressure, and decreasing level of consciousness
Respiratory condition in which a barking cough is a cardinal feature
croup
Tension pneumothorax causes the lung to
collapse
The following ABG problem indicates:
pH 7.21 PaCO2 50 HCO3 24
respiratory acidosis
What does this picture depict?
hip dysplasia
