QB# 1 Flashcards
1
Q
Growth spurt in females and males will peak at which age ?
A
12 & 14, respectively
2
Q
_________ teeth will appear in the period of adolescence
A
wisdom
3
Q
Male changes during adolescence
A
increase in genital size pubic, facial, axillary and chest hair deepening voice production of functional sperm nocturnal emissions
4
Q
Female changes during adolescence
A
breast development appearance of axillary & pubic hair menarche - first menstrual period
5
Q
psychosocial development during adolescence
A
conforms to peer pressure moody increased independence
6
Q
potential problems during adolescence
A
adolescent pregnancy poor self image automobile accidents drug/alcohol abuse AIDS high school dropout violence
7
Q
When on heparin or other anticoagulants, Herbal supplements such as ______________________________may increase the client’s risk for bleeding
A
Herbal supplements (e.g., garlic, ginger, ginkgo, ginseng, and licorice) may increase the client’s risk for bleeding
8
Q
Some medications can cause confusion and hallucinations. Older adult clients are more prone to experiencing these manifestations as the _______________declines with age, decreasing the rate at which medications are eliminated from the body.
A
renal function
9
Q
Adverse drug reactions among older adult clients may manifest as ________________________
A
altered mental status, delirium, orthostatic hypotension, incontinence, and gastrointestinal manifestations such as anorexia and nausea.
10
Q
For a client with hallucinations, what is the first priority ?
What interventions can we perform for the client with hallucinations?
A
Safety
Ask the client directly about the hallucination
avoid reacting to the hallucination as if it were real
decrease stimuli or move the client to antoher area
do not negate the clients experience
Gently challenge the client’s perceptions.
Monitor the client’s verbalized thought patterns and perceptions, as well as associated behavior.
Tactfully ask the client about current and past experiences with hallucinations.
Monitor for increased negativity of content, anxiety, and agitation, or for social withdrawal.
focus on reality based topics
attempt to engage the clients attention through a concrete activity
respond verbally to anything real that client talks about
avoid touching the client
monitor for signs of increasing anxiety or agitation, which may indicate that hallucinations are increasing
Conduct urinalysis for toxicology as indicated if hallucinations are suspected to be related to substance abuse.
11
Q
what to know about STI syphilis
A
3 stages
Stage 1- painless chancre ( genital ulcer) fades after 6 weeks
stage 2 - copper colored rash on palms & soles
stage 3 - cardiac and CNS dysfunction
spread via mucous membranes, skin, congenitally
TREAT WITH IM penicillin G
12
Q
what to know about Gonorrhea
A
frequently asymptomatic in females
symptoms in females include- purulent vaginal discharge, dysuria, dyspareunia
symptoms in males - painful urination, yellow-green discharge
spread via mucous membranes, congenitally, sexual activity
IM ceftriaxone with PO doxycycline
IM aqueous penicillin with PO probenecid
COMPLICATION of Gonorrhea - Pelvic Inflammatory Disease
13
Q
what to know about genital herpes
A
painful vesicular genital lesions
difficulty voiding
reoccurs with stress, infection, menses
spread via mucous membranes, congenitally
Acyclovir, Sitz bath, topical medication
Monitor Pap smears regularly
precautions about vaginal delivery (can cause blindness in newborn)
14
Q
what to know about chlymydia
A
Men - urethritis, dysuria, watery discharge
Women - may be asymptomatic- symptoms include thick vaginal discharge with acrid odor, pelvic pain
Spread via mucuous membranes/sexual contact
Tetracycline or Doxycycline PO
complication - sterility
15
Q
Clients should be taught that the risks of developing sexually transmitted infections are greatly reduced by
A
being in a mutually monogamous sexual relationship, reducing the number of sex partners, and using latex condoms.
16
Q
Post-tonsillectomy, the nursing interventions are focused on these 3 things
A
assessing for airway clearance, providing pain relief, and monitoring for excessive bleeding.
The nurse should instruct the client to avoid crunchy, hard foods and hot or spicy foods
After a tonsillectomy, monitor for bleeding or airway obstruction due to edema and swelling.
Frequent swallowing may indicate bleeding. Discourage coughing, clearing the throat, or nose to prevent bleeding.
Monitor the back of the throat frequently in the post-operative period for bleeding. Monitor vital signs. Once the gag reflex has returned post-operatively, offer cool fluids and ice chips. Assess and treat pain as prescribed. Corticosteroids may be administered to reduce edema.
17
Q
What is conversion disorder ?
A
The sudden onset of a physical symptom or a deficit suggesting loss of or altered body function related to psychological conflict or a neurological disorder
conversion disorder is an expression of a psychological conflict or need
The most common conversion symptoms are blindness, deafness, paralysis, and the inability to talk
conversion disorder has no organic cause
18
Q
What is post-herpetic neuralgia?
A
common in clients after the acute outbreak of herpes zoster (shingles) has been resolved.
client may experience persistent pain after the resolution of herpes zoster
19
Q
A client being discharged from the postpartum care area requests perineal pads, diapers, wipes, and perineal spray. Which response is the best for the nurse to make to this client?
A
1) INCORRECT - The nurse is responsible for maintaining costs of the care area. Many insurance companies consider ordering extra supplies the day of discharge as stockpiling and may refuse to pay the bill.
2) INCORRECT - The client does need to be responsible for obtaining needed items, but this response is not therapeutic.
3) INCORRECT - Saying that the client does not need any more supplies is argumentative and not therapeutic.
4) CORRECT— Offering supplies for one hour provides for the client ’s immediate needs in a cost-effective way.
The nurse is responsible for providing cost-effective care and should only supply the client with supplies that are needed until the client is able to obtain/purchase the items after discharge. Health insurance companies may not pay for additional items that are charged on the day of discharge. Confronting the client is not therapeutic. The client will need supplies; however, the nurse can only provide a limited amount.
20
Q
An ___________________ is a non-invasive diagnostic tool used to differentiate arterial from venous insufficiency
A
ankle-brachial index (ABI)
21
Q
What to remember about chronic venous insufficiency ?
A
results from prolonged venous hypertension, which stretches the veins and damages the valves
The resultant edema and venous stasis cause venous stasis ulcers, swelling, cellulitis, brown discoloration along the ankles extending up to the calf, pain during walking or activity, edema, non-healing wounds, and skin color changes.
Varicose veins are consistent with the diagnosis of chronic venous insufficiency. `
Pain in the lower extremities while sitting is consistent with the diagnosis of chronic venous insufficiency. Venous insufficiency may cause pain in dependent positions.
22
Q
Phlebitis
A
Symptoms include redness, warmth, and pain in the affected area.
Inflammation of a vein.
Phlebitis may occur with or without a blood clot. It can affect surface or deep veins. When caused by a blood clot, it’s called thrombophlebitis. Trauma to the vein, for instance from an intravenous catheter, is a possible cause.
Treatments may include a warm compress, anti-inflammatory medication, compression stockings, and blood thinners.
23
Q
Sickle cell disease is a severe hereditary form of anemia in which a _______________form of hemoglobin ___________the red blood cells into a crescent shape at low oxygen levels. When planning care for this client, the nurse needs to promote ______________________-
A
mutated; distorts; optimal oxygenation, adequate rest periods, hydration, and adequate pain management.
A client with sickle cell disease can experience a “crisis.” The crisis is usually precipitated by low fluid volume.
24
Q
Serious side effects of Clozapine
A
Clozapine is an atypical antipsychotic agent. It is not likely to cause extrapyramidal syndrome (EPS). Serious side effects include seizure and agranulocytosis.
Clozapine is a medication that has the potential to suppress bone marrow and cause agranulocytosis. This potentially fatal side effect occurs in 1% to 2% of clients.
The health care provider will monitor the CBC, specifically the client’s WBC count. Clozapine will be discontinued if the WBCs fall below 2000/mm3.
Clozapine is excreted in breast milk, so breastfeeding is contraindicated.
Clozapine is an antipsychotic used for the treatment of schizophrenia
25
What to know about hypercalcemia
serum calcium level that exceeds 10.5 mg/dL
caused by increase in parathyroid hormone (hyperparathyroidism), increased absorption of calcium (excessive intake of vitamin D), or decreased excretion of calcium. Elevated calcium levels can negatively affect bones, kidneys, and cardiac output. Signs and symptoms include **muscle weakness, headache, irritability, depression, bone pain, anorexia, nausea, vomiting, and constipation.** Can also be associated with renal lithiasis. Bradycardia or arrhythmias may also be noted. **Heart block is a late sign.**
***Manifestations of an elevated calcium level begin with muscle weakness and constipatio***n. If the condition continues without effective treatment, the rising calcium level can adversely effect the conduction system of the heart. **The client is at risk for developing a life-threatening dysrhythmia or complete heart block.**
**EKG changes - shortened ST segment, widened T wave**
26
What is lactose intolerance ?
***Lactase breaks down lactose, which is a form of sugar, into glucose and galactose for absorption. Without lactase, undigested lactose builds up in the colon***. As bacteria in the colon interact with the undigested lactose, gas is produced. In turn, the client experiences **bloating and abdominal pain**. ***In most cases, lactose intolerance is caused by lactase deficiency.*** Unlike a milk allergy, which involves an immune response, lactase deficiency is not an allergic reaction. Usually, some milk products can be consumed without side effects, but the **client must pay attention to ensure adequate calcium and vitamin D are consumed**. Alternate calcium sources include salmon, rhubarb, kale, spinach. Vitamin D can be obtained from salmon, tuna, eggs, and fortified foods like cereal.
**Bloating, flatulence, abdominal pain and cramping, and diarrhea are symptoms of lactose intolerance**. Symptoms usually occur about 30 minutes to several hours after ingesting milk or a milk product. The client may be able to tolerate small amounts of lactose. **If lactose is ingested in the diet, cheese and live culture yogurt are better options than milk and ice cream because they contain less lactose**. Also, some clients tolerate lactose better if lactose is ingested with meals. Instruct the client to read food labels to identify potential hidden sources of milk products.
27
In newborns, what is the most reliable assessment indicator for decreased bilirubin levels ?
the color of the oral mucosa and gum tissue is the most reliable indictor that the serum bilirubin levels are decreasing
28
The nurse provides care for a newborn who is prescribed phototherapy for hyperbilirubinemia. Which actions will the nurse implement when providing care to this client? (Select all that apply.)
1. Remove the newborn’s eye patches during feedings.
2. Place the newborn 15 cm (6 in) below the phototherapy lights.
3. Reposition the newborn every 4 hours.
4. Cover the newborn with light cotton clothing.
5. Cluster activities when caring for the newborn
1) CORRECT — The nurse should place eye patches over the newborn’s eyes to prevent retinal damage, but should remove them at least every 2 to 3 hours to assess the skin and to promote stimulation and bonding with parents during feedings.
2) INCORRECT - The newborn should be placed about 30 to 40 cm (12 to 16 in) below the bank of phototherapy lights to prevent injury to the skin.
3) INCORRECT - The nurse should reposition the newborn at least every 2 hours to provide stimulation, maximize skin exposure to the lights, and prevent skin breakdown.
4) INCORRECT - The nurse should dress the newborn only in a diaper to maximize skin exposure to the lights.
5) CORRECT — When performing care for the newborn, the nurse should cluster care to ensure the newborn obtains maximum exposure to the lights.
Phototherapy requires the newborn to be exposed to a special fluorescent light. **Increased skin area exposed increases the therapy’s effectiveness.** T**he light is absorbed through the skin and blood, and then breaks down the bilirubin in the newborn’s body so that it can be flushed out of the body in stool and urine**. When administered appropriately, phototherapy is not harmful to the newborn’s skin. However, **eye protection is applied to prevent injury to the newborn’s eyes**. Exposure to UV filtered sunlight at home may be prescribed for treatment of clients with mild cases of jaundice, but caution is required to avoid sunburn.
Content Refresher
**Phototherapy is used to promote bilirubin excretion**. Closely monitor the infant’s temperature because phototherapy can increase the body temperature. Monitor the infant’s skin for burns. Monitor for side effects of phototherapy, including **loose, greenish stools**; hyperthermia or hypothermia; increased metabolic rate; priapism; dehydration; and electrolyte imbalances, such as hypocalcemia (uncommon, but possible). The full-term and late-preterm infant may require additional fluid volume or feedings to compensate for insensible and intestinal fluid loss.
29
For the term newborn, hyperbilirubinemia is indicated when serum levels are greater than _______________ mg/dL.
12
Thereapy is aimed at preventing kernicterus, which results in permanent neurological damage resulting from the disposition of bilirubin in the brain cells
30
6 year old growth & development
self centered, show off
sensitive to criticism
begins losing temporary teeth
31
7 year old growth & development
team games/sports
develops concept of time
prefers playing with same sex child
32
8 year old growth and development
seeks out friends
writing replaces printing
33
9 year growth and development
conflicts between adult authority & peer group
conflicts between independence and dependence
34
10-12 years growth & development
remainder of teeth (except Wisdom) erupt
uses phone- loves conversation
- increasingly responsible
- more selective when choosing friends
- begins to develop interest in opposite sex
35
Potential problems that can occur with school aged child
Enuresis - bed wetting
Encopresis - incontinent of stool
Safety - child is more independent and will go places alone this age
Head Lice (Pediculosis Capitis)
36
Age appropriate toys for school aged child
- Construction Toys
Household & sewing tools
table games, sports
Bicycle with helmet
37
Erikson's stage of psychosocial developmetn for school aged children (6-12 years old)
Industry versus inferiority
the task consists of developing social, physical and learning skills
**Children who are 10 years of age need to feel competent at performing a task or skill (e.g., household chores, mechanical activities, repairing or building toys).** Developmentally, the 10-year-old is in the **stage of industry versus inferiority**. The developmental stage of a 10-year-old is focused on the achievement of specific tasks or skills,
38
In people with hemophilia, bleeding may be more \_\_\_\_\_\_\_\_\_\_\_\_\_\_
excessive or severe
39
In considering how to best provide transitional care as the client transitions home, the nurse will first perform a gap analysis and identify \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
the client's needs
The nurse will assess the client's needs, including the client's abilities to perform activities of daily living,
Once the client's needs are identified, further planning and teaching can occur.
**The nurse needs to first determine the needs of the client when preparing to discharge the client to home.**
40
Client education is an expected competency for every nurse. An essential first step is to assess the client’s teaching and learning needs, including\_\_\_\_\_\_\_\_\_\_\_\_- issues. ***Health literacy has been shown to be a stronger predictor of health status than age and educational level***.
***Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations.*** The nurse should always use the teach-back method.
literacy
41
Treatment for emphysema is directed at risk reduction practices, such as \_\_\_\_\_\_\_\_\_cessation and occupational preventive strategies to reduce inhalation of irritating substances. Oxygen therapy may be necessary, as well as methods to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_oxygen demands such as pacing activities**, eating small frequent meals**, positioning, and pursed lip breathing. Early recognition and appropriate management of exacerbation symptoms reduce the rate of disease progression.
smokingl reduce
42
Why are infants and children more vulnerable to fluid volume deficit?
Because more of their body water is in the extracellular fluid compartment. The organs that conserve water are also immature, placing them at risk for fluid volume deficit.
43
n many ways the signs of dehydration are universal; however, there are variations based upon the client's age.
Dehydration is the loss of body fluids, mainly water, with resultant changes in serum electrolytes. Risk factors associated with dehydration include \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_are at risk for dehydration. Signs and symptoms of dehydration include \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Treatment for dehydration includes oral and/or IV fluid and electrolyte replacement.
inadequate fluid intake, diarrhea, vomiting, disorders that result in fluid losses (diabetes mellitus, diabetes insipidus, fluid shifts, burns, hemorrhage, certain medications such as diuretics);
Infants, children, and the older adult populations
**thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy**
44
The nurse knows that the first line of defense against the transmission of infection is
**good hand hygiene.**
***This is the most important information to provide to the client's caregiver to prevent the spread of infection***. If needed, teach the caregiver how to properly wash his or her hands (wet hands, apply soap, lather for at least 20 seconds, rinse thoroughly, and dry).
45
Acquired immunodeficiency syndrome (AIDS) is a bloodborne sexually transmitted disease caused by a retrovirus, human immunodeficiency virus (HIV). Once the virus enters the body, it attaches to the\_\_\_\_\_\_\_\_\_\_\_\_\_ receptor on T lymphocytes and uses the lymphocytes as hosts to replicate. With successive copying of the virus, the T lymphocytes die and\_\_\_\_\_\_\_\_\_\_\_\_\_ results. Once the CD4 count drops below \_\_\_\_\_\_\_\_\_\_cells/mm 3, the client is diagnosed with ________________ and is susceptible to further complications from **immunosuppression**, such as infection. Promoting handwashing to prevent the transfer of an infection to the client is the priority.
CD4; immunosuppression; 200; AIDS
46
Transmission of HIV is through
sharing IV needles
sexual contact
transplacental
contaminated blood or body fluids
possibly through breast milk
47
When preparing a client for surgery, the nurse needs to think of multiple issues. "What is needed to perform the surgery?" The\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-- should be verified on the medical record. Vital signs are measured and recorded. Other thought processes need to focus on the client. "What safety considerations are most important?" The client is ambulated to\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_- prior to administering preoperative medication. Once the preoperative medication is provided, the client is to remain \_\_\_\_\_\_\_\_\_\_\_\_\_-
surgical consent form; void; in bed.
48
Preoperative care - newborn
newborns fear loud noises, sudden movements
use mummy restraint
6-12 months - fear of strangers/fear of heights
49
Preoperative Care - Toddlers
client fears separation, strangers, animals, changes in environment
Provide simple explanations
- Distract
- Allow choices
50
Preoperative Care - Preschoolers
Client fears separation, ghosts, scary people
- have **play** with puppets/dolls
- Demonstrate equipment/talk at eye level
51
Preoperative care- school age
- client fears dark, injury, being alone, death
- allow questions
- explain why
- allow to handle equipment
52
Preoperative Care- Adolescent
client fears social incompetance, war, accidents, death
- Explain long term benefits
- very cognizant of any altered body image due to surgery
- accept regression
- provide privacy
53
Who is responsible for obtaining the informed consent?
**Informed Consent -** surgeon is responsible for explaining the surgical procedure to the client and answering the clients questiolns . Often, the nurse is responsible for obtaining the clients signature on the consent form for surgery, which indicates the clients agreement ot the procedure based on the surgeons explanation
## Footnote
**The nurse may witness the clients signing of the consent form, but the nurse must be sure that the client has understood the surgeons explanation of the surgery**
**The nurse needs to document the witnessing of the signing of the consent form after the client acknowledges understanding the procedure**
54
Preoperative Checklist
Informed Consent
Document results of all preoperative labs and tests
- Skin or bowel prep
- IV line placed
- Ensure NPO for appropriate amount of time
- Administer preoperative medications as prescribed such as sedation/antibiotics
- Remove dentures, jewelry, nail polish
55
Age Appropriate Teaching Preoperative Care
Toddler - **Simple Directions**
Preschool and School Age - **Allow to play with equipment**
Adolescent - **Expect Resistance**
Involve family, have parents reinforce teaching
56
Preoperative Care - Why do clients need to be NPO for a certain amount of hours ?
**To reduce the risk of aspiration and prevent postoperative nausea/vomiting**
57
Postoperative Procedures
deep breathing to prevent atelectasis
leg exercises to prevent DVT
incentive spirometer
58
Perioperative Care- Encouraging the client to void must be done immediately before giving the\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-
preoperative medications.
59
TRUE OR FALSE
the client should not ambulate after receiving preoperative medication.
TRUE
60
Approximately 2-4 weeks after someone becomes newly infected with HIV, individuals typically experience \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, a period when people can have a mononucleosis-like syndrome of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
acute HIV infection
fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle, joint pain, diarrhea, and/or diffuse rash
During this time **a high viral load is noted and CD$ T cell counts fall temporarily but quickly return to baseline or near baseline levels**
61
The interval between initial HIV infection and and a diagnosis of AIDS is about _____ years in untreated infection. This is known as the ____________ infection stage
asymptomatic
62
As the CD4 T cell count declines closer to ______________ cells/uL and the viral load increases, HIV advances to a more active stage- this is the ____________ infection stage,
Symptoms include
200; symptomatic; **persistent fever, frequent night sweats, chronic diarrhea, recurrent headaches, and severe fatigue**
63
Diagnostic Criteria for AIDS
**CD4 T cell count drops below 200 cells/L**
Presence of a fungal, viral, protozoal or bacterial infection
**Presence of an opportunistic cancer (Kaposi's sarcoma, Burkitts lymphoma)**
Wasting syndrome (10% or more of ideal body mass lost)
AIDS dementia complex
64
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is a condition in which **muscles stiffen or tighten**, preventing normal fluid movement. The **muscles remain contracted and resist being stretched**, thus affecting movement, speech and gait.
Spasticity
seen in multiple sclerosis
65
What factors can cause Multiple sclerosis exacerbation ?
What position should a client with MS sleep in and why?
How should a client with MS stretch a spastic extremity ?
Fatigue, overexertion, stress, infection, overheating, chilling, forceful stretching
All can worsen muscle spasticity. Physical therapy is used to stretch and strengthen muscles. **Sleeping prone helps prevent contractures by gently stretching the muscle while at rest.**
***Sleeping prone may minimize spasm of the flexor muscles of the hips and knees of a person with multiple sclerosis***. If these spasms are not relieved, joint contractures may occur. For the client who is unable to effectively reposition, prolonged periods of supine positioning increase the risk for developing pressure injury on the sacrum and hips.
**A spastic extremity should not be forced into an extended position**. Instead, ***the spastic extremity should be gently rotated in the direction to which it is being drawn, and then gently rotated in the opposite direction.*** The rotations are repeated, incrementally increasing the degree of rotation with each repetition.
66
To encourage clients to continue doing health protective activities such as exercise, the nurse may emphasize the client’s \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
small accomplishments.
67
Assessment of client with peripheral arterial disease
Intermittent claudication (pain in the muscles resulting from an inadequate blood supply)
- rest pain, characterized by numbness, burning, or aching in the distal portion of the lower extremities, which awakens the client at night and is relieved by placing the extremities in a dependent position
- loss of hair and dry scaly skin on the lower extremities
- thickened toenails
- cold and gray-blue color of skin in the lower extremities
- elevational pallor and dependent rubor in the lower extremities
- decreased or absent peripheral pulses
- signs of arterial ulcer formation occuring on or between the toes or on the upper aspect of the foot that are characterized as painful
68
The nurse provides care for a client diagnosed with peripheral artery disease (PAD). The client reports leg pain occurs frequently when walking. Which action does the nurse advise the client to take?
1. Lie down with feet elevated above the heart when experiencing pain.
2. Apply a heating pad to the legs for 15 minutes before walking.
3. Walk until client experiences pain, rest, and then resume walking.
4. Perform stretching exercises 20 minutes before starting to walk.
1) INCORRECT – For a client with PAD, elevating the legs above the heart decreases arterial flow to legs. This will increase, not relieve, the pain.
2) INCORRECT – The decreased sensitivity to pain may result in burns.
3) **CORRECT**– **Exercise increases collateral circulation and should be encouraged. Stopping and resting will usually relieve the pain, and then the client can continue to walk.**
4) INCORRECT – Stretching will not reduce the pain due to intermittent claudication.
69
What to remember about Peripheral Vascular or Peripheral Arterial Disease?
Pain with walking in the client with peripheral vascular disease (PVD) is complex because walking is both the cure and the cause. **Peripheral vascular disease causes the lower extremities to receive too little blood flow**. The vessels are hardened and narrowed, so blood does not get through in sufficient volume or speed. Walking increases the blood flow to these extremities. However, at the point that the muscles are working hard enough to demand additional blood flow to remove waste products and provide oxygenation, pain results because additional blood flow is not possible. **The nurse instructs the client to rest until the pain subsides and then continue to walk to enhance coronary circulation**
Content Refresher
Peripheral vascular disease (PVD) , also called peripheral arterial disease, is caused by atherosclerosis, thrombus, inflammation, and vasospasm. Assess strength of distal pulses (dorsalis pedis, posterior tibial, and popliteal) and color and temperature of extremities. Assess for any non-healing wounds. **Pain during ambulation describes intermittent claudication, an ischemic pain that results from lactic acid buildup caused by anaerobic metabolism**. When the client stops exercising the lactic acid clears and pain subsides. **Educate the client about reducing the risk for disease progression (e.g. diet, exercise, weight reduction, proper management of diabetes mellitus, control hypertension, or smoking cessation).**
70
What to remember about external beam radiation therapy?
External beam radiation therapy is a form of cancer treatment that uses highly charged electrons to penetrate malignant tumors with pinpoint accuracy. During radiation therapy, the client may experience radiation dermatitis . Radiation therapy can also cause an impaired immune response, making the client susceptible to infection. Therefore, monitor the client’s white blood cell (WBC) count. Wash the radiation site with water only. **Avoid hot or cold applications to the radiation site. Do not apply lotions, creams, or powders to the site. Do not remove treatment area marks. Adhere to infection control protocols.**
Radiation treatments are typically administered daily for a month or more. **The client not only will be tired from the radiation but likely also from the daily trips to the radiation or cancer center to have the treatments administered.**
71
The nurse should focus teaching to the parents of adolescents on reducing high risk behavior and encouraging healthy behaviors. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-can lead to high risk behavior and should be followed up by the nurse.
Impulsiveness
72
What is Toxic Shock Syndrome ?
What are the symptoms?
What do tampons have to do with it?
Toxic shock syndrome (TSS) is a toxin-mediated acute life-threatening illness, usually precipitated by infection with either staphylococcusaureus or group A s treptococcus (GAS), also called streptococcus pyogenes. It is characterized by **high fever, rash, hypotension, multiorgan failure, and desquamation, typically of the palms and soles, 1 to 2 weeks after the onset of acute illness.**
Due to risk for hemodynamic compromise, the nurse should anticipate close monitoring of the client's hemodynamic parameters such as central venous pressure. The nurse should also assess for the potential cause of the client's TSS.
**Tampons, particularly highly absorbent ones, may provide the right conditions for the bacteria to grow, especially if the tampons are left in longer than recommended.**
**Leaving a tampon in for longer than 8-12 hours, can increase risk of infection or possibly TSS**
**the nurse should instruct the client to change the tampon every 3 to 6 hours**, **avoid using extra-absorbent tampons,** and use sanitary napkins at night.
73
symptoms of Toxic shock syndrome
sudden onset fever, vomiting, diarrhea, drop in systolic blood pressure, and erythematous rash on palms and souls
74
For the client with diabetic ketoacidosis, ABG results will indicate \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
metabolic acidosis.
75
Normal acid-base balance is indicated by a **pH of 7.35 to 7.45 on the pH scale**, **PCO 2 of 35 to 45 mm Hg, PO 2 of 80 to 100 mm Hg, oxygen saturation of 95 to 100%, HCO 3 of 22 to 26 mEq/L**, and base excess of −2 to +2 mEq/L.
TRUE OR FALSE
TRUE
76
Diabetic ketoacidosis (DKA)results in rapid changing fluid volumes and blood glucose levels.
TRUE OR FALSE
TRUE
77
If a private room is not available for a client with a latex allergy, then all clients in the room with that client must be treated as though they too were\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--
latex-sensitive; **A latex-free environment is essential for treatment of clients having a latex allergy**
A three-foot separation between a client and others is appropriate for droplet precautions but not a latex allergy
78
Latex allergy manifestations
***Latex allergy is a sensitivity reaction to certain proteins found in natural rubber latex.*** Potential routes of exposure include the skin, the respiratory tract, and the bloodstream. **Protect the client from latex exposure**. Review the list of client care products that contain latex (e.g., tourniquets, blood pressure and ECG pads, some adhesive bandages, and dental devices) and ensure that latex-free products are used during client care.
**Manifestations of allergic reaction to latex may include rash; itching, burning, or scaling of the skin; nasal allergy with hay fever-like symptoms; or difficulty breathing. In severe cases, the client may experience an anaphylactic reaction leading to cardiovascular collapse.**
Prescribed treatments for a client experiencing an allergic reaction to latex may include antihistamines, corticosteroids, IV fluids, and epinephrine.
**When caring for a client diagnosed with a latex allergy, most facilities require a designated latex-free cart to be stationed outside the client’s room.** The nurse should know how to quickly access emergency medications such as epinephrine (1:1000) in the event of an anaphylactic reaction.
79
Tardive dyskinesia is characterized by ..............
Tardive dyskinesia is characterized by **abnormal facial and tongue movements.** It is treated by decreasing or discontinuing the antipsychotic medication.
80
Pseudoparkinsonism is characterized by .........
Pseudoparkinsonism is characterized by **tremors, rigidity, and shuffling gait**. It is treated by administering an anticholinergic agent.
81
Acute dystonic reaction is characterized by .................
Acute dystonic reaction is characterized by **severe muscle contractions of the head and neck.** Treat by administering diphenhydramine hydrochloride.
82
What is neuroleptic malignant syndrome characterized by?
Neuroleptic malignant syndrome is **a severe reaction to antipsychotic medication** as a result of dopamine blockade in the hypothalamus. It is fatal in approximately 10% of cases. S**top the medication, and transfer the client to a medical unit**. **Cool the body**, and administer bromocriptine to treat the muscle rigidity and dantrolene to reduce the muscle spasms.
Symptoms include high fever, confusion, rigid muscles, variable blood pressure, sweating, and tachycardia
83
The nurse provides care for a client with a history of heart failure. The health care provider writes prescriptions for the client. Which prescription does the nurse question?
1. Digoxin 0.25 mg PO in a.m.
2. Oxygen at 4 L/min per nasal cannula.
3. Verapamil 120 mg orally three times daily.
4. Furosemide 40 mg IV push now.
3) CORRECT **– Verapamil is contraindicated in clients diagnosed with heart failure and in clients taking digoxin, because it can cause severe bradycardia.**
84
Verapamil can cause severe \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_in clients with heart failure who are also taking digoxin.
bradycardia
85
The clinical features of hypoparathyroidism are due to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--
hypocalcemia
Remember PTH
**Parathesia, Positive Trousseau and Chvostek’s Sign**
**Tetany (involuntary muscle cramping/contraction)**
**Hypocalcemia and Hyperphosphatemia**
lip tingling, extremity stiffness, lethargy, anxiety, and personality changes. Dysphagia, laryngospasms, and compromised breathing may occur due to tonic spasms of smooth and skeletal muscles.
86
The parathyroidhormone (PTH) regulates serum calcium. **Normally, in the bone, PTH stimulates bone resorption and inhibits bone formation, resulting in release of calcium and phosphate into the blood.** When there is not enough PTH, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_results. The client might report tingling of the lips and fingertips and increased muscle tension and stiffness. In extreme cases, \_\_\_\_\_\_\_\_\_\_\_may be observed. The nurse needs to monitor the client for airway obstruction. When giving IV calcium replacement, the nurse should infuse the medication slowly because rapid infusion may cause serious hypotension and cardiac arrest. Ideally, the client should be attached to a bedside cardiac monitor.
hypocalcemia; laryngospasms
87
What to remember about sleep apnea ?
Sleep apnea, a serious sleep disorder that occurs when a client’s breathing is interrupted during sleep, ultimately results in hypoxia if untreated; clients sometimes stop breathing hundreds of times during sleep. The two types of sleep apnea are obstructive and central. Lifestyle changes are often necessary for the client diagnosed with sleep apnea. These changes may include avoiding alcohol and medications that make the client sleepy; weight loss; sleeping on the side rather than the back; keeping nasal passages open at night with nasal sprays, strips, or allergy medications; and quitting smoking. Some clients may require specific medical interventions, including mouth pieces or breathing devices (e.g., continuous positive airway pressure [CPAP] and positive airway pressure [BiPAP]) or even surgery. Teach the client how to use the CPAP machine to improve oxygenation during sleep. Evaluate the effectiveness of the teaching/learning session.
**When CPAP is used, air is delivered under pressure to keep the upper airway open**. This prevents the symptoms of sleep apnea, which include loud snoring, cessation of breathing for 10 seconds or more, abrupt awakening from sleep with a loud snort, excessive daytime sleepiness, morning headache, sore throat, and personality and behavior changes.
**CPAP uses room air, not oxygen, and is not combustible**. It is used with spontaneous ventilation to keep the alveoli open and decrease hypoxia.
88
An internal radiation treatment that consists of the implantation or insertion of radioactive materials directly into or in close proximity to a tumor.
**Brachytherapy** can effectively treat breast, cervical, prostate, and skin cancers.
89
Nursing Implementation Procedures for client with internal radiation device
**Time, Distance, and Shielding**
No more than 30 minutes in the room during each 8 hour shift
Dosimeter badge should be worn
Provide organized and efficient care
Long handled forceps, lead container in case implant becomes dislodged
90
**The UAP may not administer or adjust prescribed therapies, such as oxygen.** The UAP is responsible for following the chain of command and reporting any abnormal findings to the nurse. **In considering whether the UAP may perform a task such as ambulation, the nurse considers whether the client is stable or whether the client has just experienced a change that may require assessment by the nurse**. Just as the first set of vital signs upon admission or post-surgery should be performed by the nurse, **the first ambulation to the bathroom post-delivery should also be done by the nurse**
**TRUE OR FALSE**
TRUE
91
Cancer is the term used for a group of diseases that result from \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**unregulated growth of malignant cells.**
This affects the structure and function of healthy cells. Risk factors associated with cancer include both non-modifiable and modifiable risk factors. Non-modifiable risk factors include age and genetic predisposition. Modifiable risk factors include a sedentary lifestyle, poor diet, excessive alcohol use, unprotected exposure to ultraviolet light, and smoking.
92
Risk factors for cancer development
Risk factors for the development of cancer include **smoking, obesity, inactivity, sun exposure, high intake of red meat, and chronic intake of alcohol.**
The client should limit, but does not need to abstain from, eating all red meat. **The client should be encouraged to attain and maintain a normal body weight.** The client should wear sunscreen or protective clothing in the sun, but not completely avoid the sun. Personal alcohol intake should be limited. **Avoiding second-hand smoke is an established method to reduce cancer risk.**
93
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Syndrome is a potentially lethal side effect of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_medications, especially high-potency drugs such as haloperidol. It is a **medical emergency.**
Neuroleptic Malignant; antipsychotic
94
What is Addison disease and Addisonian crisis?
Addison disease is an autoimmune disorder that results in destruction of the adrenal glands and loss of cortisol and aldosterone secretion. It is also known as primary adrenal insufficiency. **Addisonian crisis, a life threatening episode of acute adrenal insufficiency, can occur in response to trauma, surgery, systemic illness, or abrupt withdrawal from corticosteroid medications.** To prevent an Addisonian crisis, daily replacement medications (hydrocortisone or cortisone acetate or prednisone and fludrocortisone) are required. Treatment also requires increasing fluids, salt, and hydrocortisone during a minor illness.
95
The diet for a client with cirrhosis, without complications, should be high in calories, up to \_\_\_\_\_\_\_\_\_\_\_\_\_\_--calories each day.
3000
96
## Footnote
**Cirrhosis affects metabolic, coagulation, and detoxifying functions. True or false**
True
Cirrhosis affects multiple body systems. Gastrointestinal issues such as nausea and diarrhea make obtaining nutrition difficult, and proteins are wasted into ascites fluid. Shallow respirations and hypertension are common as ascites develops and worsens. Pancytopenia becomes an issue as hypersplenism occurs. As the liver becomes unable to process estrogen, gynecomastia develops in men. Integumentary issues such as pruritis emerge. Mental status changes require intense nursing and medical management; safety is a primary concern.
97
During an acute manic episode, the priority nursing diagnoses are **risk for injury, risk for violence, and impaired social interaction.** The nurse should note that lack of \_\_\_\_\_\_\_\_\_\_\_is a characteristic of clients with bipolar disorder. The nurse should collaborate with the mental health provider and anticipate giving the client mood stabilizers (e.g. lithium) and atypical anti-psychotics (e.g. olanzapine, quetiapine). The nurse should provide a \_\_\_\_\_\_\_\_\_\_\_environment with \_\_\_\_\_\_\_\_\_\_stimuli and should re-direct the client away from harmful activities.
insight; calm; minimal
98
Interventions for Bipolar Mania
remove hazardous objects from the environment
provide high calorie finger foods and fluids
reduce environmental stimuli
provide physical activities and outlets for tension
provide gross motor activities such as walking
provide structured activities or one to one activities with the nurse
**Provide a safe environment for clients experiencing acute mania. Reduce environmental stimuli**. S**chedule structured and purposive activities and rest breaks**. Promote sleep hygiene measures. Offer frequent snacks and fluids. Assist with self-care activities. Maintain a calm, supportive approach.
99
What is Scoliosis ?
**Lateral curvature of the spine that can affect the lumbar/thoracic area**
In general, scoliosis is a painless condition.
Assess for unequal shoulder and hip alignment. Have the client bend over and assess the spine.
For comprehensive assessment, the nurse should obverse the child at rest, sitting, and standing for evidence of poor posture.
100
When does true labor start ?
What are clinical manifestations of active labor ?
True labor starts **when the cervix begins to dilate and efface due to contractions.**
Clinical manifestations of active labor include the following: **contractions that become regular,** increasing in intensity and frequency; **duration between contractions shortens**; **contractions increase in intensity with activity;** and contractions begin in the back and radiate to the abdomen
101
It is impossible to predict the exact time of delivery.
True or false
TRUE
102
The following are indications for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_: **oxygen saturation below 95%,** tachypnea, dyspnea, or **signs of decreased perfusion** such as hypotension, decreased pulse strength, pallor, cool skin, prolonged capillary refill, and decreased level of consciousness.
oxygen therapy
103
**Risk factors for development of Type 2 diabetes mellitus**
Risk factors include heredity, obesity (especially intra-abdominal obesity), race/ethnicity, hypertension, elevated triglycerides, elevated cholesterol, and low levels of high-density lipoprotein (HDL
104
What are the different levels of prevention?
**Primary prevention includes activities to prevent the development of disease. It is about promoting health.** This would include making lifestyle adjustments such as smoking cessation.
**Secondary prevention includes activities to detect and then treat disease.** This would include diagnostic and laboratory testing and screenings.
. Breast exam is secondary health prevention.
**Secondary prevention may be directed at individuals who are at risk for the development of disease**. The goal for health intervention during this phase is early detection and diagnosis of health problems before clients exhibit symptoms of disease. Having blood tested for an infection is secondary health prevention.
Tertiary prevention includes activities to recover from disease. **It is treatment.**
105
The ideal approach to healthy weight gain includes adding foods that are both rich in \_\_\_\_\_\_\_\_\_\_\_\_\_\_and relatively high in \_\_\_\_\_\_\_\_\_\_\_\_\_
Nutrition;calories
Healthy strategies for weight gain include eating foods that are high in nutritional value and relatively high in calories.
106
Talk about pain - symptoms, treatment and goal for pain management
Pain is an unpleasant feeling conveyed to the brain by sensory neurons in response to injury, disease, and actual or potential tissue damage. Clinical manifestations associated with pain include **increased blood pressure, rapid respirations, increased perspiration, increased muscle tension, increased neuromuscular activity, nausea, vomiting, apprehension, anxiety, and irritability.** Treatment for pain includes medications, relaxation techniques, meditation, progressive relaxation, yoga, distraction, guided imagery, herbal remedies, biofeedback, acupuncture, heat/cold application, therapeutic touch, massage, and hypnosis. The goal for pain management is verbalization of a decrease in or absence of pain
107
Depending upon the procedure, surgery causes some degree of pain. Before accepting the client's report of "feeling fine," the nurse should further \_\_\_\_\_\_\_\_\_\_\_\_\_\_the client. ***The nurse needs to be aware of any cultural, or age-related, reasons for the hesitancy to report the full level of pain.***
assess
One way to complete the pain assessment is to use a scale in which the client compares personal pain level with the levels on the scale. Using a scale provides a more objective evaluation of the client's pain and ensures that appropriate treatment is provided for the client's comfort and healing.
108
Protocol for blood transfusion administration
The nurse primes the tubing with 0.9% sodium chloride to reduce hemolysis.
One unit of red blood cells should infuse within 4 hours. After this time there is an increased risk for bacterial contamination. ***Infusing the RBCs over more than 4 hours is not safe.***
***Adults require large gauge catheters (20- to 24-gauge)*** because blood is more viscous than crystalloid intravenous fluids. Smaller catheters are used in exceptional circumstances
The nurse should **stay with the client during the first 15 minutes,** the time when a reaction is most likely to occur
**Obtaining baseline vital sign**s allows the nurse to determine when changes in vital signs occur as a result of a transfusion reaction.
Blood compatibility is verified with another licensed person, such as a nurse
**verify that a prescription for the transfusion exists;** conduct a thorough physical assessment of the client (including vital signs) to help identify later changes; **teach the client about the transfusion, associated risks and benefits, and what to expect during the transfusion**; be familiar with the specific product to be transfused; and **infuse the blood product with normal saline solution only, using filtered tubing**. In some cases, to prevent immunologic transfusion reactions the provider may order medications such as acetaminophen and diphenhydramine before the transfusion begins to prevent fever and histamine release.
109
A client with diverticulosis is at risk for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_a diverticuli if undo stress or strain is placed on the abdominal region. The client should be counseled to avoid\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, but can engage in other physical activity that places less stress on the abdominal region.
rupturing; lifting weights
110
After caring for a client, the nurse needs to dispose of which item in the biohazard bin?
1. Linen soiled with urine.
2. Blood-tinged adhesive bandage.
3. Canister of gastric secretions.
4. An empty indwelling catheter bag.
1) INCORRECT— Soiled linens must be placed in a plastic bag and secured, in order to prevent exposure when transporting to the laundry facility.
2) INCORRECT— ***Dressings that are soaked with blood are considered biohazard wastes and need to be disposed of in the biohazard bin***. However, a blood-tinged bandage can be placed in the trash, as the blood on the bandage is unlikely to escape. This decreases the threat of infection.
3) CORRECT — **A canister of gastric secretions must be placed in a biohazard bin, as there is a great risk that secretions can escape and lead to infection.**
4) INCORRECT— An empty indwelling catheter bag can be disposed of in the trash. The empty catheter bag does not present a threat of urine escaping, which decreases the chance of infection.
111
Assessment of urine output is performed routinely during the postoperative period. ***It is a measurement of kidney function as well as cardiac function.*** The minimal amount of urine produced should be ______________________ Urine output can be obtained by voiding or catheterization. An indwelling catheter may be prescribed ***if closely monitoring urine output, or if the client is experiencing urinary retention***.
**30 mL/hr or 720 mL/day.**
112
The nurse should treat dysrhythmias with prescribed medications, cardioversion, or defibrillation as needed, and then provide a medication to treat the angina
TRUE OR FALSE
TRUE
The nurse administers a drug that will terminate the rhythm causing the angina first.
113
The action of the nurse after noticing that a client is in ventricular tachycardia (VT) is to activate the advance cardiac life support protocol such as performing an ABC check for 10 seconds. Ventricular tachycardia without a pulse is treated like ventricular fibrillation and requires immediate \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-Depending on the client's co-morbid conditions, epinephrine 1 mg every 3 to 5 minutes may be also given in a full-blown cardiac arrest. The nurse should keep in mind that amiodarone poses a high risk for \_\_\_\_\_\_\_\_\_\_\_when given IV and should monitor the IV site frequently.
defibrillation; phlebitis
114
The nurse anticipates several changes to vital signs when providing care to an older adult client. .
**Risk for hypertension increases with age due to atherosclerosis.** Older adults are also more prone to orthostatic hypotension with position changes. **Respiratory rate usually does not change with age**. However, lung function decreases slightly due to ossification of intercostal cartilage. Older adults have diminished vital capacity and rely more on accessory abdominal muscles during respiration. **The temperature of older adults is at the lower end of the normal range.** In an older client, fever is present when a single oral temperature is over 100°F (37.8°C)
115
When assigning clients to a reassigned nurse, the charge nurse should identify clients who require \_\_\_\_\_\_\_\_\_\_\_\_\_and whose condition is \_\_\_\_\_\_\_\_\_\_.
basic nursing care; stable
Assign clients who are stable and do not require specialized nursing knowledge.
116
Postoperative Nursing interventions for Cleft Lip Repair
**Guard suture line, which should be kept clean & dry**
Lip protection devices should be used such as the Logan Bow or tape to promote proper alignment and healing
**maintain infant in Side lying position on unaffected side**
Assess ability to suck
Provide emotional support to parents
Avoid prone positioning to prevent damage of the suture line. Use a soft-flow nipple, a plastic squeezable bottle, and syringe feedings until the suture line heals.
117
For chest pain, the administration of nitrates should be considered. However, the nurse would not administer nitrates for chest pain if the client takes sildenafil, vardenafil, or tadalafil for \_\_\_\_\_\_\_\_\_\_\_\_, which can cause a fatal drop in\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-
blood pressure
118
Foot care and diabetes
When providing teaching about diabetes mellitus, the nurse should address foot care. **The nurse should instruct the client to inspect the feet daily and assess pedal pulses**. Avoid using over the counter chemicals such as hydrogen peroxide on the feet. **Avoid placing heating pads or ice packs on the feet**. Do not apply lotion between toes. Question client about use of proper foot wear. Educate the client on proper foot care.
**A client with diabetes mellitus is at risk for developing peripheral neuropathy, which causes changes in sensation of the lower extremities.** These changes can result in complications related directly to an injury, or from the inability to recognize the severity of an injury due to impaired sensation. **The client should be instructed to never walk barefoot, even in the house.**
119
The nurse teaches a client diagnosed with type 1 diabetes mellitus (DM) about measures to prevent long-term complications. Which instruction does the nurse include?
1. “Wear slippers around the house.”
2. “Wear socks made of synthetic fibers.”
3. “Avoid wearing insulated boots in cold weather.”
4. “Wear knee-high nylons instead of pantyhose.”
**1) CORRECT —** The nurse will instruct the client to avoid walking barefoot. ***Compromise of skin integrity to the feet, such as a laceration or puncture, may result in wounds that go unnoticed due to peripheral neuropathy associated with DM***. In addition, these wounds are likely to be slow to heal as a result of associated peripheral vascular disease.
2) INCORRECT— The nurse will encourage the client to wear socks made with natural fibers, such as wool or cotton, which are more breathable than synthetic fibers, such as polyester. Natural fibers allow perspiration to dry, which assists in preventing compromised skin integrity. Clients with DM will be at higher risk for fungal infections of the feet.
3) INCORRECT— The nurse will instruct the client to wear warm and insulated boots in cold weather. This decreases the risk of injury from the cold. Clients with DM are likely to experience peripheral arterial or peripheral vascular disease, which leaves them more vulnerable to the impact of cold temperatures.
4) INCORRECT— The nurse will instruct the client to avoid wearing nylons or pantyhose altogether because they may exacerbate circulatory problems. The client should avoid wearing constricting clothes to avoid compromising peripheral blood flow
120
The nurse monitors a client newly diagnosed with diabetes mellitus (DM) for signs of complications. Which findings alert the nurse to a hyperglycemic event? (Select all that apply.)
1. Polydipsia.
2. Diaphoresis.
3. Polyuria.
4. Bradycardia.
5. Polyphagia.
1) CORRECT – **Excessive thirst and fluid intake results gradually as blood glucose levels increase**. The body attempts to rid itself of excess glucose through renal excretion. Urine levels increase, which cause dehydration. The client is thirsty and drinks more to replace lost fluids.
2) INCORRECT – Diaphoresis is not a sign of hyperglycemia. Sweating is the body’s attempt to cool itself.
3) CORRECT – **Increased urine output results gradually as blood glucose levels increase.** The body attempts to rid itself of excess glucose through renal excretion.
4) INCORRECT – Bradycardia is not a sign of hyperglycemia.
5) CORRECT – **In hyperglycemia, blood glucose is increased as the body lacks the insulin necessary to facilitate transfer of glucose into body cells**. Body cells therefore experience a lack of fuel. Increased appetite and food intake occurs as the body attempts to feed its cells.
121
Why is there polyuria, polydipsia and polyphagia in hyperglycemia ?
The nurse understands that hyperglycemia causes a client to produce a high volume of glucose-rich urine, removing glucose from the bloodstream. Glucose is a solute that attracts water via osmosis. High glucose levels in the blood attract a high volume of water, which is then excreted. This results in increased thirst because the client becomes dehydrated from so much fluid leaving with the sugar. Hyperglycemia means that the glucose is not inside the cells, where it is needed to provide energy. As long as the glucose is in the blood stream and not being pushed into the cells by insulin, the client will be excessively hungry.
122
Assessment for Hyperglycemic client
Hyperglycemia occurs in a client with diabetes mellitus who lack adequate glycemic control. Normal blood glucose is 70 to 110 mg/dL (3.9 to 6.1 mmol/L). Assess for signs of hyperglycemia, including polyuria, polydipsia, polyphagia, lethargy, malaise, headache, and blurred vision. Assess urine for glucose and ketones. Assess arterial blood gases, electrolytes, and blood glucose levels. Assess vital signs and monitor for signs of orthostatic hypotension due to dehydration. Administer insulin or oral antidiabetic agents. Discuss the need for regular exercise and dietary management of hyperglycemia. Monitor intake and output and notify the health care provider of changes suggestive of fluid overload or deficit.
123
What to remember about aspiration syndrome -
positioning, signs of aspiration risk, strategies to reduce risk of aspiration
Aspiration syndromes include conditions in which foreign matter is inhaled into the lungs. **Position the client at risk for aspiration in high-Fowler position**. Obvious difficulty swallowing food or fluids is a sign of risk for aspiration. T**hroat clearing and wet coughing after eating may indicate aspiration has occurred.** If actual or potential aspiration is suspected, notify the health care provider and plan to maintain the client on NPO status until a swallow evaluation is completed. Educate the client and family about meal planning and strategies for reducing the risk of aspiration (e.g. thickening fluids, chewing food thoroughly, eating slowly, and taking small bites).
124
Symptoms of esophageal cancer often include \_\_\_\_\_\_\_\_\_\_\_\_\_\_which indicates esophageal occlusion. In many cases, by the time of diagnosis, the esophageal tumor is large. Regurgitation of a thin liquid is a sign of a complete \_\_\_\_\_\_\_\_\_\_\_\_\_\_. The client who experiences any degree of esophageal obstruction is at high risk for \_\_\_\_\_\_\_\_\_\_\_\_which may lead to airway obstruction, pneumonia, and other serious consequences. In the event of known or suspected aspiration, priorities of care include ensuring airway patency and adequate breathing. **After implementation of priority interventions, the health care provider should be promptly notified of the client ’s status.**
dysphagia; esophageal obstruction; aspiration
125
Rosuvastatin is a medication used to lower cholesterol. The nurse is aware medications in this classification (lipid lowering) has \_\_\_\_\_\_\_\_\_\_\_\_\_\_-as an adverse effect, which begins with **muscle aching and soreness.**
rhabdomyolysis
126
Even though it is rare, one of the greatest risks to a client who is taking rosuvastatin (Crestor) is \_\_\_\_\_\_\_\_\_\_\_or muscle inflammation, that can progress to \_\_\_\_\_\_\_\_\_\_
myositis, rhabdomyolysis
127
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is a blood pressure greater than 140/90 mm Hg that is accompanied by proteinuria and occurs at or after 20 weeks gestation. Signs and symptoms include
Preeclampsia
S/S of mild preeclampsia include **hypertension and proteinuria.**
Severe cases are characterized by thrombocytopenia, severe headaches, renal insufficiency, oliguria, and intrauterine abnormalities. If gestation is greater than 34 weeks, the fetus should be delivered as soon as possible.
128
The nurse returns to the desk in the prenatal clinic and finds four phone messages. Which message does the nurse return first?
1. A multigravida at 12 weeks’ gestation experiencing heavy white vaginal discharge.
2. A primigravida at 17 weeks’ gestation stating that she has not felt the baby move.
3. A primigravida at 22 weeks’ gestation reporting feeling dizzy and clammy when lying on her back.
4. A multigravida at 32 weeks’ gestation experiencing malaise and bilateral dependent and facial edema.
View Explanation
1) INCORRECT — The heavy, white discharge likely describes leukorrhea, which is caused by hyperplasia of the vaginal mucosa and is a normal finding. The client requires further assessment to rule out candidiasis, but there is another client who is a higher priority.
2) INCORRECT — This is a normal finding for a primigravida client. Quickening, or the sensation of feeling the fetus move for the first time, generally occurs at 18–20 weeks for the primigravida woman.
3) INCORRECT — This is a normal finding in pregnancy, due to vena cava syndrome. The nurse should instruct the client to lie on the side, rather than the back.
4) CORRECT — This client is experiencing symptoms of pre-eclampsia, which poses an immediate risk of harm to the client. This represents a circulatory concern and is the highest priority.
129
Quickening, or the sensation of feeling the fetus move for the first time, generally occurs at \_\_\_\_\_\_\_\_\_\_for the primigravida woman.
18–20 weeks
130
Corticosteroids used to treat Addison disease can lead to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_and predispose a client to developing diabetes mellitus.
glucose intolerance
131
Newborns and handwashing
When the nurse is making a home visit, assessment should be made about the newborn, but should also include the environment and behaviors of the care giver. A **newborn is prone to developing or contracting an infection because the immune system is not fully developed.** The parent should be instructed to perform hand hygiene before and after touching or handling the newborn. **The nurse also needs to reinforce that handwashing is the first and most effective means of preventing infections.**
When the parent cares for the neonate, the nurse should promote handwashing to prevent the spread of infection. ***The parent should keep the cord stump and surrounding skin dry. However, if the cord stump or surrounding skin become soiled with urine or stool, they can be cleaned with water.*** The parent should provide cord care daily, or as needed. Additionally, the parent should avoid placing the diaper over the cord stump and avoid immersing the cord stump in water during bathing.
132
Disaster Planning
Do greatest good for greatest number of people
Resources used for clients with greatest probability of survival- must do triage using ABCD (Airway, Breathing, Circulation, Neurological Dysfunction)
**Red- unstable**
**Yellow - stable, can wait, 30-60 minutes might be the limit**
**Green - stable, can wait longer "the walking wounded"**
**Black - unstable, probably fatal**
**DOA - dead on arrival**
133
\_\_\_\_\_\_\_\_\_\_\_\_\_\_-occurs when a nurse fails to follow the standard of care and client harm could result.
Negligence
***Negligence/malpractice is the failure to provide the correct care to the client, which results in physical or psychological harm to the client.*** Bruising, bleeding, damage to artery or cardiac tissue, and allergy to dye are the most common complications of a cardiac catheterization. Serious complications include sepsis, cerebrovascular accident, and myocardial infarction. Post-procedure, the nurse should monitor vital signs, maintain pressure at cardiac catheter insertion site along with frequent observation of site, assess client’s response to procedure, and provide foods, fluids, and medications.
