QB 10 Flashcards
Critically low levels of sodium require immediate evaluation due to risk of _____________The incidence of seizure is__________ proportional to the serum sodium level.
seizures; inversely
Hyponatremia, defined as a sodium level less than 135 mEq/L (135 mmol/L), affects central nervous system function. Symptoms associated with hyponatremia include _____________________ .
What kind of fluids are typically administered for a client with hyponatremia ?
thirst, muscle cramping, abdominal cramps, vomiting, and seizures
Hypertonic fluids are typically administered for a client with hyponatremia.
The nurse provides care for a client who is 18 weeks pregnant with twins. The client has a child who was born at 30 weeks’ gestation and has had two spontaneous abortions previously. Which does the nurse document for the client’s GTPAL?
G-4, T-0, P-1, A-2, L-1.
The GTPAL status is calculated as follows: gravida-4 (twins count as 1 parous experience); term-0 (client carried no child to term, which is the beginning of 38th week to the end of the 42nd week); para, or preterm delivery-1 (child born at 30 weeks); abortion-2 (spontaneous and elective abortions); living-1 (1 living child at home).
Gravida is the total number of pregnancies, regardless of duration, including the present pregnancy. Para is the number of pregnancies beyond period of variability (20 weeks or 500 g). So para is the number of actual deliveries of a viable newborn, and abortion or miscarriage of a viable fetus would be noted if it occurred. For example, the client who has been pregnant twice and miscarried both pregnancies after 20 weeks is termed gravida-2, para-2. The client who has been pregnant twice, but has not carried either pregnancy past 20 weeks, is termed gravida-2, para-0. The client who delivered triplets at term is termed gravida-1, para-1.
This is a life threatening condition that can occur with spinal cordd injuries above T6
What are at least 5 S/S?
Autonomic dysreflexia
This is a neurological emergency that must be treated immediately to prevent a hypertensive stroke
Sudden onset of severe throbbing headache
Severe hypertension and bradycardia
Nausea
Diaphoresis
Piloerection
Nasal Stuffiness
Restlessness/Feeling of apprehension
flushing above the level of injury
pale extremities below the level of the injury
dilated pupils or blurred vision
A serious complication of spinal cord injuries (SCIs) at or above the level of T6, in which a noxious stimuli below the SCI sets off a cascade of uncoordinated responses that result in a unregulated and potentially life-threatening hypertensive episode.
Autonomic Dysreflexia
What can cause autonomic dysreflexia ?
Causes include visceral distension and noxious stimuli, such as skin pressure and temperature extremes
A distended bladder is the most common cause of autonomic dysreflexia
Bowel distension can be a cause of autonomic dysreflexia
What must be done to treat autonomic dysreflexia ?
Placing the client in a sitting position should be done immediately to help reduce intracranial pressure and prevent cerebral hemorrhage and seizures.
the nurse takes action to relieve intracranial pressure immediately by raising the client’s head, thus preventing serious events such as stroke.
The nurse will have to reposition the client later to complete an assessment of the bladder, bowel, and skin, looking for the irritating trigger of the autonomic dysreflexia
If AD occurs, remove restrictive clothing, compression stockings or boots, and elevate the head of bed. Give medications if prescribed for hypertension and monitor for hypotension after treatment
Treatment consists of resolving the impending emergency and identifying and resolving the precipitating event.
Risk factors for AD include _____________
(name at least 5)
noxious stimuli, including skin breakdown, bladder infection, menstrual cramping, irritated or distended bladder or bowel, fecal impaction, sexual activity, sunburn, clothing that compromises circulation or causes overheating, and wound care.
Rarely can an over-the-counter medication effectively replace a prescribed medication.
TRUE OR FALSE
TRUE
The nurse provides cares for a client who sustained a T5 spinal cord injury four weeks ago. The nurse observes that the client is diaphoretic, nauseated, and reports a severe headache. Which action does the nurse take first?
- Place the client in a sitting position.
- Assist the client to empty the bladder.
- Examine the client’s rectum.
- Administer hydralazine as prescribed.
View Explanation
1) CORRECT – These symptoms reflect autonomic dysreflexia, which is a life-threatening condition that can occur with spinal cord injuries above T6. Causes include visceral distension and noxious stimuli, such as skin pressure and temperature extremes. A primary symptom, and of most major concern, is severe and rapid-onset hypertension. Another symptom includes bradycardia. Placing the client in a sitting position should be done immediately to help reduce intracranial pressure and prevent cerebral hemorrhage and seizures.
2) INCORRECT – A distended bladder is the most common cause of autonomic dysreflexia and must be assessed very quickly, such as right after sitting the client up. If catheterization is required, an anesthetic jelly may be used to reduce autonomic stimulation.
3) INCORRECT – Bowel distension can be a cause of autonomic dysreflexia. If fecal impaction is discovered, a local anesthetic ointment should be used before impaction removal to block further autonomic stimulation.
4) INCORRECT – The nurse should use means of correcting the problem prior to considering medication. If other means (such as sitting, urinary catheterization and emptying of the bladder, removal of fecal mass, or removal of skin stimuli) have not relieved the hypertension and headache, administer hydralazine, an antihypertensive, non-nitrate vasodilator.
What is peptic ulcer disease and what kind of medications can increase the risk of developing PUD?
What substances should clients at risk avoid because of their tendency to increase stomach acid production?
Peptic ulcer disease (PUD) is caused by erosion of gastrointestinal (GI) tract mucosa by hydrochloric acid (HCl) and pepsin. Peptic ulcers can develop in any segment of the GI tract exposed to HCl and pepsin. The most commonly affected regions include the stomach, the lower esophagus, and the duodenum. The bacteria helicobacter pylori (H. pylori) is often associated with PUD. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, anticoagulants, and selective serotonin reuptake inhibitors (SSRIs) increase the risk for developing PUD. Lifestyle factors, such as smoking, alcohol intake, and stress, can contribute to the development of PUD
Clients should avoid smoking, alcohol, ASA, and caffeine, all of which increase stomach acid.
What is gastroenteritis and what are risk factors ?
what are symptoms? How is it spread?
What can be done to prevent gastroenteritis and food related illnesses ?
An inflammation of the stomach and intestines.
Gastrointestinal illnesses are easily spread from mouth to hand, from feces to hand, and/or from contaminated hand to food. Gastroenteritis is commonly called the “stomach flu,” and it causes diarrhea, vomiting, and fever. Common causes of gastroenteritis include norovirus and rotavirus. Person-to-person transmission is the typical means of spread, with contaminated food and drink being common infection sources.
To prevent the spread of viruses that may cause gastroenteritis (including norovirus), individuals with gastroenteritis should not prepare foods that will consumed by other individuals.
Content Refresher
Risk factors for gastroenteritis include ingestion of contaminated foods, and exposure to norovirus, rotavirus, escherichia coli, botulism, clostridium difficile, salmonella, giardiasis, and amebiasis. The nurse should provide education to the client/caregiver about ways to prevent food-related illnesses, such as purchasing and using food products before the expiration date, ensuring perishable items are intact, properly washing hands before handling food, separating food when preparing, ensuring food is cooked properly, avoiding raw meat, keeping leftovers a maximum of 2 days, and refrigerating foods properly.
What kind of things indicate caregiver burden?
sense of being overwhelmed with a lack of support,
Social isolation when caring for a sick family member
Lack of pleasure in activities
Expressing annoyance and isolation in care responsibility
Caregiver strain and burden describes the difficulties in assuming and functioning in the caregiver role, as well as the associated alterations in the caregiver ’s emotional and physical health that can occur when care demands exceed resources. The nurse should be aware of the warning signs and refer the caregiver to appropriate resources. Effective management of caregiver strain and burden include cognitive behavioral interventions, psychoeducation, and supportive care.
Coping mechanisms are behaviors, thoughts, or feelings that enhance control or bring psychological comfort to a person experiencing stress. There are positive coping mechanisms (e.g. exercise, listening to music, talking to a close friend, or doing a creative activity) and negative coping mechanisms (e.g. smoking, eating or drinking too much, abusing drugs, or criticizing yourself). The nurse needs to provide effective communication and emotional support. Be supportive of positive coping behaviors. Provide list of community resources that may be able to help decrease stress. Educate the client and family about coping effectively with the situation and give information about support groups, if available.
Aspiration syndromes are all conditions in which foreign matter is inhaled into the lungs, which can lead to ___________________ and possibly death. Monitor the client for symptoms of this which include________________________
aspiration pneumonia; dyspnea, chest pain, fatigue, discolored or pale skin, tachypnea, low oxygen saturation, frequent cough, foul-smelling sputum, inspiratory crackles on auscultation of lungs, and fever.
Aspiration pneumonia is diagnosed through chest X-ray, complete blood count, Gram stain, and sputum culture.
What to remember about ventilator tubing, bacterial growth, and pneumonia
3) INCORRECT— The nurse should respond to the problem rather than calling for unneeded assistance.
4) CORRECT— This client is at risk for aspiration. Caring for the tracheostomy is within the scope of nursing practice.
Think Like a Nurse: Clinical Decision-Making
An excellent environment for bacteria to grow is created when water vapor from ventilator humidification systems condenses and collects in the ventilator tubing. When the client is on mechanical ventilation, there is typically a filter attached to help prevent bacteria and viruses from entering the lungs.
The nurse should keep in mind that draining the tubing is a primary reason for breaching the ventilator circuit.
As part of ventilator-associated pneumonia bundle protocol, the ventilator circuit tubing is replaced only if visibly soiled (not done routinely).
What is the expected head circumference for newborns?
What about chest circumference ?
Head circumference is around 33-35 cm (12-14 inches)
Chest circumference is around 30.5-33 cm (12-13 inches)
The chest circumference is 1–2 cm less than the head.
An increase in head circumference size may indicate hydrocephalus or increased intracranial pressure. The nurse must alert the health care provider of this assessment finding.
Clients with heart failure shoud restrict their sodium intake to ______________________ per day
What foods should be avoided for heart failure patients ?
Clients with heart failure should follow a low-sodium diet, restricting their sodium to less than 2 g (2000 mg) of sodium daily.
This reduces fluid volume, improves pumping action of the heart, and prevents fluid from accumulating in the lungs and extremities.
Smoked, cured, salted, or canned foods should be avoided; fresh vegetables should be encouraged.
The expected appearance of candidiasis infection is the appearance of
white patches on the client’s oral mucous membranes. Other more general manifestations would include redness and possible swelling.
White patches appear on tongue, palate, and buccal mucosa in oral candidiasis.
Mouth care is the process one takes to maintain healthy teeth, gums, and tongue. Abnormal changes in the mouth could be___________________________ Risk factors for abnormal changes include___________________________________________-
dryness, cracked tongue, missing teeth, teeth in bad repair, ill-fitting dentures, and the presence of lesions, foul odors, or discolorations.
poor oral hygiene, poor fluid intake, and certain medications such as an inhaled corticosteroid.
When assessing a client’s mouth, the nurse should inspect the lips, tongue, teeth or presence of dentures, gums, and oral mucous membranes. Note any foul odors, swelling, pallor, lesions, or drainage. The nurse needs to encourage the client to seek medical attention if lesions are present. Treatments will vary based on the cause.
What is the difference between Cushing’s syndrome and Cushings disease ?
Cushing’s Syndrome: caused by an outside cause or medical treatment such as glucocorticoid therapy
Cushing’s Disease: caused from an inside source due to the pituitary gland producing too much ACTH (Adrenocorticotropic hormone) which causes the adrenal cortex to release too much cortisol.
S/S of Cushings
Remember the mnemonic: “STRESSED” (remember there is too much of the STRESS hormone CORTISOL)
Remember the mnemonic: “STRESSED” (remember there is too much of the STRESS hormone CORTISOL)
Skin fragile
Truncal obesity with small arms
Rounded face (appears like moon), Reproductive issues amennorhea and ED in male(due to adrenal cortex’s role in secreting sex hormones)
Ecchymosis, Elevated blood pressure
Striae on the extremities and abdomen (Purplish)
Sugar extremely high (hyperglycemia)
Excessive body hair especially in women…and Hirsutism (women starting to have male characteristics), Electrolytes imbalance: hypokalemia
Dorsocervical fat pad (Buffalo hump), Depression
Causes of Cushings
Glucocorticoid drug therapy ex: Prednisone
Body causing it: due to tumors and cancer on the *pituitary glands or adrenal cortex, or genetic predisposition
Cushing syndrome results from chronic exposure to excess corticosteroids. Excess corticosteroids adversely affect the bone structure, leading to weakening.
Although it can develop as a primary condition, it most often occurs after the client has been prescribed long-term steroid use to treat another health problem.
Tumors of the adrenal cortex or the pituitary gland can also cause over-secretion of hormones and increase cortisol levels.
A deficiency in this vitamin has been linked to the development of neural tube defects in the developing fetus.
FOLIC ACID
Because this birth defect can be avoided, clients are counseled to take folic acid supplements prior to and throughout a pregnancy.
Maternal folic acid deficiency is a risk factor for the development of neural tube defects (spina bifida). A daily consumption of 0.4 mg of folic acid is recommended for women of childbearing age.
Maternal serum alpha-fetoprotein (MS-AFP) screening is a blood test performed between 15 to 20 weeks (second trimester) to assess for neural tube defects and chromosomal disorders. An abnormally high AFP level may mean that the fetus has a ______________________ such as spina bifida or anencephaly (underdeveloped brain and an incomplete skull). An abnormally high AFP level may also indicate that the fetus has an __________________, which is an abdominal wall defect with organ exposure.
neural tube defect; omphalocele
What is SIRS ?
What is the criteria ?
Systemic inflammatory response syndrome (SIRS) is an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, acute inflammation, ischemia or reperfusion, or malignancy to name a few) to localize and then eliminate the endogenous or exogenous source of the insult
It involves the release of acute-phase reactants which are direct mediators of widespread autonomic, endocrine, hematological and immunological alteration in the subject. Even though the purpose is defensive, the dysregulated cytokine storm has the potential to cause massive inflammatory cascade leading to reversible or irreversible end-organ dysfunction and even death.
SIRS with a suspected source of infection is termed sepsis
Sepsis with one or more end-organ failure is called severe sepsis and with hemodynamic instability in spite of intravascular volume repletion is called septic shock.
Multiple organ dysfunction syndrome (MODS) is the presence of altered organ function in acutely ill septic patients such that homeostasis is not maintainable without intervention
Objectively, SIRS is defined by the satisfaction of any two of the criteria below –
Body temperature over 38 or under 36 degrees Celsius.
Heart rate greater than 90 beats/minute
Respiratory rate greater than 20 breaths/minute or partial pressure of CO2 less than 32 mmHg
Leucocyte count greater than 12000 or less than 4000 /microliters or over 10% immature forms or bands.
To summarize, almost all septic patients have SIRS, but not all SIRS patients are septic
The professional development educator teaches novice nurses about the causes of systemic inflammatory response syndrome (SIRS). Which types of injury will the nurse include in the teaching? (Select all that apply.)
- Burn injuries.
- Crush injuries.
- Major surgeries.
- Bowel ischemia.
- Viral infection.
1) CORRECT— Burn injuries cause mechanical tissue trauma, a trigger for SIRS.
2) CORRECT— Crush injuries cause mechanical tissue trauma, a trigger for SIRS.
3) CORRECT— Major surgeries can cause mechanical tissue trauma, a trigger for SIRS.
4) CORRECT— Bowel ischemia causes mechanical tissue trauma, a trigger for SIRS.
5) INCORRECT - This infection causes microbial invasion, not mechanical trauma.
The nurse is aware other potential causes of systemic inflammatory response syndrome (SIRS) include intra-abdominal abscess, pancreatitis, bacteremia, sepsis, shock states, post-cardiac resuscitation, and massive myocardial infarction. The nurse is expected to closely monitor the client’s hemodynamic status, including viral signs, urine output, and central venous pressure. One of the goals of treatment in SIRS is to keep the mean arterial blood pressure higher than 65 mm Hg for septic clients. Comprehensive assessment will require closely monitoring the client’s neurological status, urine output, and tissue oxygenation. Sources of infection should be actively treated with appropriate antibiotics, after cultures are drawn.
Systemic inflammatory response syndrome (SIRS) may result from a variety of life-threatening conditions, including sepsis, shock states, and myocardial infarction. With SIRS, the inflammatory response is activated, resulting in the release of inflammatory mediators, direct damage to the endothelium, hypermetabolism, increased vascular permeability, and activation of the coagulation cascade. Compromised organ function results from hypotension, decreased perfusion, microemboli, and redistribution or shunting of blood flow. SIRS can potentially lead to multiple organ dysfunction syndrome (MODS), which is the failure of two or more organ systems in an acutely ill client.
____________________ refers to the death of heart muscle cells due to ischemia from the obstruction of coronary artery blood flow. .
Myocardial infarction (MI);
Promote adequate oxygenation and administer supplemental oxygen as prescribed. Obtain a 12-lead electrocardiogram. Administer prescribed medications (e.g., nitroglycerin, morphine, clotting inhibitors, antihypertensive agents, or thrombolytic agents). Monitor serial cardiac enzymes (e.g., troponin, creatine kinase-MB, myoglobin). Ensure understanding of planned surgical interventions and procedures (e.g., angioplasty with stent placement or coronary artery bypass grafting). Complications of MI include dysrhythmias (ventricular fibrillation), cardiogenic shock, acute pericarditis, and heart failure
The nurse should recognize hypotension, tachycardia, and crackles in the lung bases of a client with an acute inferior wall myocardial infarction (MI) indicates potential ____________________-
heart failure
What is the first stage of Erikson’s psychosocial development ?
TRUST VS MISTRUST
This stage begins at birth and lasts through one year of age. Infants learn to trust that their caregivers will meet their basic needs. If these needs are not consistently met, mistrust, suspicion, and anxiety may develop.
Normally, from birth to 8 weeks, infants gaze at faces, smile responsively, and use vocalization to interact socially.
At 3 to 4 months, infants distinguish primary caregivers from others, react if removed from the home, smile readily at most people, and play alone with contentment.
At 6 to 9 months, infants discriminate strangers, demonstrate stranger/separation anxiety, actively seek adult attention, want to be picked up and held, play peekaboo, pat own mirror image, and begin to respond to own name.
The Moro disappears at _________months of age.
At _____ months of age, an infant should demonstrate a social smile
An infant should hold the bottle at ________ months of age
4;
At 2 months of age, an infant should demonstrate a social smile
6
In communicating with the client who frequently changes the subject, the nurse can use the sharing observation technique. The nurse can comment on how the other person is acting, looking, or sounding. Stating observations often helps a client communicate without the need for extensive questioning, focusing, and clarification.
TRUE OR FALSE
TRUE
. Depending upon agency protocol, use a validated instrument to assess risk for suicide. If no tool is available, ask client about
suicidal ideation (frequency of suicidal thoughts, intensity, and duration over time), suicide plan (method, lethality of method, time and place, whether or not they have prepared for suicide), any suicidal behaviors (rehearsals, prior attempts, aborted attempts, and non-suicidal self-injuries), and the client’s intent to follow through with the plan.
What to remember about Prostate cancer treatments, specifically androgen deprivation therapy:
Treatment for prostate cancer may include radical prostatectomy, nerve-sparing prostatectomy, cryotherapy, radiation therapy, androgen deprivation therapy (ADT), chemotherapy, radiotherapy, and orchiectomy.
ADT is therapy aimed at reducing the levels of circulating androgens. Prostate cancer growth is largely dependent on the presence of androgens, and ADT reduces tumor growth.
Anti-androgen medications stop testosterone and dihydrotestosterone (DHT) from stimulating prostate cancer cell growth. Side effects are directly related to the lack of normal levels of male hormones in the body.
The desired outcome is to decrease hormones that would increase the cancer.
Prostate cancer may initially produce no symptoms. However, pain in the lumbosacral area with radiation to the hips or legs, when combined with urinary symptoms, may indicate metastasis. The tumor can spread to pelvic lymph nodes, bones, bladder, lungs, and liver. Most men in the United States with prostate cancer are diagnosed by prostate-specific antigen (PSA) testing (normal level 0 to 4 ng/mL [0 to 4 mcg/L]). A biopsy of the prostate tissue is usually indicated if PSA levels are consistently elevated or if the digital rectal exam is abnormal.
Signs of Kaposi’s sarcoma include __________________-, usually apparent on the face or legs.
hyperpigmented skin lesions
One disease process commonly seen in clients with AIDS is Karposi sarcoma. This illness is characterized by skin lesions that are darker than the client’s skin tone. Definitive diagnosis of this illness occurs after a lesion is biopsied.
A client with AIDS is at risk for developing opportunistic infections because the body is unable to fend off microorganisms and disease processes.
What to remember about hypersensitivity reactions
What are S/S?
A hypersensitivity reaction is a reaction to an antigen within minutes of exposure.
Clinical manifestations include erythema, urticaria, angioedema, pruritus, wheals, wheezing, bronchospasms, stridor, hypotension, tachycardia, and arrhythmias.
Treatment options include administration of epinephrine, antihistamines, and corticosteroids to decrease the allergic response.
Oxygen and IV fluids should be given to support breathing and circulation.
What to remember about Cystic Fibrosis ………….
What is the gold standard for its diagnosis ?
An inherited respiratory disease causing severe lung damage and nutritional deficiencies. Caused by a mutation in the CFTR (cystic fibrosis transmembrane conductance regulator) gene. Secretions that contain chloride (mucus, sweat, saliva and digestive secretions) become thick and tenacious and clog airways and ducts.
Secretions become thick and sticky, rather than thin and slippery.
The sweat test is considered the gold standard for diagnosing cystic fibrosis. The sweat test measures the amount of chloride in the sweat. For a child who has cystic fibrosis, the sweat chloride test results will be positive (showing a high chloride level) shortly after birth. Pancreatic enzymes and supplemental fat-soluble vitamins are prescribed to promote adequate digestion and absorption of nutrients, and optimize nutritional status. The nurse should keep in mind that in cystic fibrosis, therapeutic management is aimed toward minimizing pulmonary complications, maximizing lung function, preventing infecting, and facilitating growth.
Sweat analysis, chest x-ray, pulmonary function tests, arterial blood gases (ABGs), and stool analysis are performed when a client has signs of cystic fibrosis.
Contact precautions are designed to prevent skin and clothing contact with the infectious organism methicillin-resistant Staphylococcus aureus (MRSA) because the organism can travel with that vector (the nurse) to another host (a client). MRSA is spread through contact with the infection source and through contact with surfaces in the room, such as bedside tables, bed controls, and linen stored in the room.
TRUE OR FALSE
TRUE
What to remember about Rheumatoid Arthritis …………
Rheumatoid arthritis is a chronic, progressive, autoimmune disease of unknown origin that causes inflammation and degeneration in the joints resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles. The client may exhibit spongy or boggy joints. The client may report weight loss, sensory changes, lymph node enlargement, and fatigue. Observe for joint swelling, warmth, and erythema. Pharmacologic interventions include non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, and immunosuppressive drugs (such as methotrexate and cyclosporine). Collaborate with the physical therapist, occupational therapist, and dietitian.
Performing basic hygiene and grooming must be done daily to maintain overall health. If the client cannot do this, it indicates the need for daily home assistance.
TRUE OR FALSE
TRUE
Amiodarone should not be administered for a client whose heart rate is less than 150 beats per minute.
TRUE OR FALSE
TRUE
What to remember about Atrial Fibrillation ?
Atrial fibrillation is characterized by an irregular atrial rate greater than 350 beats/min and an irregular ventricular rate less than or greater than 100 beats/min. P waves are fibrillatory waves and may lead to blood clots. Precipitating and causative factors include coronary artery disease, valvular heart disease, cardiomyopathy, heart surgery, hypertension, heart failure, pericarditis, thyrotoxicosis, alcohol intoxication, caffeine use, electrolyte imbalances, and stress. Observe for signs of decreased cardiac output (e.g., hypotension, syncope) as a result of the ventricular rate.
In atrial fibrillation, the cardiac output is reduced due to decreased ventricular filling or loss of atrial kick. The nurse will typically find signs and symptoms related to reduced ejection fraction (e.g., low cardiac output). Depending on the onset of atrial fibrillation, the client might require anticoagulation prior to synchronized cardioversion. If the heart rate is controlled (e.g., between 60 and 100 beats per minute), the nurse may anticipate giving the client digitalis as prescribed. For atrial fibrillation with rapid ventricular response, the nurse should anticipate giving the client a beta-blocker or calcium channel blocker IV push. Vital signs should be monitored closely. If the client is hypoxic, give supplemental oxygen.
What to remember about Raynaud’s disease
A condition in which some areas of the body feel numb and cool in certain circumstances.
In Raynaud’s phenomenon, smaller arteries that supply blood to the skin constrict excessively in response to cold, limiting blood supply to the affected area.
The fingers, toes, ears, and tip of the nose are commonly involved and feel numb and cool in response to cold temperatures or stress. It’s often accompanied by changes in the color of the skin.
Treatment beyond self-care, such as dressing warmer, usually isn’t needed.
A client is scheduled to have a transabdominal pelvic ultrasound for evaluation of a uterine mass. The nurse includes which statement when preparing the client for the procedure?
- “Do not eat anything for at least 8 hours before the test.”
- “You may feel a stinging sensation as the machine moves over your skin.”
- “Drink four glasses of water 1 hour before the test and do not urinate.”
- “Be prepared for the test to take 1 to 2 hours.”
1) INCORRECT – A transabdominal ultrasound does not require fasting.
2) INCORRECT – There is no discomfort or pain with this test.
3) CORRECT – A full bladder is necessary for this test for several reasons, including the fact that it serves as a window for the ultrasound beam transmission. It also provides a less obstructed view by pushing the uterus away from the pubic symphysis, as well as by pushing the intestine out of the pelvis.
4) INCORRECT – Examination time is approximately 30 minutes, not including preparation and waiting times.
The uterus sits low and deep in the pelvis. Given the structure of the pelvis, lifting the uterus out of the pelvic cavity offers a better view of a potential pelvic mass. Filling the bladder with water prior to the test expands the uterus, causing it to move up and out of the pelvic cavity, which improves visualization.
When performing procedures on a preschooler, encourage the presence of a ________________–
what else can we do ?
parent/caregiver.
Being apart from family is anxiety-provoking and stressful. Use play therapy and age-appropriate toys to stimulate social and motor development. The nurse can support and enhance a preschooler’s communication by reading books, repeating the child’s words or phrases, allowing time for the child to speak without interruption, and using short and simple sentences.
the client’s anxiety level may be lessened if the client is allowed to touch equipment and materials, with consideration of sterility, that will be used while providing care.
Risk factors for hypertension include
Treatment includes
smoking, obesity, heavy alcohol consumption, sedentary lifestyle, increased cholesterol and triglyceride levels, stress, family history of hypertension, and increased dietary sodium intake.
Treatment involves lifestyle changes, including smoking cessation and alcohol moderation (if indicated), weight loss, moderate physical activity, and stress reduction techniques. Dietary recommendations include restricting fat and sodium. Anti-hypertensive medications may be prescribed including alpha-adrenergic antagonists, alpha-adrenergic blockers, beta-adrenergic blockers, calcium channel blockers, or angiotensin-converting enzyme (ACE) inhibitors.
What to remember about the bite from a brown recluse spider
BE AWARE OF SIGNS OF TISSUE NECROSIS, including mottled skin
Normal findings associated with a brown recluse spider bite include vesicle formation, burning, edema, redness, pain, and pruritus.
However, signs of tissue death are concerning and require intervention to promote healing and prevent local and systemic infection. The ulcer that results from the venom can take weeks to stabilize and heal, and it requires ongoing care and monitoring.
Older adult clients are often unable to exhibit a fever response. A fever is absent in 25 to 30% of older adult clients with infection.
TRUE OR FALSE
TRUE
Older adult clients are less likely to have an leukocytosis in response to an infection. More than 20% of older adult clients with infection present without leukocytosis.
TRUE OR FALSE
TRUE
What to remember about sifns of infection in the older adult
Early identification of infection in older adults is essential. Due to the aging process, older adults typically do not exhibit the classic manifestations associated with an infection (chills and fever) and inflammation (swelling, redness, and heat). Manifestations associated with inflammation and infection in older adults may be more subtle such as alteration in mental status, agitation, fatigue, lethargy, incontinence, falls, and tachypnea.
When providing care for an older adult client, the nurse must remember that clinical manifestations of infection may not present in the usual manner. The older adult client often exhibits a change in the level of consciousness or tachypnea when developing an infection. Therefore, the nurse closely monitors the client’s respiratory status as an indicator of probable infection.
______________________________-are the most reliable signs of infection in older adult clients.
Tachypnea, along with confusion and tachycardia,
The nurse provides care for a client in the emergency department (ED). The nurse reviews the health care provider (HCP) prescription and notes that digoxin 1.25 mg PO has been prescribed to be given now. Which action by the nurse is appropriate?
- Administer the medication as prescribed.
- Validate the prescription with the HCP.
- Ask the client if this is the usual daily dosage.
- Ask another nurse if the dosage is appropriate.
The nurse provides care for a client in the emergency department (ED). The nurse reviews the health care provider (HCP) prescription and notes that digoxin 1.25 mg PO has been prescribed to be given now. Which action by the nurse is appropriate?
- Administer the medication as prescribed.
- Validate the prescription with the HCP.
- Ask the client if this is the usual daily dosage.
- Ask another nurse if the dosage is appropriate.
View Explanation
The correct answer is 2 . You answered 2.
Explanation
Step-by-Step Walkthrough
1) INCORRECT - This is an inappropriate prescription. Digoxin is a cardiac glycoside and the oral loading dose is 0.75 mg to 1.25 mg, administered in three divided doses over 24 hours.
2) CORRECT— Verify the rights of medication administration. The nurse needs to clarify the prescription with the HCP. If this is a digitalizing dose, it is to be given in three divided doses over a 24-hour time frame. If it is a maintenance dose, it would usually be between 0.1 to 0.375 mg per day.
3) INCORRECT - The nurse administering the medication should clarify the prescription with the HCP, not the client. The client may not know the actual dose of the prescribed drug, even if taking the medication at home.
4) INCORRECT - The nurse should clarify the prescription with the HCP, not another nurse.
The lower the fat content of milk, the higher the potassium content.
TRUE OR FALSE
TRUE
Eight ounces of whole milk contain 320 mg of potassium, whereas 8 ounces of 2% milk has 340 mg of potassium, and 8 ounces of nonfat milk has 380 mg of potassium.
Furosemide causes the excretion of sodium, potassium, and water. Digoxin is a cardiac glycoside, and low potassium levels precipitate digoxin toxicity.
Potassium must be maintained within normal limits to avoid digoxin toxicity.
TRUE OR FALSE
TRUE
why do clients need blood transfusions?
Blood administration is the the delivery of whole blood or blood components through an intravenous (IV) line into a vein. Transfusion of blood or blood products is necessary when blood loss reduces blood volume so that tissue perfusion is impaired, when platelets are lowered enough to cause spontaneous bleeding, or when severe anemia reduces the amount of oxygen available to the cells of the body. Blood transfusions are delivered to clients in hospitals, clinics, and in the home.
Whole blood and packed red blood cells are refrigerated and can be stored for about a month; platelets are stored at room temperature for five days; and plasma is frozen for up to a year. Blood and blood components should be delivered over two to three hours, within four hours at most.
The nurse assigns a client who is receiving a red blood cell transfusion to the unlicensed assistive personnel (UAP). Which actions can be delegated to the UAP? (Select all that apply.)
- Obtain vital signs prior to the transfusion.
- Obtain blood products from the blood bank.
- Verify the client’s identity prior to the transfusion.
- Perform hourly rounding during the transfusion.
- Assist the client with toileting during the transfusion.
1) CORRECT— Taking the client’s vital signs before and after the transfusion is within the scope of practice of a UAP.
2) CORRECT— Picking up blood products from the blood bank as directed by the nurse is within the scope of practice of a UAP.
3) INCORRECT - Verifying a client’s identity prior to a blood transfusion is not within the scope of practice of a UAP.
4) CORRECT— Hourly rounding is within the scope of practice of a UAP.
5) CORRECT— Assisting stable clients with toileting during a blood transfusion is within the scope of practice of a UAP.
Before delegating care, the nurse needs to review the scope of practice of potential care providers. Unlicensed assistive personnel (UAP) have the knowledge and training to complete routine tasks that have a predictable outcome on clients who are considered stable. Of all of the tasks that need to be completed for this client, the ones that UAP can safely complete include obtaining the blood product from the blood bank, measuring vital signs, checking on the client every hour, and assisting the client with ambulation. The nurse retains the responsibility and accountability for all delegated tasks in addition to ensuring for the client’s safety by checking the blood product with another registered or licensed care provider.
What to remember about Herpes Zoster …..
should care providers who have not had chickenpox care for the client with shingles ?
Also known as shingles, it is caused by the same virus that causes chickenpox.
Herpes zoster is a painful skin rash, caused by the varicella zoster virus, that usually appears in a band, a strip, or a small area on one side of the face or body. Medications such as acetaminophen or ibuprofen are prescribed to help reduce pain associated with the virus. Anti-viral medications, such as acyclovir, may also be prescribed. The nurse needs to educate the client to limit exposure to those with weakened immune systems to prevent the spread of the virus.
he illness occurs when something within the body activates the virus that has been laying dormant since the client experienced chicken pox decades earlier. Because it is the same virus that causes chicken pox, only care providers who have experienced chicken pox should care for the client. When herpes zoster occurs, the client will develop a characteristic rash that can be traced along a nerve root or band. The rash is extremely painful despite being treated with antiviral medication. Both pharmacologic and nonpharmacologic pain management interventions are used to promote comfort in the client with this health problem.
What to remember about intravenous pyelogram procedure, specifically Metformin use
What are contraindications for this procedure
An X-ray, which includes contrast dye, that provides pictures of the urinary tract, including the kidneys, bladder, ureters, and urethra.
the nurse determines if the client takes metformin, as this medication should be held for 48 hours before and after the procedure to avoid an interaction with the dye.
Clients at risk for adverse effects include client with diabetes mellitus who are prescribed metformin.
Determine whether the client has a sensitivity to iodine, is pregnant, has kidney disease, or renal failure because the procedure is contraindicated for these clients.
Typically, metformin has to be held 2 days before and 2 days after a procedure that involves an iodine-based dye
TRUE OR FALSE
TRUE
this medication should be held for 48 hours before and after the procedure to avoid an interaction with the dye
Clients with allergies to shellfish may potentially develop an adverse reaction to iodine-based contrast media.
TRUE OR FALSE
TRUE
The nurse prepares a client for an intravenous pyelogram. Which client statement causes the nurse the most concern?
- “I really cleaned out my bowels last night. ”
- “My face flushes when I eat shrimp. ”
- “I missed my morning cup of coffee. ”
- “They are going to be taking x-rays at multiple intervals. ”
1) INCORRECT - An intravenous pyelogram requires a bowel prep. Cleaning the bowels before the procedure is expected.
2) CORRECT— Facial flushing when eating shrimp can indicate a sensitivity to iodine. The contrast medium used for an intravenous pyelogram contains iodine. If used, the client may develop anaphylaxis. The nurse should assess for an allergy to shellfish, iodine, chocolate, eggs, and milk.
3) INCORRECT - Missing a morning cup of coffee does not cause concern because the client should be on nothing by mouth status after midnight the evening before the test.
4) INCORRECT - An intravenous pyelogram includes x-ray images that are taken at specific intervals after the contrast medium is injected.
Typically, the client should be re-assessed 30 minutes after parenteral pain medications and 60 minutes after an oral pain medication
TRUE OR FALSE
TRUE
Pain re-assessment is expected after the administration of pain medicine.
The following are nursing interventions for the client who had a recent amputation:
Administer pain medications and evaluate effectiveness, especially before and after moving client or carrying out procedures. Teach about relaxation, visualization, and deep breathing to reduce anxiety and pain. Splint and support the affected area, elevating to reduce edema immediately after surgery. Turn and reposition frequently and provide range of motion exercises. Following an amputation, the client should be position in the prone position to avoid hip contractures.
Provide nutritional support for healing. Assess wound during dressing changes and report excess bleeding or sign of infection; use aseptic technique. Teach client/family to care for skin, use elastic wraps, and massage site after wound heals. Use active listening to help the client/family grieve the loss.
What to remember about Bell Palsy
caused by a lower motor neuron lesion of cranial nerve VII that may result from infection, trauma, hemorrhage, meningitis or tumor
-results in paralysis of 1 side of the face
- recoverey usually occurs in a few weeks, without residual effects
Assessment - loss of taste, flaccid facial muscles, inability to close the eye, decreased corneal reflex, speech difficulty, inability to raise the eyebrows, frown, smile, close the eyelids or puff out the cheeks
INTERVENTIONS:
-prevent corneal abrasions (artificial tears)
-encourage facial exercises to prevent the loss of muscle tone
-chew on the unaffected side
- protect the eyes from dryness and prevent injury
Bell palsy is a form of temporary, unilateral facial paralysis that results from malfunction of the seventh cranial nerve (facial nerve). In addition to facial paralysis, symptoms of Bell palsy include inability to close the affected eye, decreased corneal reflex, increased lacrimation, speech difficulty, and loss of taste. Treatment includes electrical stimulation (to help maintain muscle tone of facial muscles), analgesics, steroid therapy (e.g., prednisone), and antiviral medications (e.g., acyclovir). Teach the client to perform isometric exercises for facial muscles, such as blow through and suck from a straw.
The client with Bell palsy cannot control movements of a portion of the face. Interventions are directed at minimizing damage to the affected facial structures. Normally, exposure to cold wind or debris automatically triggers blinking or squinting, both of which help protect the eye. However, the client with Bell palsy experiences impaired sensory perception and must be educated about taking precautions to prevent eye damage until the condition resolves.
The home care nurse instructs a client diagnosed with Bell palsy. Which client statement indicates to the nurse that further teaching is necessary?
- “I should place an eye shield over the affected eye at bedtime.”
- “I should avoid sudden movement when bending over.”
- “I should not go out when there is a cold wind.”
- “I should use heat on the affected side of my face.”
1) INCORRECT - A patch over the affected eye at night is an appropriate action. It helps prevent corneal irritation. A client may need to use artificial tears.
2) CORRECT— This is not a necessary precaution unless a client has problems with increased intraocular pressure.
3) INCORRECT - This is an appropriate action due to sensitivity of nerve endings to both extreme cold and heat.
4) INCORRECT - A warm, not hot, heat to the affected area is a method to reduce pain and discomfort. Analgesics may be used as well.
The nurse is eating lunch in a restaurant. Suddenly, a woman at the next table gasps for breath and grabs her throat. Which action does the nurse take first?
- Lean the woman forward and administer back blows.
- Offer the woman sips of water.
- Ask the woman if she can speak.
- Perform a finger sweep of the woman’s mouth.
1) INCORRECT — Back blows are utilized in the choking infant, but are not used in the adult.
2) INCORRECT — It is unclear whether this is a partial or complete airway obstruction from the question stem. The nurse should avoid introducing any further food or fluids until the airway is known to be clear.
3) CORRECT — It is unclear whether this is a partial or complete airway obstruction from the question stem. The nurse should first assess the nature of the obstruction by asking the client to speak. If the client can speak or cough, then it is a partial obstruction. If they are unable to speak or cough, then they are experiencing a total obstruction and the Heimlich maneuver should be used.
4) INCORRECT — The nurse should first assess whether this is a partial or total airway obstruction. A finger sweep may push an obstruction further into the airway and should be avoided in a partial obstruction.
Prior to implementing an emergency rescue intervention, the nurse should assess the client. If indicated, the nurse knows to perform the Heimlich maneuver until the obstruction is relieved or until the client becomes unresponsive. If the client becomes unresponsive, the nurse should initiate cardiopulmonary resuscitation, starting with chest compressions. Each time the nurse prepares to deliver breaths, the nurse knows to look inside the client’s mouth. If an object is visible and can be easily removed, the nurse should remove it with his or her fingers. However, the nurse knows to never perform a blind finger sweep.
Content Refresher
When someone is found choking, determine if the person is okay. Ask the person, “Can you speak?” If the person says “yes,” stay with the person and encourage the person to continue coughing. If the person shakes his or her head as if saying “NO!” perform the Heimlich maneuver. The Heimlich maneuver is a set of steps that uses abdominal thrusts to help a client who is choking in order to clear a partially or a totally obstructed upper airway.
What is a varicocele ?
An enlargement of the veins within the scrotum.
Varicoceles often produce no symptoms but can cause low sperm production and decreased sperm quality, leading to infertility.
Varicoceles that cause no symptoms typically require no treatment. Cases in which symptoms occur can be repaired surgically.
What to remember about Testicular Torsion
When the testicle rotates (testicular torsion), it twists the cord supplying blood to the loose bag of skin (scrotum) beneath the penis. This may occur after vigorous activity, a minor injury to the testicles, or sleep.
Sudden, severe pain and swelling in the testicle are symptoms.
Surgery is required. Treated promptly, the testicle can often be saved. A longer wait may affect fertility.
the testes twist around the spermatic chord. When this happens, it cuts off the blood flow to the testicle. It can cause pain and swelling, and should be treated as an emergency
This is very painful and is an emergency situation, which requires immediate surgical repair. Testicular torsion is the most common cause of testicular loss in young males due to hypoxic injury to the testicle.
The nurse is aware that a thickened and swollen spermatic cord is not normal and could indicate testicular torsion, which is a surgical emergency. The client needs immediate intervention to prevent the loss of a testicle. The nurse needs to be aware that testicular torsion is most common among younger male clients. This population needs to be taught that any pain in the genitals should be reported immediately to a parent or health care provider.
For the infant client who is prescribed digoxin, the nurse should hold the medication if the client’s apical pulse rate is less than _____________beats per minute. In an adult client, the nurse should hold the digoxin dose if the client’s apical pulse rate is less than _____________ beats per minute.
90; 60
Compared to an adult’s heart, the infant’s heart is much smaller and contracts less forcefully. For a newborn, normal heart rate ranges from 100 to 160 beats per minute. The infant is dependent on an increased heart rate to deliver adequate stroke volume and maintain hemodynamic stability. Decreasing the infant’s heart rate below 90 beats per minute results in decreased cardiac output and instability, resulting in hypotension and other sequelae.
What is the normal heart rate for an infant ?
A normal heart rate for an infant is 120 to 140 (resting).
Bradycardia is a rate below 80 to 100 beats per minute
The signs and symptoms of tuberculosis (TB) may not manifest until weeks after exposure. Clients exposed to TB, but not immunocompromised, may never become symptomatic
TRUE OR FALSE
TRUE
Preparing the client for an MRI
The nurse should identify whether the client has allergies, body tattoos (especially with red coloring), permanent cosmetics, transdermal patches with foil backing, and implanted metal objects.
What to remember about AIR EMBOLISM
what position should this client be placed in
An air embolism is an occlusion in the pulmonary arteries following the insertion of a central venous catheter, which puts the client at risk for developing an air embolism. While not as common, air embolis can also occur with peripheral intravenous access that become detached.
Clinical manifestations include dyspnea, chest wall pain, cough, hypoxemia, tachypnea, tachycardia, confusion, hemoptysis, crackles, and wheezing.
Treatment consists of supplemental oxygen to correct hypoxia symptoms and managing the client’s physical position in an effort to prevent the embolis from moving to the lungs or brain. The air embolis is resolved when the air is absorbed by the body.
The goal is to position the client to trap the air in the lower portion of the right ventricle, which can be achieved by positioning the client on the left side in the Trendelenburg position or in the left lateral decubitus position,
This forces the air embolism to move to the right side of the heart. The Trendelenburg position helps contain the embolism to the right ventricle. The goal of this nursing intervention is to prevent the air embolism from entering the lungs or brain, which can cause life-threatening complications.
The nurse discovers the IV infusion tubing disconnected from a peripherally inserted central catheter, and the client has tachycardia, chest pain, and shortness of breath. In which position will the nurse place the client?
- Supine with the head of bed elevated 30 to 45 degrees.
- Left side-lying Trendelenburg.
- Right lateral decubitus.
- Reverse Trendelenburg.
1) INCORRECT - Since the client exhibits signs and symptoms of an air embolism, the goal is to position the client to trap the air in the lower portion of the right ventricle, which can be achieved by positioning the client on the left side in the Trendelenburg position or in the left lateral decubitus position. A supine position with the head of bed elevated 30 to 45 degrees reduces the risk for hospital-acquired pneumonia.
2) CORRECT– The client exhibits signs and symptoms of an air embolism. Therefore, the nurse should position the client on the left side in the Trendelenburg position to trap the air in the lower portion of the right ventricle.
3) INCORRECT - Since the client exhibits signs and symptoms of an air embolism, the goal is to position the client to trap the air in the lower portion of the right ventricle, which can be achieved by positioning the client on the left side in the Trendelenburg position or in the left lateral decubitus position, not a right lateral decubitus position.
4) INCORRECT - The client shows signs and symptoms of an air embolism. Therefore, the client should be positioned on the left side in the Trendelenburg position, not the reverse Trendelenburg position.
What to remember about the influenza vaccine
Contraindications
The influenza vaccine does not provide automatic protection from the flu as it takes approximately 2 weeks for protection to develop. Once developed, the protection lasts for the duration of the current flu season.
The influenza vaccine is incubated in a medium that contains egg proteins. Because of this, the nurse knows that a person with an egg allergy should not receive this vaccination. Other circumstances that contraindicate the use of the influenza vaccine include a history of previous allergic reaction and Guillain-Barré Syndrome (GBS). While it is usually okay for a client to receive the influenza vaccine when experiencing a mild illness, it may be appropriate to ask the client to return for the vaccine once he or she is feeling better to decrease the likelihood of a reaction.
What is a pheochromocytoma ?
A hormone-secreting tumor that can occur in the adrenal glands.
Pheochromocytomas usually develop in the small glands on top of the kidneys (adrenal glands). They most commonly affect people between the ages of 20 and 50, but can occur at any age.
Because of hormones secreted, symptoms include high blood pressure, sweating, rapid heartbeat, and headache.
Surgery to remove the tumor is usually required.
Pheochromocytoma is a rare tumor of adrenal gland tissue. It results in the release of too much epinephrine and norepinephrine, hormones that control heart rate, metabolism, and blood pressure
The nurse provides care for a client scheduled for an adrenalectomy to treat pheochromocytoma. For which symptom will the nurse monitor the client first?
- Hypertension.
- Urine glucose.
- Intake and output.
- Urine acetone.
The nurse provides care for a client scheduled for an adrenalectomy to treat pheochromocytoma. For which symptom will the nurse monitor the client first?
- Hypertension.
- Urine glucose.
- Intake and output.
- Urine acetone.
View Explanation
The correct answer is 1 . You answered 4.
Explanation
Step-By-Step Walkthrough
1) CORRECT – Hypertension is the classic sign of pheochromocytoma. The client’s blood pressure should be closely monitored.
2) INCORRECT – Monitoring urine glucose is an accurate nursing intervention for this condition, but is not the first priority.
3) INCORRECT – Monitoring intake and output is an accurate nursing intervention for this condition, but is not the first priority.
4) INCORRECT – Monitoring urine acetone is an accurate nursing intervention for this condition, but is not the first priority.
Hypertension has often been characterized as “the silent killer” and there can be a physiologic reason for the development of this health problem. The nurse is aware one reason for secondary hypertension to develop is the presence of a pheochromocytoma, which is a tumor within the adrenal gland. This tumor alters adrenal gland hormone secretion, which causes hypertension. While clients with pheochromocytoma may present with thirst, increased urinary output, and increased blood glucose, these symptoms are unlikely to result in immediate harm to the client. The severe hypertension found in pheochromocytoma may result in stroke or myocardial infarction.
Content Refresher
The adrenal glands are located above the kidneys. The medulla of the glands produces epinephrine and the cortex produces cortisol and aldosterone. A pheochromocytoma is a tumor that affects the adrenal gland and releases excessive hormones that result in high blood pressure. Clinical manifestations of hypertension may include headache, blurred vision, dyspnea, dizziness, heart palpitations, fatigue, and angina. Many of these symptoms occur secondary to the organ damage caused by hypertension. Persistent high blood pressure can result in coronary artery disease, left ventricular hypertrophy, heart failure, stroke, encephalopathy, dementia, renal disease, peripheral vascular disease, and retinal damage. Surgical removal of the tumor is required to treat the hypertension.
What to remember about Carpal Tunnel Syndrome
Carpel tunnel syndrome is a repetitive stress injury that results in numbness, tingling, and chronic pain in the hands and fingers. Carpal tunnel syndrome is caused by the entrapment of the medial nerve that runs through the wrist, palm, and areas of the fingers.
To assess for entrapment of this nerve, the client should be asked to place the backs of the hands together and then bend the wrists simultaneously. If tingling of the median nerve occurs during this action, the client will likely be diagnosed with carpal tunnel syndrome.
This is called the Phalen maneuver. This maneuver produces paresthesia of the median nerve distribution within 60 seconds for clients experiencing carpal tunnel syndrome. 80% of clients diagnosed with carpal tunnel syndrome have a positive result.
The condition may be treated with anti-inflammatory medications or surgery.
What is the Schamroth sign?
the Schamroth method is used to detect clubbing. If a diamond shape is visible between the nails, there is no clubbing. Clubbing indicates oxygen deprivation from respiratory or cardiovascular conditions.
The Schamroth sign is observed when the normally appearing diamond-shaped window that is formed by placing the dorsal surfaces of opposite terminal phalanges together disappears
When an unplanned event occurs on a care area, the nurse manager is responsible for conducting a _________________________
root cause analysis.
This is a process whereby every step is studied in order to determine the reason for the client outcome.
Teach the client about the onset, peak, and duration of prescribed insulins.. To enhance insulin absorption, instruct the client to rotate injection sites. Hypoglycemia is the most common adverse effect of insulin. Ensure that the client can recognize signs and symptoms of hypoglycemia, such as _______________________________________
shakiness, hunger, nervousness, poor concentration, sweating, tachycardia, and palpitations.
The nurse should educate friends and family members about the warning signs of suicidal thoughts (e.g., a statement like “I wish I hadn’t been born”). Additional signs that a client may be contemplating suicide include_____________________________________________________________________________________If these signs develop, the nurse should notify the health care provider immediately.
buying a gun or stockpiling pills; mood swings (happy one day and deeply discouraged the next); preoccupation with death, dying, or violence; social withdrawal and isolating self from others; and feeling trapped or hopeless about a situation.
Types of Central Venous Access Devices include
what is their main advantage
Types of central venous access devices (CVADs) include peripherally inserted central catheters (PICCs), tunneled central catheters, non-tunneled (percutaneous) central catheters, and implanted ports.
Central venous access devices are placed in large blood vessels, such as the subclavian or jugular vein.
Advantages of CVADs include immediate access to the central venous system, a reduced need for venipunctures, and decreased risk for extravasation injury. Infection is the major disadvantage of a CVAD.
The nurse provides discharge instructions to a client with a central venous access device (CVAD) for continued treatment of osteomyelitis. Which client statements require further instruction by the nurse? (Select all that apply.)
- “I’m going to wear bigger shirts so I don’t accidentally pull this catheter out when I change clothes.”
- “If the dressing over this catheter gets loose, I’ll tape it back down.”
- “I will wash my hands before touching the catheter or any of the medication.”
- “If the catheter starts to fall out, I will gently reinsert it.”
- “If I see blood in the catheter, I will call my home care nurse.”
- “I’ll put all these supplies in the trash as soon as I’m done with them.”
1) INCORRECT – The client needs to find ways to avoid accidental catheter removal.
2) CORRECT – The client must be instructed to call the home health nurse if the sterile dressing becomes loose, damp, or soiled.
3) INCORRECT – Appropriate hand hygiene will minimize the risk of an infection when using the catheter or providing medication.
4) CORRECT – The client should be instructed to apply pressure with sterile gauze if the catheter becomes dislodged and to avoid reinserting it.
5) INCORRECT – The client should call the home care nurse if the infusion slows or stops because of blood in the catheter.
6) CORRECT – The client should be instructed on the proper disposal of sharps and contaminated items. All intravenous therapy trash should be treated as a potential biohazard and should not be placed with regular household trash.
Elastic bandage application cannot be delegated to the UAP.
TRUE OR FALSE
TRUE
The nurse must assess distal pulses, skin color, and skin temperature to ensure the bandage is not too tight.
The skill of applying an abdominal binder can be delegated to the UAP.
TRUE OR FALSE
TRUE
However, the nurse is responsible for assessment of the area where the binder will be applied and the client’s comfort level after application.
The nurse reviews the laboratory results for a client taking lithium. Which client finding will the nurse immediately report to the health care provider?
- Serum sodium 125 mEq/L (125 mmol/L).
- Lithium level 1.2 mEq/L (1.2 mmol/L).
- Thyroxine T4 4.5 mcg/dL (57.9 nmol/L).
- White blood cell count 12,000/mm3 (12×109/L).
View Explanation
The nurse reviews the laboratory results for a client taking lithium. Which client finding will the nurse immediately report to the health care provider?
- Serum sodium 125 mEq/L (125 mmol/L).
- Lithium level 1.2 mEq/L (1.2 mmol/L).
- Thyroxine T4 4.5 mcg/dL (57.9 nmol/L).
- White blood cell count 12,000/mm3 (12×109/L).
View Explanation
The correct answer is 1 . You answered 1.
Explanation
Step-By-Step Walkthrough
1) CORRECT – The body compensates for low serum sodium by retaining lithium. Serum sodium of 125 mEq/L (125 mmol/L) is below the expected reference range, which places the client at risk for lithium toxicity. Therefore, this finding is the priority for the nurse to report to the health care provider.
2) INCORRECT – The therapeutic range of lithium during initial management is 1 to 1.5 mEq/L (1–1.5 mmol/L). The maintenance range is 0.8 to 1.2 mEq/L (0.8–1.2 mmol/L). The nurse should report that the client has a therapeutic lithium level, but there is another finding that the nurse should identify as the priority.
3) INCORRECT – Thyroxine T4 of 4.5 mcg/dL (57.9 nmol/L) is below the expected reference range, which can result from lithium decreasing thyroid hormone secretion. The nurse should report this finding to the health care provider to determine if the client will receive hormone therapy. Since this does not pose the greatest risk to the client, there is another finding that the nurse should identify as the priority.
4) INCORRECT – White blood cell count of 11,000/mm3 (11×109/L) can indicate leukocytosis, which can occur with lithium therapy. The nurse should report this finding and continue to monitor the client. Since this does not pose the greatest risk to the client, there is another finding that the nurse should identify as the priority.
The nurse should be aware that lithium is a medication that can interfere with ___________________in the body. Because lithium is a form of a salt, the body sees the medication as sodium and retains the medication over the sodium chloride ions. The sodium chloride ions are excreted, which causes the serum sodium level to be low. The client is at risk for_________________ because of the lithium being retained. A client who is prescribed lithium needs to understand the importance of ___________________–
toxicity; sodium balance; adequate sodium and fluid intake in the diet.
Lithium is a mood stabilizing agent that stimulates neuronal growth and reduces brain atrophy in people with long-standing mood disorders. It is prescribed for clients with bipolar disorder, specifically to help control manic episodes. The nurse should assess renal function, as well as electrolyte levels. A sodium deficit causes more lithium to be reabsorbed and increases the risk of lithium toxicity. The nurse should also observe for the presence of a metallic taste, hand tremors, nausea, polyuria, polydipsia, diarrhea, muscular weakness, fatigue, edema, and weight gain. Review recent laboratory tests to determine lithium level.
What to remember about dehydration in the older client
Older adults are at increased risk for dehydration due to age-related changes such as decreased thirst sensation. They are also more sensitive to fluid status alterations and decreases in cardiac output, as their compensatory mechanisms are not as efficient in comparison to younger adults.
In the older adult client, signs may be subtle, such as confusion or mood changes. Dehydration results in decreased cardiac output. The heart rate speeds up to compensate for decreased intravascular volume and decreased filling of the heart.
If IV fluid replacement is prescribed, the nurse closely monitors the client for signs and symptoms of fluid volume overload, including changes in lung sounds (such as crackles or rhonchi), which may indicate pulmonary edema.
Causes of dehydration include inadequate fluid intake, diarrhea, vomiting, and disorders that result in fluid losses (e.g. diabetes mellitus, diabetes insipidus, fluid shifts, burns, and hemorrhage). Certain medications, such as diuretics, may cause dehydration. Signs and symptoms of dehydration include thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy. Treatment includes oral or IV fluids and electrolyte replacement. Evaluate the client’s response to fluid therapy by monitoring urine output, lung sounds, blood pressure, and heart rate.
For the client diagnosed with dehydration, laboratory testing may include blood and urine chemistry, urine specific gravity, complete blood count, and serum osmolality.
What to remember about diabetes and foot care
The nurse is aware that diabetes mellitus is a chronic disease that can adversely affect the blood vessels and nerve endings. Because the amount of glucose in the bloodstream alters the integrity and function of both blood vessels and nerve endings, the client is at risk for accidental injury. Foot care is a priority for these clients since the feet are one of the first locations for an alteration in perfusion and sensation to occur. Because of this, the client with diabetes mellitus should be instructed to wear appropriate footwear at all times. Walking barefoot increases the client’s risk for a potentially life-threatening injury.
Clients with diabetes mellitus experience problems with their feet because of vascular disease, neuropathy, and infection. In diabetes mellitus, circulation is compromised by the development of atherosclerosis, changes in the arterial walls, and changes in smaller vessels such as capillaries. These changes lead to impaired circulation and changes in capillary membranes, thus causing destruction of the myelin sheath and impaired nerve conduction. Educating diabetic clients about proper footwear (avoid walking barefoot at all times) and foot care can help prevent costly and painful complications. The client needs to inspect the feet daily and avoid using over-the-counter chemicals such as hydrogen peroxide on the feet.
In addition, the client needs to avoid placing heating pads or ice packs on feet and applying lotion between toes.
Toddlers and psychosocial development and picky eating
Psychosocial development theory states that a toddler must master autonomy or experience shame and doubt.
The parents should provide opportunities for the child to demonstrate independence.
A toddler may be testing and exerting independence by refusing to eat certain foods. Offering finger foods is one way to help support the child’s independence, while ensuring an adequate nutritional intake.
Finger foods will help the child establish autonomy and encourage independence.
Additionally, the parents should provide positive reinforcement for good behavior, distract the child from unsafe or unwanted behaviors, keep routines simple and consistent, set reasonable limits, give simple rationales, limit selections to two when providing choices, and follow through on discipline.
The nurse instructs a client about the care of a new colostomy. Which information does the nurse include? (Select all that apply.)
- Change the ostomy appliance following a meal.
- Use a moisturizing soap to clean skin around stoma.
- Place tissue on stoma when changing the appliance.
- Cut the skin barrier 1/8 inch larger than the stoma.
- Empty the pouch of stool before removing the appliance.
- Check stoma for color, size, and shape.
1) INCORRECT - The ostomy appliance needs to be changed first thing in the morning or 2 –4 hours after a meal. The client should avoid changing the appliance following a meal, for this stimulates bowel evacuation.
2) INCORRECT - The client needs to avoid using moisturizing soap to clean the skin around the stoma, for it will interfere with the adhesive of the skin barrier.
3) CORRECT— The client should place tissue on the stoma when changing the appliance, for this will absorb stool and prevent stool from contacting the skin.
4) CORRECT— The client needs to cut the skin barrier no more than 1/8 inch larger than the stoma. This will allow the stoma to expand and prevent stool from contacting peristomal skin.
5) CORRECT— The client needs to empty the pouch of stool before removing the appliance. This will prevent contact of stool to the client’s skin.
6) CORRECT— The client needs to check the stoma for color, size, and shape. This will ensure adequate blood flow to the stoma.
Upper right quadrant pain is felt with ________________heart failure.
right-sided
When the right side of the heart loses the ability to pump, blood backs up into the veins causing edema in the abdomen, GI tract, and liver, eventually leading to ascites
The client with heart failure will typically have signs of biventricular failure (right and left-sided symptoms). Other manifestations of left-sided heart failure include ____________________________________________The nurse should anticipate giving the client diuretics, digoxin, antihypertensive, and inotropic agents.
pulmonary edema, S3 heart sound, pleural effusion, changes in mental status, and frothy pinkish sputum.
The nurse assesses several newborns after delivery. Which findings are anticipated by the nurse during the physical examination? (Select all that apply.)
- Respiratory grunting.
- Head circumference 13 in (33 cm).
- Respiratory gasping.
- Irregular respiration.
- Chest circumference 10 in (25 cm).
View Explanation
1) INCORRECT - Grunting is an abnormal finding. It indicates respiratory distress.
2) CORRECT—Normal head circumference is 13 to 14 in (33 to 35 cm).
3) INCORRECT - Gasping is an abnormal finding. It indicates respiratory depression.
4) CORRECT—Irregular respiration is a normal finding. However, a period of apnea > 20 seconds or with a change in heart rate or color is abnormal and indicative of respiratory depression, sepsis, and/or cold stress.
5) INCORRECT - This is an abnormal finding. Normal chest circumference is 12 to 13 in (30.5 to 33 cm).
The infant ’s lungs may sound “wet ” immediately after delivery as fluid is gradually absorbed. Tachypnea, retractions, nasal flaring, and grunting indicate respiratory distress. A smaller-than-average thorax measurement might indicate pulmonary hypoplasia or a neuromuscular disorder.
After delivery, the infant ’s Apgar score is evaluated at the 1 minute and 5 minute mark. An Apgar score between 7 and 10 indicates that the newborn is in good condition, whereas a score between 4 and 7 suggests that the newborn requires intervention, often in the form of stimulation. An Apgar score below 4 indicates that resuscitation measures need to be implemented. The normal newborn weight is 6 to 9 pounds (2700 to 4000 grams), and the normal newborn length is 19 to 21 inches (48 to 53 centimeters). The normal newborn temperature is 97.7 to 99.7 °F (36.5 to 37.6 °C), the normal respiratory rate is 30 to 60 breaths per minute, and the normal blood pressure is 65/40 mm Hg in the arm and calf.
What to remember about CVP
what does a increased and decreased CVP represent
central venous pressure (CVP) is used to assess the heart’s response to the body’s fluid volume. When preparing to assess CVP, the nurse needs to mentally review the procedure and the meaning of assessment findings. The nurse needs to know CVP determines the pressure within the vena cava and right atrium, which measures the venous return to the heart. It is through this measurement that a client’s fluid balance can be determined; low measurements indicate low fluid volume (shock), and high measurements are indicative of fluid overload (heart failure).
Content Refresher
Central venous pressure (CVP) is the measurement of blood pressure in the right atrium and vena cava. The CVP represents the volume of blood that returns to the heart and the ability of the heart to pump blood back into the arterial system. A normal reading is 2 to 6 mm Hg. An elevated CVP is a sign of fluid volume overload, heart failure, positive pressure breathing, and straining. A decreased CVP is a sign of hypovolemic shock and dehydration. The treatment for a client is dependent on the specific CVP value and the corresponding clinical disorder.
The nurse prepares to measure a client’s central venous pressure (CVP). Which parameter is measured by the CVP?
- Pulmonary artery pressure.
- Right atrium pressure.
- Cardiac output.
- Left ventricle pressure.
1) INCORRECT– The Swan-Ganz line measures pulmonary artery pressure.
2) CORRECT– Right atrium pressure is determined by blood volume, vascular tone, and the action of the right side of the heart. It is obtained from the CVP line.
3) INCORRECT– The Swan-Ganz line measures cardiac output.
4) INCORRECT– The Swan-Ganz line measures left ventricle pressure.
Clients who are prescribed a monoamine oxidase inhibitor (MAOI) are at risk for a___________________– crisis if foods containing tyramine are consumed.
What are these foods ? What are S/S of hypertensive crisis ?
hypertensive
Those foods include aged cheese, bologna, liver, pepperoni, salami, figs, yogurt, sour cream, yeast, pickled products, bananas, raisins, beer, and wine.
This client should be monitored for symptoms of a hypertensive crisis, which include severe headache, dizziness, fatigue. sweating, palpitations, stiff neck, and intracranial hemorrhage.
Phenelzine sulfate is a potent inhibitor of monoamine oxidase (MAO). Clients who are prescribed this classification of medication must be taught to avoid foods that contain ____________-due to the risk for a ________________
tyramine; hypertensive crisis
Disseminated herpes zoster requires both __________ and ________________-precautions.
airborne and contact
The Centers for Disease Control and Prevention (CDC) recommends that if a client is immunocompetent with disseminated herpes zoster, then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted. Health care facilities should ensure that all health care workers have evidence of immunity to the varicella-zoster virus (VZV). This measure prevents VZV and nosocomial spread of VZV. A health care worker’s immunity to VZV should be documented and readily available in the workplace. The health care worker who lacks evidence of immunity should receive teaching about the risks of possible infection and offered two doses of varicella vaccine (administered 4 to 8 weeks apart).
Shoes with thin, nonslip soles are the safest to prevent falls.
The client should avoid slippers and athletic shoes with deep treads.
TRUE OR FALSE
TRUE
What to remember about St. John’s wort
The Food and Drug Administration (FDA) does not recommend use of St. John’s wort for the treatment of any mental or physical condition. St. John’s wort is an unregulated supplement that may interact with many medications.
Nutritional supplements are not intended to treat any medical condition. Even so, clients may add St. John’s wort to their health regimen as an adjunct to treatment for a variety of conditions, including mild to moderate depression and sleep disorders. Clients may also take St. John’s wort to promote skin and wound healing. Side effects include fatigue, photosensitivity, allergic reactions, and restlessness. Check the client’s prescribed medications and additional supplements for incompatibilities and interactions. St. John’s wort is contraindicated for clients diagnosed with major depression and transplant recipients. Additional contraindications include concurrent use of selective serotonin reuptake inhibitor (SSRI) medications, monoamine oxidase inhibitor (MAOI) medications, and hormonal contraceptives.
What to remember regarding intraabdominal pressure and abdominal aortic aneurysm
The client with an abdominal aortic aneurysm (AAA) must be taught to avoid all types of straining and any activities that increase systemic blood pressure. Avoiding constipation, and the associated straining that may occur during a bowel movement, is an important part of the client’s plan of care. An unrepaired AAA can obstruct sections of the intestines, resulting in constipation. Performing the Valsalva maneuver to forcefully defecate a hard or firm stool causes sudden pressure changes across the abdominal aortic wall, potentially causing a life-threatening rupture.
Instruct the client not to lift heavy objects, which may increase intra-abdominal pressure and lead to rupture of the aneurysm.
The modified Trendelenberg position is contraindicated because it increases pressure in the aortic artery, which may increase the risk of rupture.
Increasing intake of fiber and fluid prevents constipation and the need for straining with bowel movements. This increased intra-abdominal pressure presents a risk of rupture.
