QB 10 Flashcards

Question

What is SIRS ? What is the criteria ?

Answer 1

Systemic inflammatory response syndrome (SIRS) is an e**xaggerated 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, t**he 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**

Answer 2

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.

Answer 3

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

Answer 4

heart failure

Answer 5

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.

Answer 6

4; At 2 months of age, an infant should demonstrate a social smile 6

Answer 7

**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.**

Answer 8

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.

Answer 9

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.

Answer 10

**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.

Answer 11

**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.

Answer 12

**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.

Answer 13

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.**

Answer 14

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.

Answer 15

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.

Answer 16

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.

Answer 17

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.

Answer 18

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.

Answer 19

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.

Answer 20

**Tachypnea, along with confusion and tachycardia,**

Answer 21

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? 1. Administer the medication as prescribed. 2. Validate the prescription with the HCP. 3. Ask the client if this is the usual daily dosage. 4. 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.

Answer 22

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.

Answer 23

Blood administration is the the delivery of whole blood or blood components through an intravenous (IV) line into a vein. T**ransfusion 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.

Answer 24

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.

Answer 25

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 clien**t. 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.

Answer 26

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.

Answer 27

TRUE this medication should be held for 48 hours before and after the procedure to avoid an interaction with the dye

Answer 28

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.

Answer 29

TRUE Pain re-assessment is expected after the administration of pain medicine.

Answer 30

**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.

Answer 31

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.**

Answer 32

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.

Answer 33

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.

Answer 34

An enlargement of the veins within the scrotum. ## Footnote 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.

Answer 35

**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.

Answer 36

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.

Answer 37

A normal heart rate for an infant is **120 to 140 (resting).** Bradycardia is a rate below 80 to 100 beats per minute

Answer 38

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.**

Answer 39

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. T**he goal of this nursing intervention is to prevent the air embolism from entering the lungs or brain, which can cause life-threatening complications.**

Answer 40

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.

Answer 41

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.

Answer 42

A hormone-secreting tumor that can occur in the adrenal glands. ## Footnote **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. I**t results in the release of too much epinephrine and norepinephrine, hormones that control heart rate, metabolism, and blood pressure**

Answer 43

The nurse provides care for a client scheduled for an adrenalectomy to treat pheochromocytoma. For which symptom will the nurse monitor the client first? 1. Hypertension. 2. Urine glucose. 3. Intake and output. 4. 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.

Answer 44

**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.

Answer 45

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

Answer 46

root cause analysis. This is a process whereby every step is studied in order to determine the reason for the client outcome.

Answer 47

shakiness, hunger, nervousness, poor concentration, sweating, tachycardia, and palpitations.

Answer 48

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.**

Answer 49

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.

Answer 50

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.**

Answer 51

TRUE The nurse must assess distal pulses, skin color, and skin temperature to ensure the bandage is not too tight.

Answer 52

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.

Answer 53

The nurse reviews the laboratory results for a client taking lithium. Which client finding will the nurse immediately report to the health care provider? 1. Serum sodium 125 mEq/L (125 mmol/L). 2. Lithium level 1.2 mEq/L (1.2 mmol/L). 3. Thyroxine T4 4.5 mcg/dL (57.9 nmol/L). 4. 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.

Answer 54

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.

Answer 55

**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.

Answer 56

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.**

Answer 57

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.

Answer 58

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.

Answer 59

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

Answer 60

pulmonary edema, S3 heart sound, pleural effusion, changes in mental status, and frothy pinkish sputum.

Answer 61

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.**

Answer 62

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.

Answer 63

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.

Answer 64

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.**

Answer 65

tyramine; hypertensive crisis

Answer 66

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).

Answer 67

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.**

Answer 68

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.