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.
