QB 5 Flashcards
What is the scope of nursing practice for the LVN/LPN?
They cannot make clinical judgements, partake in nursing assessment or provide client teaching
They cannot EAT (Evaluate, Assess, Teach)
Can only take care of Stable Patients Predictable Outcomes (SPPO)
How is calcium regulated in the body ? Whate is calcium needed for ?
What other electrolyte has an inverse relationship to calcium levels ?
What are risk factors for developing hypocalcemia ?
What two signs indicate positive hypocalcemia ?
Calcium levels are regulated by the parathyroid hormone, calcitonin and calcitriol.
Calcium is required to maintain normal cardiovascular, musculoskeletal, and neurological functioning; extremes in calcium level will affect these body systems
Feedback mechanisms regulate calcium levels, and hormones increase or decrease calcium levels as needed. Bones rely on adequate absorption of calcium to maintain stores. Serum phosphate is inversely related to calcium. Calcium is also necessary for adequate cardiac output. Risk factors for developing hypocalcemia include surgical removal of the parathyroid glands, older age (decreased intake of calcium, decreased exposure to sunlight, and immobility), lactose intolerance, and alcoholism. Diagnostic testing includes monitoring electrolytes, specifically calcium and phosphorus. The nurse needs to assess for Chvostek and Trousseau signs, which indicate hypocalcemia is present.
Carpal spasms that occur after inflation of a blood pressure cuff on the arm indicate positive ____________sign and possible ________-calcemia.
Trousseau; hypocalcemia
An occlusion in the pulmonary arteries from a blood clot, fat or air embolus, or other tissue. Most arise from a deep venous thrombosis (DVT) in the lower leg. It obstructs blood flow in the lung and may cause profound shock and death if not diagnosed and treated effectively.
Pulmonary Embolism
Name at least 3 clinical symptoms of Pulmonary Embolism
Chest wall Pain, Dyspnea, Hypoxemia,
cough, tachypnea, confusion, hemoptysis, crackles, and wheezing. Massive pulmonary embolism may cause sudden hypotension and shock
What to remember about Cataracts
This is partial or total opacity of the normally transparent lens of the eye. It occurs gradually. It causes blurry vision because the cataract scatters and blocks the light as it passes through the lens
With a cataract, the pupil changes from black to gray to milky white.
The nurse informs the client that as the cataract continues to develop, the clouding becomes denser and involves a bigger part of the lens. Sharply defined images will not reach the retina as the cataract scatters and blocks the light as it passes through the lens. This results in blurred vision. Cataracts often develop in both eyes, but the cataract in one eye may be more advanced. As a result, visual acuity in the left eye may be better than visual acuity in the right eye (or vice versa). It is important for the nurse to teach the client about safety measures and how to navigate activities of daily living with diminished vision.
Stages of Heart Failure
Stage 1 - There is cardiac disease but no symptoms and no limitation in ordinary physical activity
Stage 2: MIld symptoms present and slight limitation during ordinary activity
Stage 3: Significant limitation in activity due to symptoms. Comfortable only at rest
Stage 4: Severe limitations. Symptoms even while at rest
Name at least 3 goals for the client with heart failure
Maintain adequate systemic perfusion
improve and preserve cardiac contractility
Decrease systemic vascular resistance
Prevent CV complications (MI and dysrhythmias)
prevent complications related to organ system damage (e.g. kidney failure);
preventing or resolving fluid volume overload;
promoting healthy lifestyle changes
providing client education.
What is dehiscence ?
Dehiscence is a surgical complication where the edges of a wound no longer meet. It is also known as “wound separation.” A healthy, healing wound will have edges that meet neatly and are held closely together by sutures, staples or another method of closure.
What is a fistula ?
Name 3 factors that increase the risk of their development
Abnormal passages from one organ to another. Two organs are physically communicating in a way they should not.
Factors that increase risk for fistula development include malnutrition, infection, surgery, and cancer.
Fever and pain may be the initial presentation of a fistula. Additionally, assessment findings vary depending on the origin of the fistula. Generally, unanticipated drainage is noted in an area that does not ordinarily drain body fluids.
Treatment varies depending on the size, location, and cause of the fistula.
Small fistulas may heal with support for infection and nutrition. Larger fistulas may require surgical intervention. The nurse should address nutritional needs, fluid and electrolyte needs, and pay attention to wound healing and drainage.
During pregnancy, when does the nurse expect to palpate fetal movement ?
After 18 weeks gestation
No fetal movement by 20 weeks requires health care provider intervention.
Fetal development is characterized by physiological growth and development that takes place over approximately 40 weeks. The first 8 weeks of development is called the embryonic stage. By the end of this stage, all essential external and internal structures have been formed.
Prenatal development is most dramatic during the remaining 32 weeks, the fetal stage.
Organ systems continue to develop and grow. The heart is beating and the lungs have developed sufficiently that breathing is possible. During this stage, the fetus becomes more active, and the mother begins to feel fetal movements. Towards the end of this stage, organ systems have matured and the fetus is ready to live outside the womb.
What is ballotment in pregnancy?
During the fourth to fifth month, the fetus should rise and then rebound to the original position when the nurse taps sharply on the abdomen.
When should the nurse be able to hear the fetal heart rate ?
The nurse should be able to hear the fetal heart rate at 110 to 160 beats/min with Doppler at 10 to 12 weeks of gestation.
What should we remember about intestinal obstruction
Occurs when the intestinal contents cannot pass through the GI tracts - can occur in small or large intestine, can be complete or incomplete. Can be mechanical (physical occlusion of lumen) or nonmechanical (neuromuscular or vascular disorder or insult) - nonmechanical is also referred to as a parylytic ileus (the absence of peristalsis with no bowel sounds)
Assessment: nausea/vomiting high pitched bowel sounds above obstruction; absent or decreased bowel sounds below. Abdominal pain and distension “colicky”, absence of stool or gas (obstipation)
Implementation: Intestinal decompression
NPO
Fluid/electrolyte replacement
(if the obstruction is high in the gastrointestinal tract, client is more likely to have metabolic alkalosis. If obstruction is low in the GI tract, client is more likely to have metabolic acidosis.)
Fowler’s position
Sometimes emergency surgery must be performed: exploratory laparatomy, resection & anastomosis, abdominal perineal resection
The client who is post-laparotomy is best served by resting the bowels and is limited to ice chips or clear liquids. Early introduction of oral medication, food, or laxatives can precipitate an intestinal obstruction.
what are 3 risk factors for intestinal obstruction
Postoperative procedures for intestinal obstruction
Risk factors for intestinal obstruction include intra-abdominal adhesions, hernias, Crohn and other inflammatory bowel diseases, malignancies, volvulus, ileus after abdominal or pelvic surgery, previous radiation therapy, tuberculosis, and parasitic infections
Maintain NPO status until peristalsis returns. Insert and maintain suction through a gastric tube as prescribed. Administer IV fluids as prescribed. Frequently assess peripheral pulses, skin color, temperature, urinary output, and capillary refill for signs of hypovolemic shock. Assess for changes in pain, bowel sounds, vomitus, and flatus.
After abdominal surgery, trapped air can cause gas pains. Ambulation is the best way to help this gas to move out of the body via the rectum. Assisting the client with ambulation as prescribed promotes peristalsis and helps “wake up ” the bowels.
An NG tube would be in place after the procedure until peristalsis resumes. When the client is able to take food by mouth, a clear liquid diet is prescribed.
What is an ileus?
Ileus is the medical term for this lack of movement somewhere in the intestines that leads to a buildup and potential blockage of food material. An ileus can lead to an intestinal obstruction. This means no foo
What is a premature ventricular contraction ?
A premature ventricular contraction is caused by one or more ectopic foci that stimulate a premature ventricular response. This contraction may decrease the efficiency of the heart. The client may complain of palpitations, a feeling of an irregular heartbeat, or a “lump in the throat.”
How do we assess the inner ear in a child under 3 years of age ?
What about 3 years of age and over
In the child under 3 years of age, we should pull the pinna of the ear down and back
Over 3 years of age, we should pull the pinna up and back.
Young children with otitis media may exhibit
irritability, problems feeding or sleeping, pulling or tugging at the ear, fever, vomiting, and drainage from affected ear.
To assess the inner ear, the pinna is pulled down and back if the child is under 3 years of age. For children over 3 years of age and adults, the pinna is pulled up and back.
To prevent injury, the uncooperative child will need to be properly restrained before examining the client’s inner ear with an otoscope. Examine the color of the tympanic membrane, which is normally translucent, shiny, and pearly gray in color. If otitis media is diagnosed and antibiotics are prescribed, instruct the parent/caregiver to administer the full course of antibiotics, even after symptoms abate.
Thyroidectomy and an important complication to remember
When the thyroid gland is removed, there is a risk of accidentally removing or injuring the parathyroid glands. These glands help with calcium balance in the body. If removed or injured, calcium balance is affected. Numbness in the fingers is a symptom of hypocalcemia.
Content Refresher
Removal of the parathyroid glands may occur with removal of the thyroid gland since they are embedded in the thyroid tissue.
The nurse needs to assess electrolytes, specifically calcium and phosphorus, if the parathyroid glands are removed. Assess for Chvostek and Trousseau signs indicating hypocalcemia is present.
Other manifestations of hypocalcemia are numbness in the fingers; tingling around the mouth, nose, and toes; and muscular twitching. Supplemental doses of electrolytes may be prescribed as needed.
What to remember about internal radiation implants
for nurses and
For clients
These are used to treat a malignant lesion within the body
- Nurses should adhere to principles of Time, Distance & Shielding
- No more than 30 minutes in the room during each 8 hour shift
- Dosimeter film badge should be worn
- provide organized and efficient care so you don’t have to enter room too many times
- Long handled forceps and lead container should be kept in room in case implant becomes dislodged
Client will be on bedrest to prevent dislodging the implant. Will also be given enemas to prevent dislodging by straining during a bowel movement. Low residue diet (Bowel movements can dislodge the radium implant. This diet will decrease the amount of stool and number of bowel movements), plenty of fluids, and an indwelling catheter, fracture pan used
The position of the applicator should be checked every 8 hours.
What is the goal of a low residue diet ?
It limits high-fiber foods, like whole-grain breads and cereals, nuts, seeds, raw or dried fruits, and vegetables. “Residue” is undigested food, including fiber, that makes up stool. The goal of the diet is to have fewer, smaller bowel movements each day
Name at least 5 risk factors for stroke occurence
Diabetes, hypertension, family history, cardiovascular disease, atrial fibrillation, increasing age, hyperlipidemia, obesity, smoking, previous cerebrovascular accident (CVA) and substance abuse (e.g., alcohol and cocaine)
African American race, male gender, and substance abuse, which includes illegal drugs, smoking, and alcohol.
Diabetes is a well-established risk factor for stroke. It can cause pathologic changes in blood vessels at various locations and can lead to stroke if cerebral vessels are directly affected. Additionally, mortality is higher and poststroke outcomes are poorer in patients with stroke with uncontrolled glucose levels.
Blood vessels damaged by high blood pressure can narrow, rupture or leak. High blood pressure can also cause blood clots to form in the arteries leading to your brain, blocking blood flow and potentially causing a stroke.
Hemorrhagic strokes are caused by bleeding in the brain. Several mechanisms have been proposed to explain why oral contraceptives increase stroke risk, including by raising blood pressure and by making blood hypercoagulable (more likely to clot).
What to remember about nutrition during pregnancy and lactation
Nutrition during Pregnancy- recommended weight gain is 24-28 pounds
- Folic acid is needed to prevent neural tube defects and anemia
- Pregnant women should receive a supplement of 30 mg of ferrous iron daily, starting by 12 weeks’ gestation. The recommended daily intake for pregnant women is 60 mg/day, as opposed to the 30 mg/day recommended for adult women.
- because cell growth is rapidly occurring during pregnancy, pregnant women should be encouraged to consume good sources of zinc daily.
There are no additional caloric requirements for the first trimester of pregnancy. During the second trimester of pregnancy, the recommended caloric intake is 340 kcal/day greater than the pre-pregnancy needs. During the third trimester, the amount is 462 kcal/day greater than pre-pregnancy needs.
Each day, pregnant women need to eat at least three servings of protein, six or more servings of whole grains, five or more servings of fruits and vegetables, and three or more servings of dairy products. The diet should also consist of eating foods with essential fats, taking daily prenatal vitamins, and drinking at least eight glasses of water per day. Pregnant women should be counseled to avoid alcohol, excessive caffeine, raw meats and seafood, high-mercury fish, uncooked or processed meats, and unpasteurized dairy products.
Nutrition during Lactation - recommended diet increase of 500 calories per day
An abnormal rise in body temperature above 38℃ (100.4℉)
Fever
Individuals who are at risk for complications associated with fever are children and older adult clients. For diagnostic purposes, fever patterns need to be assessed since patterns vary based on the causative agent. There are four fever patterns: sustained, intermittent, remittent, or relapsing. As older adults may show atypical signs of infection, mental status should be regularly assessed as well.
How does an infection often present in the older adult ?
Manifestations of infection in an older adult client are not the same as those seen in young adult or middle-adult clients. The most common indication of an infection is a change in mental status. Because of changes in immune status, an older adult client may not develop a fever in the presence of an infection.
In the older adult client, fever may be absent even when bacteremia or pneumonia is present. The baseline temperature in the older adult population is low. An oral temperature of 100°F (37.8°C) or greater (or an increase of 1.4°F or 0.6°C or more in baseline temperature) should cause the provider to suspect infection.
To effectively plan client care, the nurse must know the client’s ________________.
baseline health status
he plan of care has, as its central goal, the client’s return to the desired functional status or state of being. Client goals should be measurable and realistic. For example, if the client typically requires the use of a wheelchair, anticipating the client’s ambulation upon hospital discharge likely is an unrealistic goal. If the client engaged in gardening, mowing the lawn, and tending to grandchildren prior to the acute illness, the nurse would not anticipate the client’s need for a referral to a long-term care facility unless some debilitating event or major change in health status has occurred.
Content Refresher
The older adult population faces multidimensional problems that affect health and quality of life. Therefore, older adult care delivery requires strategies to attain the highest possible level of quality functioning. For the hospitalized older adult client: Assess changes in body systems and organs related to aging and resulting from disease. Assess visual, hearing, and cognitive problems that may interfere with daily life. Assess losses in taste and smell that may lead to poor nutrition. Assess mental health. Assess for impediments to mobility. Provide training to improve muscular strength, balance, and reaction time. Teach cognitive enhancement strategies, accident and fall prevention, and provide education on nutrition.
What is the main focus in clients with an external fixator ?
Neurovascular assessment is the main focus in clients with an external fixator.
This includes monitoring for the color, temperature, capillary refill, peripheral pulses, paresthesia, and edema on the affected extremity. Motor function should be evaluated at frequent intervals (e.g., dorsiflexion and plantar flexion), unless contraindicated. Both sides should be assessed and compared. The nurse should note that partial or full loss of sensation is a late sign of neurovascular impairment
What are the 6 P’s of compartment syndrome ?
Pallor, paresthesia, pain, pulselessness, pressure, paralysis
Compartment syndrome results from swelling and increased pressure within a muscle compartment. The fascia surrounding the muscle has limited ability to stretch, so as swelling continues, the function of blood vessels and nerves within the compartment are compromised. Trauma, fractures (especially of long bones), extensive soft tissue damage, and crush injuries are usually associated with compartment syndrome.
Characteristics of Compartment syndrome
Unrelenting pain is a characteristic of compartment syndrome.
Parethesia is a characteristic of compartment syndrome.
Cold and edematous extremity are characteristics of compartment syndrome.
An alteration in pulse strength in the affected extremity is a characteristic of compartment syndrome.
1 mL = ______________oz
30
What is Ergocalciferol ?
Vitamin D2 supplement
As a supplement it is used to prevent and treat vitamin D deficiency.
. Ergocalciferol (vitamin D 2) is often taken in low doses as a supplement, but doses up to 200,000 units are used for hypoparathyroidism and doses up to 500,000 units daily are used for clients with rickets.
What to remember about transdermal nicotine patches - specifically the risks of smoking while wearing one
A nicotine patch assists the client with smoking cessation, because the patch provides a steady level of nicotine. The patch can be used up to 8 weeks. Teach the client common side effects of the nicotine patch (e.g. transient itching, burning, redness at patch site, insomnia, nausea, and headache). Instruct the client to rotate sites to reduce skin irritation.
Nicotine causes vasoconstriction, so the use of multiple forms of nicotine can dangerously increase the client’s blood pressure and lead to a myocardial infarction.
Clients who use the nicotine patch should be advised not to smoke while wearing the nicotine patch. Smoking while wearing the nicotine patch can cause serious complications, including myocardial infarction.
It is important for the nurse to inform the client that smoking while wearing the patch causes nicotine overdose. The nurse should also inform the client of the signs and symptoms of nicotine overdose such as, nausea, vomiting, dizziness, weakness, and rapid heartbeat.
The nurse has the responsibility to understand that the nicotine patch reduces nicotine cravings associated with smoking cessation by providing the client with nicotine.
This maneuver is used to open the airway in a person with a suspected cervical spine injury
Jaw Thrust Maneuver
Do not use head tilt-chin lift when cervical injury is suspected because it hyperextends the neck and can further compromise cervical injury
Redesigning positions is a major task that should be completed by the nurse manager with____________________-Delegating the redesigning of positions to the nursing staff is not appropriate since the staff most likely does not have the knowledge and expertise to complete the task.
input from the staff.
The nurse manager should use the expertise of all staff members. This decision impacts everyone and the decisions should be as collaborative as reasonable.
What is Myasthenia Gravis ?
A systemic disorder of nerve impulse transmission due to a deficiency of acetylcholine
Muscular Weakness produced by repeated movement that soon dissapears following rest, Diplopia, Ptosis, Dysphagia, respiratory distress
Our number one priority is to prevent choking and aspiration
We also want to provide good eye care - artificial tears, a patch if they are experiencing double vision, and a restful environment
Medications include anticholinesterases, corticosteroids and immunosup
the client may have ptosis (drooping of the eyelids), and one or both eyelids may not close completely. Instillation of artificial tears as prescribed is especially important for clients who experience incomplete closure of the eyelids. To prevent corneal abrasion and other eye injuries, the client also may tape the eyelids closed for short intervals.
corticosteroids cause serum glucose to increase,
TRUE OR FALSE
TRUE
What is the Somogyi effect ?
characterized by a normal or elevated blood glucose at bedtime, hypoglycemia between 0200 and 0300, and a rebound hyperglycemia in the morning.
A rebound phenomenon that occurs in clients with Type 1 diabetes. Normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at about 2-3 AM. Counterregulatory hormones, produced to to prevent further hypoglycemia, result in hyperglycemia. (evident in the prebreakfast blood glucose level) Treatment includes decreasing the evening (predinner or bedtime) dose of intermediate-acting insulin or increasing the bedtime snack.
What is the Dawn phenomenon ?
Characterized by hyperglycemia upon morning awakening that results from excessive early morning release of GH and cortisol
Treatment requires an increasein the clients insulin dose or a change in the time of insulin administration
