BoardVitals Physiological adaptation
A 65 year old male client presents to the clinic and states his wife thinks he has a prostate issue. Which of the following statements indicates that the client is experiencing the most common symptoms of benign prostate hypertrophy (BPH)?
"I wake up many times during the night to urinate" "my urine stream is the narrow" "lately, it feels like it takes more effort to urinate" -Because the prostate is enlarged additional pressure is put on the urethra as a result urine is retained in the bladder, causing clients to urinate more often or more urgently. When the gland is enlarged, the client may take notice it takes more effort to void, urinary stream is narrower and dribbling may occur.
A nurse is reinforcing teaching with the family of a client who has acute respiratory distress syndrome (ARDS) and is receiving vecuronium. The nurse should identify that which of the following statements by a family member indicates an understanding of the teaching?
"This medication is given to decrease resistance to the ventilator" -Vecuronium is a neuromuscular blocking agent used to produce skeletal muscle paralysis prior to endotracheal intubation and to reduce resistance to mechanical ventilation. Vecuronium is used to improve client/ventilator synchronization and to increase oxygenation in the client who has ARDS -Vecuronium causes apnea due to paralysis of the skeletal muscles. The nurse should never administer this medication to a client who is not receiving ventilator support.
What are cerebral neoplasms?
(commonly called brain tumors) A cancerous or noncancerous mass or growth of abnormal cells in the brain.
A nurse is reviewing their client assignment for the evening shift. Which of the following clients would be most likely to develop metabolic alkalosis?
*A client who uses excessive antacids *A client who takes a daily diuretic *A client who had been vomiting for four days -Metabolic alkalosis can be caused by the excessive LOSS of acids in the body or an increased amount of bicarbonate in the body. -Causes: excessive use of antacids, diuretic therapy, & loss of fluids through either GI suctioning or vomiting
A nurse is doing an intake assessment of a 50 yr old client in the clinic. The nurse sees the active diagnosis list from the medical record states the client has systemic lupus erythematous (SLE). The nurse knows which of the following is a common presentation with SLE?
A butterfly rash across the bridge of the nose and cheeks -This is a typical sigh of lupus
The nurse is caring for a client with pyelonephritis. The nurse recognizes that this is:
A renal disease brought on quickly due to inflammation or infection of the kidney -Pyelonephritis is an inflammation of the renal pelvis and parenchyma of the kidney, often due to infection
The nurse is trying to assess the nutritional status of a 47 yr old client. What factors should be considered when assessing nutritional status?
Albumin lvls Body mass index (BMI) A dietary history Weight -Evaluation of nutritional status should include one or more of the following: measurement of BMI and waist circumference, weight, laboratory values such as serum albumin and serum protein, as well as a comprehensive metabolic panel to assess electrolytes, clinical examination findings, and dietary history.
The nurse is caring for a client who is ordered to be on best rest for 4weeks. What should the nurse include in care planning for the client to prevent venous stasis?
Anti-embolism stockings to be worn at all times -Anti-embolism stockings along with sequential compression devices will aid the client in the prevention of deep vein thrombosis
A client complains to the nurse that she can't fall asleep. Which of the following is the least appropriate for the nurse to try as an initial intervention?
Call the physician to ask for a sedative -Non- pharmacological methods should be attempted to help the client relax and go to sleep before asking for medication. This is not appropriate as an initial intervention
In resuscitation of an infant, which of the following is true?
Chest compressions should be done 100times per min at minimum. -When performing cardiopulmonary resuscitation on an infant, you should perform 5 compressions to one breath or a minimum of 100 per minute. This is the same rate used in adults
The nurse is assessing body systems on a 86 yr old client. Which of the following are expected/typical age-related changes affecting an older adult's renal or urinary system?
Decreased bladder capacity Decreased glomerular filtration rate -Urinary incontinence is NOT a normal age-related change but is more common in older adults, especially in women, bc the loss of pelvic muscle tone.
The nurse is caring for an 86 yr old client and recognizes that there are expected change in older adults cardiovascular structure and function. What are age related changes that may occur in the older adult?
Decreased elasticity of the aorta Widening of the aorta -Changes in cardiovascular structure and function are observable in the aging heart and associated vessels. -For example, aging results in decreased elasticity and widening of the aorta, thickening or rigidity of the cardiac valves, ^ connective tissue in the SA and AV node, and an ^ left ventricular ejection time.
A nurse is reviewing the medical record of a client who has syndrome of inappropriate antidiuretic hormone (SIADH). which of the following findings should the nurse expect?
Decreased serum sodium Decreased serum osmolarity Decreased temp ^ urine specific gravity -SIADH is an endocrine disorder in which over-secretion of antidiuretic hormone (ADH) occurs resulting in retention of water. If not corrected SIADH can lead to fluid overload -SIADH can be caused by malignancies, CNS, or pulmonary disorders and as a result of some meds -TX includes: maintaining fluid restrictions, drug therapy with vasopressin antagonists and diuretics, replacing critically sodium lvls, and monitoring for complications.
A nurse is teaching an adolescent who has a growth hormone deficiency. What are complications of untreated growth hormone deficiency?
Delayed sexual development Short stature -The tanner staging system is used to determine sexual maturity
The nurse is providing care for a client who has right-sided weakness and has been instructed to use a cane when ambulating. Which action by the client indicates he understands correct use of the cane while walking?
He carries the cane in his left hand and moves it at the same time he moves his right foot -The cane should be held on the unaffected side. When ambulating, the client should move the cane and the affected leg at the same time.
A 54 yr old client is diagnosed with type 2 DM and prescribed medication to control high blood glucose. The nurse teaches them about the S/S of hypoglycemia. Which symptoms would mean the client needs to raise their blood glucose lvls?
Heart palpitations Diaphoresis Shakiness -Classic signs of hypoglycemia are shakiness, confusion, heart palpitations and diaphoresis. -Classic signs of hyperglycemia are sleepiness, thirst, blurry vision, and frequent urination. -Neurogenic symptoms are signs associated with elevated epinephrine lvls including shakiness, anxiety, nervousness, palpitations, sweating, dry mouth, pallor, and pupil dilation.
A nurse is assisting with admitting a child who have HIV. The nurse should identify which of the following findings as indications that the child is in the moderately symptomatic category(B)?
Herpes zoster Bronchitis Oral candidiasis -HIV is a viral infection that attacks the lymphatic system by altering the RNAA and DNA of the cells of the lymphocytes. The lymphatic system is responsible for ridding the body of infections. HIV causes a decrease in the CD4 count & makes the individual prone to infections. It is transmitted through blood and bodily fluids
Trouseau's sign is one of the clinical signs associated with:
Hypocalcemia
A 14 month old is receiving Digoxin and Lasix twice a day. In planning his care, the nurse should assess for which complication?
Hypokalemia -Clients who are prescribed digoxin and lasix are much more likely to experience hypokalemia and this lvl should be monitored closely
The nurse is caring for an older adult with elevated liver enzymes and direct bilirubin. The client is noted to have ascites & jaundice. Where is the best location to observe jaundice in a client what is black?
Inspecting the oral mucosa especially the hard palate -Baseline skin variations can be seen in the mucous membrane and nail beds
A nurse is preparing to perform suctioning on a unconscious client. which of the following positions should the nurse place the client?
Lateral position -When performing suctioning in an unconscious client, a lateral position should be given to allow the tongue fall forward, so that it will not obstruct the catheter on insertion. This position also facilitates drainage of secretions form the pharynx and prevents the possibility of aspiration
What is a vasovagal response?
Life-threatening reaction caused by contrast agent, may cause: bradycardia, loss of pulse and hypotension. -If the occurs, a code must be called immediately.
A nurse is caring for a 55 yr old client with an upper motor neuron lesion. What clinical manifestations would the nurse expect this client to exhibit?
Loss of voluntary control -Upper motor neuron lesions occur due to cerebrovascular accidents, traumatic brain or spinal cord injury, infections, inflammatory disorders, neurodegenerative disorders, or metabolic disorders. -S/S: weakness, spasticity, hyperreflexia, and loss of voluntary control.
The nurse Is caring for a 67 yr old client with suspected hypercalcemia. What signs and symptoms would the nurse expect to see in a client with hypercalcemia?
Muscle weakness Constipation -The high calcium lvls interact with sodium channels in the body which can cause diminished deep tendon reflexes and skeletal muscle weakness -This muscle weakness can also affect the GI tract, leading to constipation. -Other signs of hypercalcemia include: Hypertension, nausea/vomiting, abdominal distention, confusion or lethargy and bradycardia in the late stages of hypercalcemia
A clients physician has recommended that the client increased her daily intake of dietary iron. what menu selections would suggest to the nurse that the client understands the recommendations.
OJ, toast and scrambled eggs -The best food choices contain. Iron (eggs) and vitamin c (OJ) to ^ the absorption of iron.
A 69-year-old client is brought into the emergency room following a motor vehicle accident in which they sustain trauma to the head. The client is reporting a visual disturbance in the left eye. The nurse suspects the client had an injury to which of the lobes of the brain during the accident?
Occipital lobe -The occipital lobe is responsible for visual interpretation
CDC classification system for children with HIV Classification B characteristics:
Oral candidiasis, enlarged heart, pneumonia, herpes simplex virus (HSV), hepatitis, anemia, bronchitis, lymphoid interstitial pneumonia. (Moderate) child presents with manifestations of more serious illnesses or organ dysfunction
CDC classification system for children with HIV Classification A characteristics:
Persistent or recurring upper respiratory infections or otitis media, swollen lymph nodes, hepatomegaly, splenomegaly. (Mild) child presents with 2 or more of these symptoms
A nurse is collecting date form an adolescent who has scabies. In which area should the nurse expect to find lesions?
Popliteal folds -Scabies occurs between the fingers and in the axillary-cubital area, popliteal fold, and inguinal area. -Popliteal folds= a diamond-shaped space behind the knee joint. The inguinal region= sometimes called the groin, is the lower part of the anterolateral abdominal wall
A nurse reviews a clients lab repot and notes that the serum calcium lvl is 5.2 mg/dL (low). What would the nurse note on the electrocardiogram based on the lab value?
Prolonged ST interval -The normal serum calcium lvl is 8.6-10 in hypocalcemia the electrocardiogram changes are prolonged ST interval and prolonged QT interval.
The nurse reviews a 45 yr old clients lab values and notices the serum sodium level this morning is 129 mEq/L (ref range 135-145 mEq/L) what signs or symptoms could the nurse anticipate the client would show with this level of sodium?
Rapid pulse Weakness Confusion -Hyponatremia occurs when the serum lvl drops below 135 mEq/L. This is typically due to too much water in the body diluting the sodium. To compensate, water moves into the cell, causing them to swell. -Swelling causes hyponatremia's clinical S/S: Rapid & thready pulse, weakness, abdominal cramping, poor skin turgor, muscle twitching & seizures, apprehension and confusion. (You will see confusion, seizures, and muscle twitching in hypernatremia.
A nurse is assessing a 4 yr old child who presents with his parent for evaluation of a cough that kept the child up all night. What assessment findings suspect respiratory distress in a 4 yr old?
Restlessness Use of accessory muscles Sweating in a cool environment -Resp distress in the pediatric population can usually be identified in early stages by the inability to sit still, resp rate >32, non-productive coughing and inspiratory or expiratory wheezing, cool moist skin. -Signs of respiratory distress include, tachycardia, tachypnea, nasal flaring, retraction of accessory muscles, agitation, irritability, anxiety, pallor. -Late signs/Impending resp failure include: cyanosis, altered lvl of consciousness, apnea, and bradycardia (late sign).
A nurse is assessing a client who has rheumatoid arthritis. Which of the following manifestations should the nurse expect?
Swelling of bilateral joints Ulnar deviation Crepitus Morning joint stiffness -Rheumatoid arthritis is an autoimmune disorder affecting the synovial tissues and joints -Swelling, pain, warmth, erythema, and decreased function can occur in both wrists, asymmetric inflammation of a joint is related to osteoarthritis -Rheumatoid arthritis can result in deformities of the hand and feet, With ulnar deviation, the fingers deviate toward the ulnar bone -Changes in the joint and bone structure which result in the development of bone spurs, fissures and disintegration of the cartilage and bone, this disintegrated results in pieces of bone and cartilage floating in the synovial fluid, which can manifest as crepitus, or a grating sounds. -Morning joint stiffness presents upon arising and can last 1 or more hr. Osteoarthritis can also cause morning stiffness, but usually resolves in 30 mins or less.
Which of the following is a symptom of a vasomotor reaction to contrast agent?
Syncope -Vasomotor reaction include: anxiety, syncope, lightheadedness, and nausea -A vasomotor reaction is a nonallergic reaction that results primarily in anxiety based effects and emotional responses. -These reactions are not life-threatening and the patient should be reassured
Vital capacity definition:
The maximum volume of air exhaled from the point of maximum inspiration
A 54 yr old client is diagnosed with a small disc herniation that does not require surgical intervention. What conservative management measures will the nurse teach the client to implement?
To continue daily activity and exercise To apply a hot, moist compress to the back of the neck as tolerated To initiate physical therapy for strengthening and flexibility -A client with a cervical disc herniation would benefit from hot, moist compresses to increase blood flow and help relax spastic muscles -Normal daily activities and routine exercise should continue as tolerated -Physical therapy may be indicated to help pt's with strengthening and flexibility while enhancing safety and supervision.
A client arrived in the emergency department with a chemical eye injury. The initial nursing action will be to?
Use sterile saline to irrigate the eye -This should be done for at least 10mins to remove any chemicals from the eye.
What is cerebral anoxia?
lack of oxygen supply to the brain
What does RICE mean?
rest, ice, compression, elevation
A nurse is reviewing the medical record of a client who has osteoporosis. Which of the following findings should the nurse expect?
*A decrease in height of 5.1cm (2in) *Kyphotic curve at upper thoracic spine *Hx of lactose intolerance -Osteoporosis is a chronic metabolic disease. Bone loss results in a decrease in bone density and increases the risk for fractures. -Risk factors include: Family hx, current tobacco use, alcohol intake of three of more drinks per day, inactive/sedentary lifestyle, males over 60, females postmenopausal, inadequate calcium and vitamin D intake, low body mad index and Hx of bone fractures during adulthood.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. What information should the nurse include?
*An autoimmune response can trigger the onset of type 1 DM *Type 1 DM usually develops before 20 years of age *Regular exercise can reduce insulin requirements In clients who have type 1 DM -Viral infections or certain genetic links can trigger an autoimmune response that causes type 1 DM -Type 1 DM Is caused by lack of insulin that is due to the destruction of beta cells of the pancreas. It has a sudden onset with manifestations including Polyphagia, polyuria, polydipsia. -Type 1 DM is treated with insulin in addition to dietary changes and physical exercise
What best describes anisocoria?
*Refers to the unequal size of the pupils. It affects up to 20% of the population and is usually benign or represent a variety of medical conditions -When assessing a client with anisocoria, it's important to determine how long it has ben present. Pupils should be measured and reactivity to light and dark should be assessed. -Associated S/S such as diplopia, ptosis, and any neuron changes, will help the nurse determine the etiology
A nurse is caring for a client who has manifestations of dehydration while in the PACU, What findings should the nurse report to the provider?
*Urine output less than 25 mL/hr *Hematocrit 55% *BUN 30 mg/dL *Tenting of skin over the sternum -These are all manifestations of dehydration and requires IV fluid therapy -Fluid volume deficit can be caused by hypovolemia or dehydration. The nurse should report changes if fluid status of a postoperative client to the provider immediately.
Name the 6 QSEN competencies
1. Patient-centered care 2. Teamwork and collaboration 3. Evidence-based practice 4. Quality improvement 5. Safety 6. Informatics
A nursing instructor is teaching nursing students about the clinical manifestations of a cerebral neoplasm. What physiological changes can occur due to a growing cerebral neoplasm that start to infiltrate healthy tissue?
Altered pituitary function Increased intracranial pressure Seizures -The compression or infiltration into normal tissue causes the symptoms of cerebral neoplasms. This can result in Increased ICP, cerebral edema, seizure activity, headaches, visual disturbances, hydrocephalus, and altered pituitary function. In addition the skull & bran are sensitive to any changes in the brain volume, and growing neoplasm can cause shifts in the cerebral spinal fluid and increased ICP.
A 33 yr old female client comes to the clinic with a history of hypothyroidism and severe fatigue. The nurse is concerned about myxedema. Which of the following symptoms is the nurse likely to observe?
Amenorrhea Low body temp Decreased blood pressure Hoarse voice -Hypothyroidism occurs when there is insufficient secretion of the thyroid hormones, causing slower metabolism -Other symptoms include raspy voice, slow speech, lethargy, weight gain, thinning hair, and dry skin. -Myxedema is a severe form of hypothyroidism, if left untreated can be life-threating. -A hoarse voice is an expected symptom with myxedema. Voice changes are expected as the lack of thyroid hormone affects the laryngeal tissue.
A 46 yr old client is admitted with acute diverticulitis and is being cared for by a staff nurse and student nurse. The student asks the staff nurse what the signs of bowel perforation are. How should the staff nurse answer the student?
Elevated body temp -Bowel perforation is a medical emergency, and it requires immediate diagnosis and treatment. It occurs when there is a hole in the intestine that allows the contents of the intestine to leak into the abdominal cavity, leading to infect or sepsis. S/S of bowel or diverticular perforation include: Elevated white blood cell count, elevated sedimentation rate, increased body temp, tachycardia and hypotension.
The nurse is caring for a 43 yr old client with a peptic ulcer. The client asks the nurse what a peptic ulcer is. What best describes a peptic ulcer?
Erosion of the lining of the stomach -Peptic ulcer is the erosion of the lining of the stomach or intestine -The most common reasons for the breakdown of the lining of the stomach are: Infection with H. Pylori bacteria or long term use of NSAIDS -Common S/S include: burning or indigestion, nausea, weight loss -Inflammation of the lining of the stomach is gastritis -A GI bleed can be caused by an ulcer, but this is not always the case. Infection of the lining of the stomach can cause an ulcer.
A nurse is monitoring a postoperative client. The nurse should identify which of the following signs as an indication of potential complication?
Increasing restlessness -In the post operative period, restlessness can indicate hypoxemia, hemorrhage, or shock.
A nurse is reviewing the medical hx of a client who has Cushing's disease. The nurse should identify that clients who have this disease are at increase rick for which of the following conditions?
Infection Gastric ulcer Bone fractures -Suppression of the immune system places a client with Cushing's at risk for infection -Overproduction of cortisol inhibits the production of a protective mucus lining in the stomach and causes and increase in gastric acid and then puts the client at risk for gastric ulcers -Bone fractures occur bc decreased calcium absorption leads to osteoporosis -Cushing's is an endocrine disorder cause by ^ secretion of cortisol from the adrenal gland -Excess cortisol can lead to fluid and electrolyte imbalances, decreased muscle mass, osteoporosis, hyperglycemia, suppressed immune system and depression.
A client is feeling a burning sensation at the IV insertion site. When the nurse assesses the site, it is cold and swelling is present. The nurse determines which of the following occurred at the site?
Infiltration -Infiltration is manifested by pallor, coolness, and swelling at the IV site. Phlebitis, infection and thrombosis lead to warmth and redness.
A nurse is providing care to a client who has diabetic keto acidosis the nurse should expect which of the following manifestations?
Fruity breath odor Abdominal discomfort Kussmaul respirations Metabolic acidosis -Abdominal pain and discomfort are GI manifestations of ^ ketones and acidosis -Other manifestations include the presence of ketones in the urine, the 3 P's: Polyphagia (^hunger), Polydipsia(^thirst), Polyuria(^urine), GI upset, mental status changes, dehydration and weakness.
A nurse on a pediatric unit is teaching a group of student nurses about childhood diseases that are associated with pneumonia. Which of the following diseases can result in pneumonia?
Rubeola (measles) Pertussis (whooping cough) Varicella (chickenpox) -Diseases such as rubeola and pertussis have initial symptoms related to the respiratory tract. If left untreated, pneumonia can develop when bacteria or viruses enter the lungs. -s/s of pneumonia include: productive cough, fever, chills and fatigue
CDC classification system for children with HIV Classification C characteristics:
Sepsis, encephalopathy, meningitis, histoplasmosis, esophageal or pulmonary candidiasis, abscesses in an organ or body cavity, mycobacterial pneumonia, tuberculosis. (Severe)child presents with history of severe bacteria infections
A nurse is caring for a client who has undergone hemorrhoidectomy. Which position would be best for the client in the early postoperative period?
Side-laying -After a hemorrhoidectomy, the client can be placed in the side-lying or prone position to avoid stress on the surgical site. The lateral position is more comfortable, as the prone position is association with low back ache and pain over the pubis.
The nurse is planning care for a client who is hearing impaired. Which of the following actions by the nurse will be the most helpful in establishing effective communication with the client?
Speak slowly and clearly -The nurse should speak slowly and clearly to the client who is hearing impaired. This will enable the client to hear better if they are able, read lips and understand more clearly in both situations.
A client is admitted complaining of epigastric pain that he describes as burning and gnawing after meals. A gastric ulcer is a likely diagnosis. What is true concerning diagnosis of gastric ulcers?
Testing for H. Pylori infection is essential in all clients with peptic ulcer disease (PUD) -Rapid urease test are the endoscopic diagnostic test of choice, but a fecal antigen test is a more accurate noninvasive test & antibody testing. It is less expensive than urea breath tests -The most common symptoms of both gastric and duodenal ulcers are gnawing or burning epigastric pain that occurs after meals. -Documentation of PUD depends upon radiographic and endoscopic confirmation, with upper GI endoscopy is the preferred diagnostic test.
A nurse is assessing a 58 yr old client who was hospitalized for suspected GI bleed. The nurse obtains the vital signs, reviews the medical chart, and listens to the nurse hand off report from the prior shift. The nurse recognizes that the client is at risk for hypovolemic shock after which of the following assessment findings?
The client's blood pressure has decreased -Pt's in hypovolemic shock present with hypotension bc of the decrease in intravascular volume -This is a life-threatening emergency that is characterized by a decrease in intravascular volume due to sudden loss of blood of fluids. -S/S: reduced cardiac output, decrease blood pressure, rapid heart rate, reduced urine output, weakness, anxiety, confusion and pale, cool, or clammy skin.
A client is admitted to the ER with reported heroin intoxication. What sign is consistent with opiate use?
The clients pupils are constricted -Opiate overdose results in dilated pupils due to cerebral anoxia
