dee MEDSURGE GOAL 7-29 SUMMER START

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instruction should be included in the discharge teaching plan to reduce the risk of future episodes ? Select all that applies 1. Drink plenty of water 2. Exercise regularly 3. Follow a low residue diet 4. Include whole grains fruits and vegetable in the diet . 5. Increase intake of red meat .

1. Drink plenty of water 2. Exercise regularly 4. Include whole grains fruits and vegetable in the diet . Diverticular disease of the colon is a condition in which there are saclike protrusions in the large intestine die particular . Diverticula oasys is characterized by the presence of these protrusions the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula becomes infected an inflamed. Complication of diverticulitis include abscesses fistula formation intestinal obstruction Paratenonitis and sepsis . Diverticular bleeding occurs when a blood vessel next to one of these pouches burst this may cause blood in the stool . The etiology of diverticular disease has been linked to chronic Constipation a major cause of excess intra Cola Nick pressure . Preventing Constipation may help reduce the risk of diverticula formation and becoming inflamed. Measures to prevent Constipation include a diet high in fiber whole grains fruits and vegetables daily intake of eight glasses of water or other fluids an exercise a fiber supplement such as is Liam or bran may be advised . In the past clients have been taught to avoid consuming seeds and nuts popcorn however current evidence does not indicate that avoidance of these food will prevent an episode of diverticulitis. Option 3A low residue diet which avoids all high fiber foods may be used in treating acute diverticulitis however after symptoms have resolved a high fiber diet is resumed to prevent future episodes. Clients with diverticula oasys should take measures to prevent Constipation example high fiber diet increased food intake regular exercise which may help prevent reoccuring episode of diverticulitis.

28. A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations of acquired immune deficiency syndrome (Al DS). Which of the following statements should the nurse include in the teaching? A. "You can expect a persistent fever and swollen glands." B. "You can expect an elevated white blood cell count." C. "You can expect increased blood pressure and edema." D. "You can expect weight gain."

A. "You can expect a persistent fever and swollen glands." Clients who have AIDS can have a persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of Al DS. B. Clients who have AIDS are more likely to have a decreased WBC count as a result of HIV destroying CD4-T-cells. This decrease in WBC and CD4-T-cell counts is why clients who have Al DS are at an increased risk of infection. C. Clients who have Al DS can have hypotension due to an adrenal insufficiency. These manifestations are indicative of heart failure. D. Clients who have Al DS may experience weight loss due to an alteration in metabolism.

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client B. Ask open-ended questions c. Limit visitors to 3 at a time D. Use different words if the client does not

A. Add gestures when speaking with the client The nurse should use gestures when speaking with the client to increase the client's understanding of the conversation. B. The nurse should ask questions that can be answered with "yes" or "no" to reduce the client's confusion. C. The nurse should limit visitors to 2 at a time to reduce the client's confusion. D. The nurse should use the same words when repeating a statement

.A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A. Aspiration of water B. Infection of the stoma C. Bleeding around the stoma D. Skin breakdown around the stoma

A. Aspiration of water The client should be careful during bathing and showering and should avoid swimming due to the risk of aspiration of water. The client should use a shower shield over the stoma when bathing or showering to keep water out of the airway B. Exposure to water alone does not cause infection; infectious microorganisms cause infection. The nurse should instruct the client to examine the stoma every day for any signs of infection. C. After initial healing, bathing should not cause bleeding around the stoma. Even in the immediate postoperative period, hemorrhage is unlikely. D. Breakdown of the wound is possible in the postoperative period due to many factors such as poor nutrition. However, brief contact with water during bathing does not cause this complication.

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite

A. The client rigidly extends his arms. A client who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline. B. A client who exhibits decorticate posturing internally flexes the wrists and arms and extends and plantar-flexes the legs. C. A fetal position is not a manifestation of a decerebrate posture. D. A client who exhibits decorticate posturing flexes the arms with internal rotation of the forearms and extends and plantar-flexes the legs. GCS scores are calculated by using appropriate stimuli (a painful stimulus can be necessary) and then assessing the client's response in three areas. ●● Eye opening (E): The best eye response, with responses ranging from 4 to 1 ◯◯ 4 = Eye opening occurs spontaneously. ◯◯ 3 = Eye opening occurs secondary to sound. ◯◯ 2 = Eye opening occurs secondary to pain. ◯◯ 1 = Eye opening does not occur. ●● Verbal (V): The best verbal response, with responses ranging from 5 to 1 ◯◯ 5 = Conversation is coherent and oriented. ◯◯ 4 = Conversation is incoherent and disoriented. ◯◯ 3 = Words are spoken, but inappropriately. ◯◯ 2 = Sounds are made, but no words. ◯◯ 1 = Vocalization does not occur. ●● Motor (M): The best motor response, with responses ranging from 6 to 1 ◯◯ 6 = Commands are followed. ◯◯ 5 = Local reaction to pain occurs. ◯◯ 4 = General withdrawal from pain. ◯◯ 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. ◯◯ 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. ◯◯ 1 = Motor response does not occur. Responses within each subscale are added, with the total score quantitatively describing the client's level of consciousness. E + V + M = Total GCS ●● In critical situations, where head injury is present and close monitoring is required, subscale results may also be documented. Thus, a GCS may be reported as either a single number, indicating the sum of the subscales (3 to 15), or as 3 numbers, one from each subscale result, and the total (E3 V3 M4 = GCS 10). This allows providers to determine specific neurologic function. ●● Intubation limits the ability to use GCS summed scores. If intubation is present, the GCS may be reported as two scores, with modification noted. This is generally reported by totaling the eye and motor score, and recording it with a "t", such as "GCS 5t" (with the t representing the intubation tube).

A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenos is and report to the provider? A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul respirations

A. The nurse should identify increased coughing as a manifestation of tracheal stenosis. Other manifestations include an inability to cough up secretions and difficulty talking or breathing. B. Diaphragmatic breathing is the act of inhaling deeply by flexing the diaphragm. It is not a manifestation of tracheal stenosis. C. Coughing up blood, otherwise known as hemoptysis, is an abnormal finding following endotracheal extubation that should be reported to the provider. However, it is not a manifestation of tracheal stenosis. D. Kussmaul respirations are a deep and labored breathing pattern that is most often seen in clients who have metabolic acidosis. It is not a manifestation of tracheal stenosis. Kussmaul respirations: Increased respiratory rate and depth in attempt to excrete carbon dioxide and acid due to metabolic acidosis Diabetic ketoacidosis ●● Lack of sufficient insulin related to undiagnosed or untreated type 1 diabetes mellitus or nonadherence to a diabetic regimen ●● Reduced or missed dose of insulin (insufficient dosing of insulin or error in dosage) ●● Any condition that increases carbohydrate metabolism (physical or emotional stress, illness) ●● Infection is the most common cause ●● Increased hormone production (cortisol, glucagon, epinephrine) that stimulates the liver to produce glucose and decreases the effect of insulin Hyperglycemic hyperosmolar state ●● Sustained osmotic diuresis results in a hyperglycemic hyperosmolar state, resulting from one of the following. ◯◯ Lack of sufficient insulin related to undiagnosed or poorly managed diabetes mellitus. There is sufficient endogenous insulin present to prevent the development of ketosis, but not enough to prevent hyperglycemia. ◯◯ Inadequate fluid intake or poor kidney function. ●● Most common in adult clients age 50 to 70 years old. ●● Mortality rates in older clients are 40% to 70%, given older clients often seek medical attention later when much sicker, and have age-related changes that affect the body's ability to recover (decreased ability for urine concentration, decreased thirst perception). ●● Other factors that contribute to the development of HHS include infection, stress, medical conditions (myocardial infarction, cerebral vascular injury, sepsis), and some medications (glucocorticoids, thiazide diuretics, phenytoin, beta blockers, calcium channel blockers). EXPECTE D FIN DINGS DKA HHS Polyuria: Osmotic diuresis resulting in excess urine production ✔ ✔ Polydipsia (excess thirst): Osmotic diuresis causing excess loss of fluids resulting in dehydration and increased thirst ✔ ✔ Polyphagia: Cell starvation due to inability to receive glucose resulting in increased appetite ✔ ✔ Weight loss: Cells are unable to use glucose because of insulin deficiency. The body is placed in a catabolic state. ✔ ✔ GI effects (nausea, vomiting, abdominal pain): Increased ketones and acidosis lead to nausea, vomiting, and abdominal pain ✔ Blurred vision, headache, weakness: Fluid volume depletion caused from osmotic diuresis resulting in dehydration ✔ ✔ Orthostatic hypotension: Fluid volume depletion caused by osmotic diuresis resulting in dehydration ✔ ✔ Fruity odor of breath: Elevated ketone bodies (small fatty acids) used for energy that collect in the blood, which leads to metabolic acidosis ✔ Kussmaul respirations: Deep rapid respirations occur in an attempt to excrete carbon dioxide and acid when in metabolic acidosis ✔ Metabolic acidosis: Breakdown of stored glucose, protein, and fat to produce ketone bodies ✔ Mental status changes: Lack of glucose circulating to the brain can cause neuron dysfunction and even cell death of the brain. The brain cannot produce or store glucose. ✔ ✔ Seizures, myoclonic jerking: Related to blood osmolarity greater than 350 mOsm/L ✔ Reversible paralysis: Related to how elevated the blood osmolarity becomes (coma occurs once blood osmolarity is greater than 350 mOsm/L)

30. A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation. B. Vital lung capacity measures the amount of air the client can exhale after maximum inhalation. C. Functional residual capacity measures the amount of air in the lungs after normal expiration. D. Residual volume measures the amount of air in the lungs after forced expiration.

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply.) A. Weight gain B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis

A. Weight loss occurs when the cells are unable to use glucose because of insulin deficiency and places the body in a catabolic state, and fluid loss from dehydration decreases body weight. B. CORRECT: Fruity odor of breath is a manifestation of elevated ketone levels that lead to metabolic acidosis. C. CORRECT: Abdominal pain is a GI manifestation of increased ketones and acidosis. D. CORRECT: Kussmaul respirations are an attempt to excrete carbon dioxide and acid when in metabolic acidosis. E. CORRECT: Metabolic acidosis is caused by glucose, protein, and fat breakdown, which produces ketones. depth in attempt to excrete carbon dioxide and acid due to metabolic acidosis Diabetic ketoacidosis ●● Lack of sufficient insulin related to undiagnosed or untreated type 1 diabetes mellitus or nonadherence to a diabetic regimen ●● Reduced or missed dose of insulin (insufficient dosing of insulin or error in dosage) ●● Any condition that increases carbohydrate metabolism (physical or emotional stress, illness) ●● Infection is the most common cause ●● Increased hormone production (cortisol, glucagon, epinephrine) that stimulates the liver to produce glucose and decreases the effect of insulin Hyperglycemic hyperosmolar state ●● Sustained osmotic diuresis results in a hyperglycemic hyperosmolar state, resulting from one of the following. ◯◯ Lack of sufficient insulin related to undiagnosed or poorly managed diabetes mellitus. There is sufficient endogenous insulin present to prevent the development of ketosis, but not enough to prevent hyperglycemia. ◯◯ Inadequate fluid intake or poor kidney function. ●● Most common in adult clients age 50 to 70 years old. ●● Mortality rates in older clients are 40% to 70%, given older clients often seek medical attention later when much sicker, and have age-related changes that affect the body's ability to recover (decreased ability for urine concentration, decreased thirst perception). ●● Other factors that contribute to the development of HHS include infection, stress, medical conditions (myocardial infarction, cerebral vascular injury, sepsis), and some medications (glucocorticoids, thiazide diuretics, phenytoin, beta blockers, calcium channel blockers). EXPECTE D FIN DINGS DKA HHS Polyuria: Osmotic diuresis resulting in excess urine production ✔ ✔ Polydipsia (excess thirst): Osmotic diuresis causing excess loss of fluids resulting in dehydration and increased thirst ✔ ✔ Polyphagia: Cell starvation due to inability to receive glucose resulting in increased appetite ✔ ✔ Weight loss: Cells are unable to use glucose because of insulin deficiency. The body is placed in a catabolic state. ✔ ✔ GI effects (nausea, vomiting, abdominal pain): Increased ketones and acidosis lead to nausea, vomiting, and abdominal pain ✔ Blurred vision, headache, weakness: Fluid volume depletion caused from osmotic diuresis resulting in dehydration ✔ ✔ Orthostatic hypotension: Fluid volume depletion caused by osmotic diuresis resulting in dehydration ✔ ✔ Fruity odor of breath: Elevated ketone bodies (small fatty acids) used for energy that collect in the blood, which leads to metabolic acidosis ✔ Kussmaul respirations: Deep rapid respirations occur in an attempt to excrete carbon dioxide and acid when in metabolic acidosis ✔ Metabolic acidosis: Breakdown of stored glucose, protein, and fat to produce ketone bodies ✔ Mental status changes: Lack of glucose circulating to the brain can cause neuron dysfunction and even cell death of the brain. The brain cannot produce or store glucose. ✔ ✔ Seizures, myoclonic jerking: Related to blood osmolarity greater than 350 mOsm/L ✔ Reversible paralysis: Related to how elevated the blood osmolarity becomes (coma occurs once blood osmolarity is greater than 350 mOsm/L)

20. A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? A. Zoster vaccine B. Acyclovir C. Amoxicillin D. lnfliximab

B. Acyclovir The nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster. Incorrect Answers: A. The nurse should anticipate a prescription for the zoster vaccine for an older adult client to prevent herpes zoster. C. The nurse should anticipate a prescription for amoxicillin for a client who has a bacterial infection. D. The nurse should anticipate a prescription for infliximab for a client who has Crohn's disease.

19. A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in respiratory isolation B. Monitor vital signs every 2 hr C. Assess neurological status every 4 hr D. Maintain the client in a modified Trendelenburg position E.Keep the client's room darkened

B. Monitor vital signs every 2 hr, C. Assess neurological status every 4 hr E. Keep the client's room darkened The nurse should monitor the client's vital signs to assess for changes consistent with increased intracranial pressure. In addition, the nurse should monitor the client's neurological status at least every 4 hours or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. The nurse should provide the client with a low-stimulation environment to promote comfort and decrease agitation. Incorrect Answers: A. West Nile virus is an arbovirus that is transmitted to humans after a person is bitten by an infected organism such as a mosquito. The nurse should follow standard precautions when caring for a client who has encephalitis due to West Nile virus. B. D. A client who has encephalitis is at risk for increased intracranial pressure; therefore, the nurse should maintain the head of the client's bed at 30 to 45 degrees. The Trendelenburg position (TP) is defined as a body tilt where the head is lower than the body or legs in the supine position. The modified Trendelenburg position (mTP) is when the head is level with the body and legs are passively raised in the supine position.

The nurse understands that which of these body substance are modes of transmission for hepatitis B select all that applies 1. Blood 2. Feces 3. Semen 4. Urine 5. Vaginal secretions

Blood, Semen, vaginal secretions Viral hepatitis is a disease of the liver characterized by inflammation necrosis and cirrhosis. One of the most common Viral strains that cause hepatitis is hepatitis B. The transmission of hepatitis B is primarily through contact with blood semen and vaginal secretion B for body fluids commonly through unprotected sexual intercourse and intravenous illicit drug use infants born to infected mothers are also at risk 4 vertical transmission of hepatitis B . Although kissing sneezing and sharing drinks and utensils and breast feeding are not known routes of transmission hepatitis B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite . Option 2 the transmission of hepatitis A occurs through the fecal oral route via poor hand hygiene and improper food handling . Hepatitis A 4 *** . Hepatitis A is common in developing countries as it is transmitted through infected water water infected with fecal matter . Option 4 urine is not known to be mode of transmission for any form of hepatitis . The transmission of hepatitis B occurs through parent role or sexual intercourse with body fluids such as blood semen or vaginal secretions B is for body fluids . A: Infectious hepatitis transmission is fecal oral route. ❖ Poor sanitation ❖ Person to person ❖ Water ❖ Food ❖ Possible contact with anal or oral sex B/C: Hepatitis B virus transmitted via blood. ❖ Sex ❖ Mother baby ❖ IV drug use ❖ C: hepatitis C virus ❖ Transmitted via blood ❖ Blood transfusion ❖ Sex ❖ Drug paraphernalia D: Only those whom have contacted Hep B are at risk. E: Hepatitis E. Transmitted via fecal oral route. Labs & Diagnostics ❖ ALT: Elevated into the thousands. Normal 10- 40 U/L. ❖ AST: Elevated into the thousands. Normal 10-30 U/L. ❖ Ammonia : Elevated. May lead to encephalopathy. Normal 10 mcg/dl. ❖ Total Bilirubin levels: Elevated in serum urine. Normal is lower than 1.5mg/dl. Prevention ❖ Hep A: Encourage proper sanitation, good hygiene practice, safe food preparation, effective supervision of schools, dorms and community facilities, community health education, mandatory reporting, vaccines. ❖ Hep B: Vaccination, safe sex, do not share drug paraphernalia. Screen blood donors, daily cleaning of work areas, education on prevention and transmission. ❖ Hep C: Avoid high risk behaviors, use standard clinical precautions, needleless IV systems, barrier precautions when handling blood or body fluids, avoid using multidose vials of medications, avoid IV drug use. Treatments ❖ Hep B: Alpha interferon, lamivudine (epivir), adenovir, bed rest, nutritional support, Hep B immune globulin, Hep B vaccine. Do not give the Hep B IG and vaccine in the same injection or the same site. ❖ Hep C: Interferon, Ribavirin, restrict animal protein.

1. A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include? A. "Drink at least 1 liter of fluid each day." B. "Continuously wear support hose." C. "Elevate your legs when sitting." D. "Use dental floss daily."

C. "Elevate your legs when sitting." Clients who have polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation. A. Clients who have polycythemia vera should drink at least 3 L of fluid per day to help lower blood viscosity. B. Clients who have polycythemia vera should wear support hose when awake. D. Clients who have polycythemia vera take anticoagulants. They should not floss between the teeth due to the risk of bleeding. Instead, they should use a soft toothbrush to clean their teeth. RBC Females: 4.2 to 5.4 million/uL Males: 4.7 to 6.1 million/uL Elevated level: Erythrocytosis, polycythemia vera, severe dehydration Decreased level: Anemia, hemorrhage, kidney disease WBC 5,000 to 10,000/mm3 Elevated level: Infection, inflammation. Decreased level: Immunosuppression, autoimmune disease MCV 80 to 95 fL Elevated level: Macrocytic (large) RBCs, megaloblastic anemia. Decreased level: Microcytic (small) RBCs, iron deficiency anemia. MCH 27 to 31 pg/cell Elevated/decreased level: Same as above for MC V TIBC 250 to 460 mcg/dL Elevated level: Iron deficiency anemia, polycythemia vera Decreased level: Malnutrition, cirrhosis, pernicious anemia IRON Females: 60 to 160 mcg/dL Males: 80 to 180 mcg/dL Elevated level: Hemochromatosis, iron excess, liver disorder, or lead toxicity. Decreased level: Iron deficiency anemia, chronic blood loss, inadequate dietary intake of iron. PLATELETS 150,000 to 400,000 mm3 Increased level: Malignancy, polycythemia vera, rheumatoid arthritis. Decreased level: Enlarged spleen, hemorrhage, leukemia

23. A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first tube."

C. "The lower tube will drain blood, and the higher tube will remove air." The tube that is lower on the thorax will drain blood, and the tube that is higher on the thorax will allow for removal of air. A. Excessive bleeding indicates a complication that the surgeon must address. B. Blood typically drains from the base of the lung, not the apex. D. If a tube becomes blocked, the nurse should report it to the surgeon and prepare to attempt to re-establish patency or remove and replace the tube.

29. A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include? A. "If the test is positive, it means you have an active case of tuberculosis." B "If the test is positive, you should have another tuberculin skin test in 3 weeks." C. "You must return to the clinic to have the test read in 2 or 3 days." D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

C. "You must return to the clinic to have the test read in 2 or 3 days." The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hours indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hours, another tuberculin skin test is necessary. A. A positive test means the client has been exposed to tubercle bacillus, but it does not mean that the client has an active case of tuberculosis. The client should have a chest X-ray to rule out active tuberculosis. B. A client who has a positive skin test should have a chest X-ray to rule out active tuberculosis. When the client has a positive skin test, subsequent skin tests will always be positive. D. The nurse will inject 0.1 ml of purified protein derivative intradermally to the dorsal aspect of the client's forearm. DI Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. TB is transmitted through aerosolization (airborne route). Once inside the lung, the body encases the TB bacillus with collagen and other cells. This can appear as a round nodule or tubercle on a chest x‑ray. Only a small percentage of people infected with TB actually develop an active form of the infection. The TB bacillus can lie dormant for many years before producing the disease. TB primarily affects the lungs but can spread to any organ in the blood. The risk of transmission decreases after 2 to 3 weeks of antituberculin therapy. AGNOST IC PROCEDURES Mantoux test (23.1) ●● A client will have a positive intradermal TB test within 2 to 10 weeks of exposure to the infection. ●● An intradermal injection of an extract of the tubercle bacillus is made. It should be read in 48 to 72 hr. ●● An induration (palpable, raised, hardened area) of 10 mm or greater in diameter indicates a positive skin test. ●● An induration of 5 mm is considered a positive test for immunocompromised clients. ●● A positive Mantoux test can indicate that the client has developed an immune response to TB. It does not confirm that active disease is present. ●● Clients who have had a positive Mantoux test or have received a Bacillus Calmette‑Guerin vaccine within the past 10 years can have a false‑positive Mantoux test. These clients need a chest x‑ray or QuantiFERON‑TB Gold test to evaluate the presence of active TB infection. ●● Clients experiencing immunocompromise can demonstrate anergy, or lack of response to Mantoux testing, even if M. tuberculosis is present in the body. In this case, other diagnostic testing is indicated to rule out infection. ●● Individuals who have latent TB can have a positive Mantoux test and can receive treatment to prevent development of an active form of the disease. ●● Clients who are immunocompromised (such as those who have HIV) and older adult clients should be tested for TB. Clients starting immunosuppressive therapy (such as tumor necrosis factor antagonists) should be tested for TB prior to starting treatment. CLIENT EDUCATION: Return for a reading of the injection

1. A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

C. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax. A. A friction rub is a scratching or squeaking sound heard when auscultating the client's lungs. This condition occurs due to the pleural surfaces rubbing together. A friction rub is a clinical manifestation of pleurisy. B. Crackles (sometimes called rales) are wet, popping sounds heard when auscultating the client's lungs. This condition occurs when fluid is present in the client's airways or alveoli. Crackles are a clinical manifestation of pneumonia. D. Tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client's chest as the client repeats a syllable such as "nine, nine." Indicate pneumonia

11. A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with ST-segment depression B. Relief of chest pain with deep inspiration C. Dyspnea with hiccups D Chest pain that increases when sitting upright

C. Dyspnea with hiccups A client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardiaI compression due to constrictive pericarditis or cardiac tamponade. A. Pericarditis is usually seen on an ECG as an ST-T spiking. This elevation represents ischemic changes caused by inflammation around the heart. A client who has pericarditis will have tachycardia because of decreased cardiac output and oxygen perfusion. B. Chest pain associated with pericarditis will increase with deep inspiration due to greater pressure on the pericardial sac. D. Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac.

24. A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy c. Liver transplant D. Transjugular intra hepatic portal-systemic shunt placement

C. Liver transplant Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients. A. Endoscopic sclerotherapy is the injection of a sclerotherapy agent during an endoscopy to target esophageal varices that are actively bleeding. This promotes thrombosis, which eventually leads to sclerosis. B. A liver lobectomy is used for localized cancer of a lobe of the liver. This is not appropriate for a client experiencing rapidly progressive liver failure. D. A transjugular intrahepatic portal-systemic shunt is placed to treat esophageal varices through a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension. It is not used for fulminant hepatic failure. COMPLICATIONS of hepatitis Chronic hepatitis ●● Ongoing inflammation of the liver cells ●● Results from hepatitis B, C, or D ●● Increases the client's risk for liver cancer Fulminant hepatitis ●● Extremely severe and potentially fatal form of viral hepatitis. ●● Clients develop manifestations of viral hepatitis, then within hours or days develop severe liver failure. ●● No medications, supportive care. Cirrhosis of the liver: Permanent scarring of the liver that is usually caused by chronic inflammation Liver cancer Liver failure: Irreversible damage to liver cells, with decreased ability to function adequately to meet the body's needs Hepatic encephalopathy: A life-threatening complication of liver failure. Toxic substances, which are normally detoxified by the liver, enter systemic circulation. Ammonia levels rise and enter the brain, causing clients to develop changes in neurologic status that can progress to stupor, asterixis (hand flapping), fetor hepaticus (fruity, musty breath odor), seizures, and coma.

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute Ml? A. Dyspnea B .Pain in the shoulder and left arm c. Substernal chest pain D. Palpitations

C. Substernal chest pain Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation. A. Evidence-based practice indicates that dyspnea is a common manifestation of acute Ml, but it is not the most common. Other findings include diaphoresis and nausea. B. Evidence-based practice indicates that pain in the shoulder and left arm is a common manifestation of acute MI, but it is not the most common. Other findings include dizziness and anxiety. D. Evidence-based practice indicates that palpitations are a common manifestation of acute MI, but they are not the most common. Other findings include epigastric discomfort The continuum from angina to myocardial infarction (MI) is acute coronary syndrome. Manifestations of acute coronary syndrome are due to an imbalance between myocardial oxygen supply and demand. When blood flow to the heart is compromised, ischemia causes chest pain. Anginal pain is often described as a tight squeezing, heavy pressure, or constricting feeling in the chest. The pain can radiate to the jaw, neck, or arm. Pain unrelieved by rest or nitroglycerin and lasting for more than 15 min differentiates an MI from angina. Females and older adults do not always experience manifestations typically associated with angina or MI. The area of infarction in clients experiencing a myocardial infarction (MI) develops over minutes to hours. Early recognition and treatment of an acute MI is essential to prevent death. Research shows improved outcomes following an MI in clients treated with aspirin, beta‑blockers, and angiotensin‑converting enzyme inhibitors or angiotensin receptor blockers. Cardiac tamponade can result from fluid accumulation in the pericardial sac. ●● Manifestations include hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration). ●● Hemodynamic monitoring reveals intracardiac and PAPs are similar and elevated (plateau pressures). NURSING ACTIONS ●● Notify the provider immediately. ●● Administer IV fluids to combat hypotension. ●● Obtain a chest x‑ray or echocardiogram to confirm diagnosis. ●● Prepare the client for pericardiocentesis. (Verify informed consent. Gather materials. Administer medications as appropriate.) ●● Monitor hemodynamic pressures. ●● Monitor heart rhythm. Changes indicate improper positioning of the needle. ●● Monitor for reoccurrence of manifestations after the procedure. ●● Monitor for dyspnea, and provide oxyg

26. A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite

C. Third-degree frostbite When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled, and the skin does not blanch. A. When a client has first-degree frostbite, the skin of the affected area is reddened and looks waxy. B. When a client has second-degree frostbite, the skin of the affected area has large, fluid-filled blisters. D. When a client has fourth-degree frostbite, the skin of the affected area is frozen. Blisters do not appear, and the client's muscles and bones are affected. ●● Occurs when the body is exposed to freezing temperatures. ●● Common sites include the earlobes, tip of the nose, fingers, and toes. ●● Frostnip does not lead to tissue injury and can be treated by warming. ●● Frostbite presents as white, waxy areas on exposed skin. Tissue injury occurs. ●● Frostbite can be full‑ or partial‑thickness. ●● Warm the affected area in a 37° to 42° C (98.6° to 108° F) water bath. ●● Provide pain medication. ●● Administer a tetanus vaccination. FROSTBITE ●● Skin condition which occurs after prolonged exposure to freezing temperatures. ●● Extent of injury to exposed skin may not be evident for at least 24 hr after injury and is categorized as superficial (first degree), partial thickness (second degree), or full thickness (third and fourth degree). ◯◯ 1st degree: Least severe form. Only superficial layers of exposed skin are affected with hyperemia and edema. ◯◯ 2nd degree: Blisters cover the exposed skin areas causing necrotic tissue death and swelling. ◯◯ 3rd degree: Extensive edema and blisters to the affected skin which does not blanch. Affected areas will be treated by debridement of damaged tissue. ◯◯ 4th degree: The affected area completely lacks blood supply and is considered full thickness necrosis of skin with potential progression to gangrene. The extent of the gangrene may require amputation of affected areas. NURSING ACTIONS ●● Clients require rewarming. Bathing affected areas in warm bath (104º to 108º F [40º to 42º C]) will improve blood circulation and promote healing of damaged tissue. This rewarming process can increase pain as circulation improves to affected areas of skin. ●● Administer tetanus toxoid IM vaccine to prevent complications related to growth of tetanus in wo

18. A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (Ml). Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain

Correct Answer: A. Ventricular dysrhythmias The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery. Incorrect Answers: B. The appearance of Q waves indicates infarction, not reperfusion. C. The elevated ST segments indicate infarction, not reperfusion. D. The recurrence of chest pain can indicate an extension of acute MI. With reperfusion, chest pain should subside.

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? (Select all that apply.) A. Use a 5 ml syringe to flush the line B. Cleanse the insertion site with half-strength hydrogen peroxide C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use

Correct Answers: C. Flush the line with sterile 0.9% sodium chloride before and after medication administration, D. Access the PICC for blood sampling, E. Perform a heparin flush of the line at least daily when not in use The nurse should flush the line with 10 ml of sterile 0.9% sodium chloride solution before and after administering medication through the PICC. The nurse should use a PICC to deliver fluids, medications, and total parenteral nutrition to the client. The PICC is also used to obtain blood samples, and the nurse should practice the appropriate technique to access and flush the line. Ideally, blood samples should come from a 4 French lumen catheter or larger. PICCs can remain in place for months or years. When not actively in use, the nurse should perform heparin flushes at least daily to prevent clotting within the line. A. A 5 ml syringe generates too much pressure and could rupture the line. The nurse should use a 10 ml syringe instead. B. The nurse should use chlorhexidine for cleansing the insertion site. Chlorhexidine is effective in reducing the incidence of bloodstream infections.

A nurse is reviewing the plan of care for a client that is experiencing an acute exacerbation ulcerative colitis which of the following treatment should the nurse expect to administer? a. docusate b. a bowel cathartic medication c. aspirin d corticosteroid medication

Corticosteroid medication CHRONIC INFLAMMATORY BOWEL DISEASE Ulcerative colitis and Crohn's disease are characterized by frequent stools, cramping abdominal pain, exacerbations, and remissions. Ulcerative colitis Edema and inflammation primarily in the rectum and rectosigmoid colon ● In severe cases, it can involve the entire length of the colon. Mucosa and submucosa become hyperemic (increase in blood flow), and the colon will become edematous and reddened. It can lead to abscess formation. ● Edema and thickened bowel mucosa can cause partial bowel obstruction. Intestinal mucosal cell changes can lead to colon cancer or insufficient production of intrinsic factor, resulting in insufficient absorption of vitamin B12 (pernicious anemia). ● Classified as either mild, moderate, severe, and fulminant. Crohn's disease Inflammation and ulceration of the gastrointestinal tract, often at the distal ileum ● All bowel layers can become involved; lesions are sporadic. Fistulas are common. ● Can involve the entire GI tract from the mouth to the anus. ● Malabsorption and malnutrition can develop when the jejunum and ileum become involved. Requires supplemental vitamins and minerals, possibly including vitamin B12 injections. Diverticulitis Diverticulitis is inflammation and infection of the bowel mucosa caused by bacteria, food, or fecal matter trapped in one or more diverticula (pouch‑like herniations in the intestinal wall). Diverticulitis is not to be confused with diverticulosis, which is the presence of many small diverticula in the colon without inflammation. ● Not all clients who have diverticulosis develop diverticulitis. ● Diverticula can perforate and cause peritonitis, and/or severe bleeding. ASSESSMENT Etiology of ulcerative colitis and Crohn's disease is unknown but possibly due to a combination of genetic, environmental, and immunological causes. RISK FACTORS Genetics: Ulcerative colitis and Crohn's disease Culture: Caucasians (ulcerative colitis), Jewish heritage (ulcerative colitis and Crohn's disease), and African Americans (diverticular disease) Sex and age: The incidence of ulcerative colitis peaks at adolescence to young adulthood (more often in females) and older adulthood (more often in males). Crohn's disease usually develops in adolescents and young adults, but can occur at any age. Diverticulitis occurs more often in older adults and affects males more frequently than females. Tobacco use: Crohn's disease CHAPTER 52 07/24/15 April 9, 2019 11:37 AM rm_rn_2019_ams_chp52 07/24/15 April 9, 2019 11:37 AM rm_rn_2019_ams_chp52 348 CHAPTER 52 Inflammatory Bowel Disease CONTENT MASTERY SERIES EXPECTED FINDINGS Ulcerative colitis ● Abdominal pain/cramping: often left‑lower quadrant pain ● Anorexia and weight loss PHYSICAL ASSESSMENT FINDINGS ● Fever ● Diarrhea: up to 15 to 20 liquid stools/day ● Stools containing mucus, blood, or pus ● Abdominal distention, tenderness, and/or firmness upon palpation ● High‑pitched bowel sounds ● Rectal bleeding Crohn's disease ● Abdominal pain/cramping: often right‑lower quadrant pain ● Anorexia and weight loss PHYSICAL ASSESSMENT FINDINGS ● Fever ● Diarrhea: five loose stools/day with mucus or pus ● Abdominal distention, tenderness and/or firmness upon palpation ● High‑pitched bowel sounds ● Steatorrhea LABORATORY TESTS Ulcerative colitis Hematocrit and hemoglobin: Decreased Erythrocyte sedimentation rate (ESR): Increased WBC: Increased C‑reactive protein: Increased Albumin: Decreased Stool for occult blood: Can be positive K+, Na, Mg, Ca, and Cl: Decreased Ulcerative colitis Edema and inflammation primarily in the rectum and rectosigmoid colon ● In severe cases, it can involve the entire length of the colon. Mucosa and submucosa become hyperemic (increase in blood flow), and the colon will become edematous and reddened. It can lead to abscess formation. ● Edema and thickened bowel mucosa can cause partial bowel obstruction. Intestinal mucosal cell changes can lead to colon cancer or insufficient production of intrinsic factor, resulting in insufficient absorption of vitamin B12 (pernicious anemia). ● Classified as either mild, moderate, severe, and fulminant. Crohn's disease Inflammation and ulceration of the gastrointestinal tract, often at the distal ileum ● All bowel layers can become involved; lesions are sporadic. Fistulas are common. ● Can involve the entire GI tract from the mouth to the anus. ● Malabsorption and malnutrition can develop when the jejunum and ileum become involved. Requires supplemental vitamins and minerals, possibly including vitamin B12 injections. Diverticulitis Diverticulitis is inflammation and infection of the bowel mucosa caused by bacteria, food, or fecal matter trapped in one or more diverticula (pouch‑like herniations in the intestinal wall). Diverticulitis is not to be confused with diverticulosis, which is the presence of many small diverticula in the colon without inflammation. ● Not all clients who have diverticulosis develop diverticulitis. ● Diverticula can perforate and cause peritonitis, and/or severe bleeding. ASSESSMENT Etiology of ulcerative colitis and Crohn's disease is unknown but possibly due to a combination of genetic, environmental, and immunological causes. RISK FACTORS Genetics: Ulcerative colitis and Crohn's disease Culture: Caucasians (ulcerative colitis), Jewish heritage (ulcerative colitis and Crohn's disease), and African Americans (diverticular disease) Sex and age: The incidence of ulcerative colitis peaks at adolescence to young adulthood (more often in females) and older adulthood (more often in males). Crohn's disease usually develops in adolescents and young adults, but can occur at any age. Diverticulitis occurs more often in older adults and affects males more frequently than females. Tobacco use: Crohn's disease Crohn's disease Hematocrit and hemoglobin: Decreased ESR: Increased WBC: Increased C‑reactive protein: Increased Albumin: Decreased Folic acid and B12: Decreased Anti‑glycan antibodies: Increased Stool for occult blood: Can be positive Urinalysis: WBC K+, Mg, and Ca: Decreased Diverticulitis Hematocrit and hemoglobin: Decreased ESR: Increased WBC: Increased Stool for occult blood: Can be positive DIAGNOSTIC PROCEDURES Magnetic resonance enterography: Used with all IBD CLIENT EDUCATION: Maintain NPO for 4 to 6 hr prior to the exam. You might be asked to drink a contrast medium prior to the test. Ulcerative colitis Sigmoidoscopy or colonoscopy: Can diagnose ulcerative colitis Barium enema: Helpful to distinguish ulcerative colitis from other disease processes CT scan or MRI: Can identify the presence of abscesses Stool examination: For the presence of parasites or microbes Crohn's disease Endoscopy ● Newer diagnostic tools used, such as video capsule endoscopy ● Proctosigmoidoscopy: Performed to identify inflamed tissue ● Colonoscopy and sigmoidoscopy: A lighted, flexible scope inserted into the rectum to visualize the rectum and large intestine Abdominal ultrasound, x‑ray, and CT scan: CT scans can show bowel thickening. PATIENT‑CENTERED CARE NURSING CARE Ulcerative colitis and Crohn's disease ● The client should receive instructions regarding the usual course of the disease process. ● The client should receive instructions regarding medication therapy and vitamin supplements. ● Monitor by colonoscopy due to the increased risk of colon cancer. ● Assist the client in identifying foods that trigger manifestations. ● Monitor for electrolyte imbalance, especially potassium. Diarrhea can cause a loss of fluids and electrolytes. ● Monitor I&O, and assess for dehydration. ● Educate the client to eat high-protein, high-calorie, low-fiber foods. CLIENT EDUCATION ● Seek emergency care for indications of bowel obstruction or perforation (fever, severe abdominal pain, vomiting). ● For extreme or long exacerbations, NPO status and administration of total parenteral nutrition promotes bowel rest while providing adequate nutrition. ● Avoid caffeine and alcohol. ● Take a multivitamin that contains iron. ● Small, frequent meals can reduce the occurrence of manifestations. ● Dietary supplements that are high in protein and low in fiber (elemental and semi‑elemental products, canned nutrition beverages) can be used. ● Weigh 1 or 2 times weekly. ● Use of vitamin supplements and B12 injections, if needed. Diverticulitis ● For severe manifestations (severe pain, high fever), the client is hospitalized, NPO, and receives nasogastric suctioning, IV fluids, IV antibiotics, and opioid analgesics for pain. ● Instruct the client who has mild diverticulitis about self‑care at home. The client should take medications as prescribed (antibiotics, analgesics, antispasmodics) and get adequate rest. ● Provide the client with instructions to promote normal bowel function and consistency. (Avoid laxatives and the use of enemas. Drink adequate fluids.) CLIENT EDUCATION ● Consume a clear liquid diet until manifestations subside. ● Progress to a low‑fiber diet once solid foods are tolerated without other manifestations. Slowly advance to a high‑fiber diet as tolerated when inflammation resolves. ● Avoid seeds or indigestible material (nuts, popcorn, seeds), which can block diverticulum. ● Avoid foods or drinks that can irritate the bowel. (Avoid alcohol. Limit fat to 30% of daily calorie intake.) MEDICATIONS FOR ULCERATIVE COLITIS, CROHN'S DISEASE 5‑aminosalicylic acid: Anti‑inflammatory Reduces inflammation of the intestinal mucosa and inhibits prostaglandins Sulfonamides: Sulfasalazine ● These medications are contraindicated if the client has a sulfa allergy. ● Sulfasalazine is given orally. ● Adverse effects include nausea, fever, and rash. ● Can take up to 2 to 4 weeks for therapeutic effects. NURSING ACTIONS ◯ Monitor CBC, and kidney and hepatic function. ◯ Monitor for the development of agranulocytosis, hemolytic anemia, and macrocytic anemia. CLIENT EDUCATION ◯ Take the medication with a full glass of water after meals. ◯ Avoid sun exposure. ◯ Increase fluid intake to 2 L/day. ◯ This medication can cause urine, skin, and contact lenses to have a yellow‑orange color. ◯ Notify the provider if nausea, vomiting, anorexia, sore throat, rash, bruising, or fever occur. ◯ Take medication as directed. The usual maintenance dose of sulfasalazine is 2 to 4 g/day. ◯ Take a folic acid supplement. Nonsulfonamides ● Mesalamine ● Balsalazide ● Olsalazine (for clients intolerant to sulfasalazine, rarely used) ● The adverse effects are not as serious as sulfasalazine. ● These medications can be contraindicated if the client has a salicylate or sulfa allergy. NURSING ACTIONS: Monitor for kidney toxicity. CLIENT EDUCATION: Report headache or gastrointestinal problems (abdominal discomfort, diarrhea). Corticosteroids Reduces inflammation and pain ● For rectal inflammation, topical steroids can be administered by a retention enema. ● Used to induce remission. ● Not for long‑term use due to adverse effects. ● Prolonged use can lead to adrenal suppression, osteoporosis, risk of infection, and cushingoid syndrome. Use corticosteroids in low doses to minimize adverse effects. ● Can slow healing. MEDICATIONS ● Prednisone ● Prednisolone ● Hydrocortisone ● Budesonide NURSING ACTIONS ● Monitor blood pressure. ● Reduce systemic dose slowly. ● Monitor electrolytes and glucose. CLIENT EDUCATION ● Take the oral dose with food. ● Avoid discontinuing dose suddenly. ● Report unexpected increase in weight or other indications of fluid retention. ● Avoid crowds and other exposures to infectious diseases. ● Report evidence of infection (Crohn's disease can mask infection). Immunosuppressants Mechanism of action in treatment of IBD is unknown. MEDICATIONS ● Cyclosporine ● Methotrexate ● Azathioprine ● Mercaptopurine NURSING ACTIONS ● Monitor for pancreatitis and neutropenia. ● Can take up to 6 months to see therapeutic effects. ● Not used as monotherapy. ● Reserved for refractory disease due to toxicity. CLIENT EDUCATION ● Avoid crowds and other chances of exposures to infectious diseases, and report evidence of infection. ● Monitor for indications of bleeding, bruising, or infection. Immunomodulators ● Suppresses the immune response ● Inhibits tumor necrosis factor, an antibody found in Crohn's disease MEDICATIONS ● Infliximab ● Adalimumab (self‑administered by subcutaneous injection) ● Natalizumab (can cause progressive multi‑focal leukoencephalopathy, a deadly brain infection) ● Certolizumab NURSING ACTIONS ● Follow directions for IV use with care and in accordance with facility policy; can require pretreatment to reduce infusion reactions. ● Many adverse effects are possible, including chills, fever, hypotension/hypertension, dysrhythmias, and blood dyscrasias. ● Monitor liver enzymes, coagulation studies, and CBC. CLIENT EDUCATION ● Avoid crowds and other exposures to infectious diseases, and report evidence of infection. There is a risk for development or reactivation of tuberculosis. ● Monitor and report evidence of bleeding, bruising, or infection, and transfusion or allergic reaction. Antidiarrheals Suppress the number of stools ● Used to decrease risk of fluid volume deficit and electrolyte imbalance. They also reduce discomfort. ● Use of antidiarrheals can lead to toxic megacolon (massive dilation of the colon with a risk of the development of gangrene and peritonitis). Use cautiously. MEDICATIONS ● Diphenoxylate and atropine ● Loperamide NURSING ACTIONS ● Observe for manifestations of toxic megacolon that can result in gangrene and peritonitis (hypotension, fever, abdominal distention, decrease or absence of bowel sounds). ● Observe for indications of respiratory depression, especially in older adult clients. CLIENT EDUCATION: Due to the central nervous system effects, avoid hazardous activities until the response to the medication is established. MEDICATION FOR DIVERTICULITIS Antimicrobials Treat infection (decrease inflammation in Crohn's disease, used to treat abscesses or fistulas) ● Discontinue ciprofloxacin for tendon pain. Can cause tendon rupture. ● Decreased dose should be used for clients who have impaired kidney function.

8. A client comes to the emergency department in severe respiratory distress following left- sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion

D. Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system. A. The client might require mechanical ventilation to stabilize the respiratory status; however, there is no indication at this time for a tracheostomy. B. A thoracentesis is indicated for a client who has an increase of pleural fluid due to cancer, pleurisy, or tuberculosis or for a client who requires microscopic examination of the pleural fluid. C. While the client will require several portable chest X-rays, there is no immediate indication for a CT scan of the chest. ● Dullness: In fluid or solid tissue, this can indicate pneumonia or a tumor. Hyperresonance: In the presence of air, this can indicate pneumothorax or emphysema. A pneumothorax can cause alveolar hypoventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis. Pneumothorax Pneumothorax is a collapsed lung. It can occur due to injury to the lung during the procedure. NURSING ACTIONS ●● Monitor for manifestations of pneumothorax (diminished breath sounds, distended neck veins, asymmetry of the chest wall, respiratory distress, cyanosis). ●● Monitor postprocedure chest x‑ray results. CLIENT EDUCATION: A pneumothorax can develop during the first 24 hr following a thoracentesis. Indications include deviated trachea, pain on the affected side that worsens at the end of inhalation and exhalation, affected side not moving in and out upon inhalation and exhalation, increased heart rate, rapid shallow respirations, nagging cough, or feeling of air hunger. Due to the risk of causing a tension pneumothorax, chest tubes are clamped only when prescribed in specific circumstances, such as in the case of an air leak, during drainage system change, accidental disconnection of tubing, or damage to the drainage system. Tension pneumothorax ●● Sucking chest wounds, prolonged clamping of the tubing, kinks or obstruction in the tubing, or mechanical ventilation with high levels of positive end expiratory pressure (PEEP) can cause a tension pneumothorax. ●● Assessment findings include tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, asymmetry of the chest, and cyanosis. ●● Notify the provider or rapid response team immediately. Chest tube removal ●● Provide pain medication 30 min before removing chest tubes. ●● Assist the provider with sutures and chest tube removal. ●● Instruct the client to take a deep breath, exhale, and bear down (Valsalva maneuver) or to take a deep breath and hold it (increases intrathoracic pressure and reduces risk of air emboli) during chest tube removal. ●● Apply airtight sterile petroleum jelly gauze dressing. Secure in place with a heavyweight stretch tape. ●● Obtain chest x‑rays as prescribed. This is performed to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion. ●● Monitor for excessive wound drainage, findings of infection, or recurrent pneumothorax

1. A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? A. Maintain the client's knees and hips in a flexed B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

D. Encourage increased fluid intake The nurse should encourage increased fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can aggravate sickling and client discomfort. Incorrect Answers: A. The nurse should avoid flexion of the client's knees and hips during a sickle cell crisis to promote adequate perfusion to all areas of the client's body, which can decrease pain. The nurse should keep the room warm during a sickle cell crisis and apply warm, moist compresses to painful joints. The application of cold compresses causes vasoconstriction, which increases sickling. C. The nurse should administer opioids, including morphine and hydromorphone, on a routine schedule during a crisis to manage the client's pain.

1. A nurse is caring for a client who has had repeated middle ear infections. The client reports that the provider said the infections are due to an obstruction of the structure that connects the middle ear to the throat. The nurse should identify that the provider was referring to which of the following structures? A. Oval window B. Auricle C. Tympanic membrane D. Eustachian tube

D. Eustachian tube The eustachian tube connects the middle ear to the throat and allows equalization of pressure and drainage of fluids from the middle ear into the throat. A. The oval window is located between the middle ear and the inner ear structures. B. The auricle is the external ear. C. The tympanic membrane, often referred to as the eardrum, separates the external ear from the middle ear. The middle ear consists of the tympanic membrane (eardrum) and the three smallest bones (ossicles) of the body (malleus, incus, and stapes), and connects to the nasopharynx via the Eustachian tube. The inner ear is located deep within the temporal bone, separated from the middle ear by the oval window. It consists of the cochlea (hearing organ) and semicircular canals (responsible for balance). Cranial nerves VII (facial nerve) and VIII (vestibulocochlear nerve) are part of the inner ear anatomy. Visual, vestibular, and proprioceptive systems provide the brain with input regarding balance. Problems within any of these systems pose a risk for loss of balance. Nurses should be knowledgeable about the types of middle‑ and inner‑ear disorders, including infection, tumors, and issues with balance and coordination. Hearing loss ●● Environmental or workplace exposure to noise can lead to hearing loss. ●● Conductive hearing loss is caused by factors such as otitis media, otosclerosis, and presence of a foreign body (such as impacted cerumen). ●● Color of cerumen and external ear canal varies depending on client's race and skin tone. Normal variations should be recognized during assessment. ●● Sensorineural hearing loss is caused by damage to cranial nerve VIII. ●● Combined hearing loss is caused by a mixture of conductive and sensorineural problems. ●● Changes in the middle and inner ear related to aging include thickening of the tympanic membrane (loss of elasticity), loss of sensory hair cells in the organ of Corti, and limitations to movement of the ossicles. Conditions of the middle ear ●● Conditions of the middle ear can be caused by injury, disease, and the aging process. ●● Acute otitis media is a viral or bacterial infection of the middle ear. ●● Manifestations include ear pain, pressure, fever, headache, conductive hearing loss, and purulent or bloody drainage if perforation of the eardrum occurs. ●● An otoscopic exam can show redness, bulging tympanic membrane, and inability to visualize usual landmarks. ●● Medical management includes systemic antibiotic therapy, analgesics and application of heat for pain, and decongestants. ●● Surgical management includes myringotomy (opening of the eardrum made surgically) and placement of a grommet to equalize pressure. RIS K FACTORS Middle ear disorders ●● Recurrent colds and otitis media ●● Enlarged adenoids ●● Trauma ●● Changes in air pressure (scuba diving, flying) Inner ear disorders ●● Viral or bacterial infection ●● Damage due to ototoxic medications EXPECTED FINDI NGS Middle ear disorders ●● Hearing loss ●● Feeling of fullness and/or pain in the ear ●● Red, inflamed ear canal and tympanic membrane (TM) ●● Bulging TM ●● Fluid and/or bubbles behind TM ●● Diffuse appearance of or inability to visualize normal light reflex ●● Fever Inner ear disorders ●● Hearing loss ●● Tinnitus ●● Dizziness or vertigo ●● Vomiting ●● Nystagmus ●● Alterations in balance

A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care? A. Prevent depression in the client B. Refer the client to occupational therapy C. Support the client's family D. Monitor the client for increased intracranial pressure (ICP)

D. Monitor the client for increased intracranial pressure (ICP) The greatest risk to this client is an injury from increased ICP, which can result in decreased cerebral perfusion and neurological injury. Therefore, the priority intervention the nurse should include in the plan of care is monitoring the client for increased ICP. Manifestations of increased ICP include a decreased level of consciousness and a change in pupils. A. The nurse should take measures to prevent depression in the client such as providing a referral to a support group; a client who has physical or cognitive impairments is at risk for depression. However, another intervention is the priority. B. The nurse should refer the client to an occupational therapist to assist the client in self-care activities and promote independence. However, another intervention is the priority. C. The nurse should provide support for the client's family because the family might feel stressed and overwhelmed while caring for the client. However, another intervention is the priority.

A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? A. Warm the unit of blood to room temperature before administering it B. Administer acetaminophen prior to the blood transfusion C. Give an antihistamine prior to the transfusion D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate

D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate These are the manifestations of a hypervolemic reaction due to circulatory overload, which likely occurs when the blood transfusion is too rapid for the client's size or status. To prevent this problem with future transfusions, the nurse should use a transfusion pump to regulate the transfusion at a slower rate. A. This intervention helps prevent chills and hypothermia; however, the client's manifestations are not related to the temperature of the blood. B. This medication can prevent a febrile reaction; however, the client's manifestations do not indicate a febrile reaction. C. If a client is allergy-prone, an antihistamine prior to the blood transfusion can help prevent a reaction; however, the client's manifestations do not indicate an allergic transfusion reaction. Types of blood reactions and onset ●● Acute hemolytic: immediate or during subsequent transfusions ●● Febrile: within 2 hr of starting the transfusion ●● Allergic: during or up to 24 hr after transfusion ●● Bacterial: during or up to several hours after the transfusion ●● Circulatory overload: any time during the transfusion Medications ●● Antipyretics (acetaminophen): febrile ●● Antihistamines (diphenhydramine): mild allergic ●● Antihistamines, corticosteroids, vasopressors, epinephrine: anaphylactic ●● Antibiotics: bacterial ●● Diuretics, morphine: circulatory overload NURSING ACTIONS Acute hemolytic ●● Stop the transfusion. ●● Remove the blood tubing. ●● Initiate an infusion of 0.9% sodium chloride. ●● Monitor vital signs and fluid status. ●● Send the blood bag and administration set to the lab for testing. Febrile ●● Use a WBC filter to help prevent a febrile reaction. ●● Stop the transfusion. ●● Administer antipyretics. ●● Initiate an infusion of 0.9% sodium chloride. Mild allergic reaction ●● Stop the transfusion. ●● Initiate an infusion of 0.9% sodium chloride. ●● Administer an antihistamine. ●● If prescribed, restart the transfusion slowly to continue. Anaphylactic reaction ●● Stop the transfusion. ●● Administer epinephrine, corticosteroids, vasopressors, and oxygen. ●● Administer CPR if indicated. ●● Remove the blood tubing from the client's IV access. ●● Initiate an infusion of 0.9% sodium chloride. Circulatory overload ●● Slow or stop the transfusion depending on the severity. ●● Position the client upright with feet lower than the level of the heart. ●● Administer oxygen, diuretics, and morphine. Bacterial ●● Stop the transfusion. ●● Administer antibiotics as prescribed. ●● Initiate an infusion of 0.9% sodium chloride. ●● Obtain blood samples for culture.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? Drowsiness decreased BP hyperactive deep-tendon reflexes increased bowel sounds

Hyperactive deep-tendon reflexes hyperactive deep tendon reflexes is an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling. Hypomagnesemia Hypomagnesemia is a blood magnesium level less than 1.3 mg/dL. ASSESSMENT RISK FACTORS for Hypomagnesemia ●● Celiac disease or Crohn's disease ●● Malnutrition (insufficient magnesium intake) ●● Ethanol ingestion (magnesium excretion) ●● Diarrhea, steatorrhea, or chronic laxative use ●● Citrate from blood products ●● Steatorrhea ●● Myocardial infarction or heart failure ●● Concurrent hypokalemia and hypocalcemia ●● Medication therapy (aminoglycoside antibiotics, cisplatin, cyclosporine, amphotericin B) EXPECTED FINDINGS for Hypomagnesemia Cardiovascular: Risk for increased blood pressure and dysrhythmias or ECG changes (presence of PVCs, flat/inverted T waves, ST depression, prolonged PR, widened QRS) Neuromuscular: Increased nerve impulse transmission (hyperactive DTRs, paresthesias, muscle tetany, seizures), positive Chvostek's and Trousseau's signs Gastrointestinal: Hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus Other: Possible depressed mood, apathy, or agitation NURSING CARE for Hypomagnesemia ●● Correct concurrent imbalance of other electrolytes to prevent worsening of either condition. ●● Encourage foods high in magnesium (dark green vegetables, nuts, whole grains, seafood, peanut butter, cocoa). If there is mild hypomagnesemia, dietary changes can be used to correct it. ●● Discontinue magnesium‑depleting medications (loop diuretics, osmotic diuretics, medications that contain phosphorus). ●● Administer oral magnesium sulfate for mild hypomagnesemia. Oral magnesium can cause diarrhea and increase magnesium depletion. ●● IV magnesium sulfate is prescribed if hypomagnesemia is severe. Administer via an infusion pump not to exceed 150 mg/min, or 67 mEq over an 8‑hr period. Monitor DTRs hourly during administration. ●● Monitor clients taking digitalis closely if magnesium is low because it predisposes the client to digitalis toxicity. ●● Have calcium gluconate readily available to reverse hypermagnesemia. INTERPRO FESSIONAL CARE for Hypomagnesemia ●● Endocrinology can be consulted for electrolyte and fluid management. ●● Respiratory services can be consulted for oxygen management. ●● Nutritional services can be consulted for food choices high in magnesium. ●● Cardiology can be consulted for dysrhythmias. CLIENT EDUCATION for Hypomagnesemia ●● Intake foods that are high in magnesium. ●● Increase magnesium in diet by reading food labels. 1. A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/L. The nurse should recognize that which of the following

1A nurse is caring for a patient who has a cuffed endotracheal (ET) tube in place ? Which of the following is an appropriate component of ET care for this patient? Repositioning the ET tube in the patient's mouth every 12 hr Providing oral care every 24 hr Applying the securing tape over the patient's ears Maintaining a cuff pressure of 35 mm

Repositioning the ET tube in the patient's mouth every 12 hr Moving the ET tube to the other side of the patient's mouth every 12 hr (or according to facility policy) helps prevent irritation to the oral mucous membranes. Providing oral care every 24 hrOral care should be performed every 12 hr. Applying the securing tape over the patient's ears Applying the tape over the patient's ears can result in pressure ulcers. Maintaining a cuff pressure of 35 mm HgMY ANSWER The recommended cuff pressure is 20 to 25 mm Hg to minimize the risk of injury to the tracheal mucosa.

When serum calcium levels are low, the nurse should implement ___ ___ due to the client's risk for low excitation threshold as a result of decreased calcium level.

Seizure precautions Other electrolyte imbalances CALCIUM: Hypocalcemia, hypercalcemia CHLORIDE: Hypochloremia, hyperchloremia MAGNESIUM: Hypomagnesemia, hypermagnesemia PHOSPHORUS: Hypophosphatemia, hyperphosphatemia In particular, nurses should be aware of the implications of hypocalcemia and hypomagnesemia. Hypocalcemia Hypocalcemia is a total blood calcium less than 9.0 mg/dL. ASSESSMENT RISK FACTORS for Actual calcium deficitHypocalcemia due to hypoparathyroidisim ●● Inadequate intake of calcium, including lactose intolerance, malabsorption issues ●● Diarrhea or steatorrhea ●● Inadequate vitamin D intake ●● End-stage kidney disease ●● Wound drainage Relative calcium deficit ●● Conditions: alkalosis, acute pancreatitis, hyperproteinemia, hyperphosphatemia, immobility ●● Treatments: calcium chelators, citrate, mithramycin, sodium cellulose phosphate, penicillamine, pamidronate ●● Immobility ●● Parathyroid removal or damage EXPECTED FINDINGS for Hypocalcemia Tetany is the most common manifestation seen in clients in a hypocalcemic state. It is caused by neural excitability‑spontaneous discharges from both the sensory and motor fibers (peripheral nerves). ●● Paresthesia of the fingers and lips (early manifestation) ●● Muscle twitches as hypocalcemia progresses ●● Seizure due to irritability of the central nervous system ●● Frequent, painful muscle spasms at rest in the foot or calf (Charley horses) ●● Hyperactive DTRs ●● Positive Chvostek's sign (tapping on the facial nerve triggering facial twitching) ●● Positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation) ●● History of thyroid surgery or irradiation of the upper chest or neck, which places a client at risk for developing hypocalcemia CARDIOVASCULAR: Prolonged QT interval as a result of a prolonged ST segment. Risk of torsades de pointes. Decreased myocardial contractility (decreased heart rate and hypotension when hypocalcemia is severe). GASTROINTESTINAL: Hyperactive bowel sounds, diarrhea, and abdominal cramps LABORATORY TESTS for Hypocalcemia ●● Calcium level less than 9.0 mg/dL ●● Decreased blood albumin level can make the total blood calcium level falsely low. ●● The ionized calcium level should give the true calcium level when the client appears to have hypocalcemia with hypoalbuminemia. DIAGNOSTIC PROCEDURES for Hypocalcemia Electrocardiogram changes: Prolonged QT and ST interval NURSING CARE for Hypocalcemia ●● Administer oral or IV calcium supplements. Vitamin D supplements enhance the absorption of calcium. ●● Implement seizure and fall precautions. ●● Avoid overstimulation. Keep the client's room quiet, limit visitors, and use soft lighting in the room. ●● Have emergency equipment on standby. ●● Encourage foods high in calcium, including dairy products, canned salmon, sardines, fresh oysters, and dark leafy green vegetables. ●● A client exhibiting life-threatening manifestations of hypocalcemia will require rapid treatment with calcium gluconate or calcium chloride (not used as often due to risk of tissue damage if infiltrated). IV administration should be diluted in dextrose 5% and water and given as a bolus infusion (using an infusion pump). If administered too quickly, cardiac arrest could occur. INTERPRO FESSIONAL CARE for Hypocalcemia ●● Endocrinology can be consulted for electrolyte and fluid management. ●● Respiratory services can be consulted for oxygen management. ●● Nutritional services can be consulted for food choices high in calcium. ●● Cardiology can be consulted for dysrhythmias. CLIENT EDUCATION for Hypocalcemia ●● Consume foods high in calcium (yogurt, milk). ●● Increase calcium in diet by reading food labels

1. A nurse is assessing a female client who reports severe joint pain. The nurse should identify that which of the following factors places the client at risk for gout? A. Perimenopause B. Migraine headaches C. Diuretic use D. Irritable bowel syndrome

The client's use of diuretics is a risk factor for gout. Gout is a systemic disorder that affects the joints as a result of high uric acid levels in the blood. A client who is postmenopausal is at risk for gout. Migraine headaches are a risk factor for fibromyalgia. Irritable bowel syndrome is a risk factor for fibromyalgia. Types of GOUT Primary gout ● Most common. ● Uric acid production is greater than excretion of it by the kidneys. ● Can have genetic component. ● Middle- and older-adult males (peak onset between ages 40 and 50), as well as postmenopausal women are commonly affected. Secondary gout ● Caused by another disease or condition (chronic kidney failure, excessive diuretic use) that causes excessive uric acid in the blood. ● Treatment is based on treating the underlying condition. ● Can affect people of any age. GOUT risk factors RISK FACTORS ● Obesity ● Cardiovascular disease ● Trauma ● Alcohol ingestion ● Starvation dieting ● Diuretic use ● Some chemotherapy agents ● Chronic kidney failure GOUT expected findings/physical assessment findings ● Severe joint pain, especially in the metatarsophalangeal joint of the great toe ● Redness, swelling, and warmth of affected joint PHYSICAL ASSESSMENT FINDINGS ● Painful, swollen joint that is very painful if touched or moved ● Appearance of tophi (chronic gout) GOUT LABS Erythrocyte sedimentation rate (ESR): Elevated Serum uric acid: Repeated measurements obtained due to effect of dietary intake on results. Consistent elevation above 6.5 mg/dL is associated with gout. Urinary uric acid: Elevated Blood urea nitrogen (BUN), serum creatinine: Elevated GOUT client education ● Remind the client to stay on a low-purine diet, which includes no organ meats or shellfish. ● Teach the client to limit alcohol intake. ● Tell the client to avoid starvation diets, aspirin, and diuretics. ● Teach the client to limit physical or emotional stress. ● Remind the client to increase fluid intake. ● Encourage medication adherence. Describe FIBROMYALGIA pain ● The pain is typically described as a burning a gnawing pain that can be elicited by palpating "trigger points". ● The client can also experience chronic fatigue, sleep disturbances, and functional impairment. ● Pain and tenderness vary depending on stress, activity, and weather conditions. FIBROMYALGIA risk factors ● Females between ages of 30 and 50 ● History of rheumatologic conditions, chronic fatigue syndrome, or Lyme disease ● Deep sleep deprivation FIBROMYALGIA expected findings ● Mild to severe fatigue ● Sleep disturbances ● Numbness/tingling of extremities ● Sensitivity to noxious smells, loud noises, and bright lights ● Headaches ● Jaw pain ● Depression ● Concentration and memory difficulties ● GI manifestations: abdominal pain, heartburn, constipation, diarrhea ● Genitourinary manifestations: frequency, urgency, dysuria, pelvic pain ● Visual changes FIBROMYALGIA nursing care/client teaching ● Assess/monitor pain, mobility, and fatigue. ● Provide emotional support to the client and family CLIENT EDUCATION FIBROMYALGIA ● Teach the client to limit intake of caffeine, alcohol, and other substances that interfere with sleep. ● Teach the client to develop a routine for sleep.

1. A nurse is preparing to perform endotracheal (ET) tube care and plans to use tape to secure the tube. Which of the following is an appropriate preparatory action for this procedure ? Cut a piece of tape that reaches posteriorly from naris to naris. Have tincture of benzoin ready to apply to the patient's face. Prepare an astringent solution for cleaning the patient's face. Open a package of sterile gloves so they are ready to use.

The tape should be about 6 in longer than the distance from naris to naris posteriorly. Tincture of benzoin or a liquid adhesive not only protects the patient's skin, but it also prepares the skin around the nose or mouth and on the face for better adherence of the tape. The patient's face and neck should be cleaned with a soapy washcloth, then rinsed and dried. An astringent solution is inappropriate. Sterile gloves are not required when securing an ET tube.

A nurse is reviewing a client's repeat lab results 4 hrs after administering fresh frozen plasma (FFP). Which of the following lab results should the nurse review? a) Prothrombin time b) WBC count c) Platelet count d) Hematocrit

a) Prothrombin time The nurse should review the clients prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time Prothrombin Time (PT) (Coumadin) 11-14 seconds: therapeutic range 1.5-2x normal or control value Partial thromboplastin Time (aPTT) (Heparin) 16-40 range; therapeutic range 1.5-2x normal or control value

A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer? a. Corticosteroids b. Antimalarials c. Antidepressants d. Opioids

a. Corticosteroids . A red edematous rash bilaterally on the cheeks is a manifestation of systemic lupus erythematosus. Auto-antibody screening tests ● Detect the presence of antibodies against a person's own DNA (self cells). ● The presence of antibodies against self cells is associated with autoimmune conditions (systemic lupus erythematosus, rheumatoid arthritis). Lupus erythematosus ● Lupus varies in severity and progression. It is generally characterized by periods of exacerbations (flares) and remissions. ● Lupus is classified as discoid or systemic. A temporary form of lupus can be medication‑induced. ◯ Discoid lupus erythematosus (DLE) only affects the skin. ◯ Systemic lupus erythematosus (SLE) affects the connective tissues of multiple organ systems and can lead to major organ failure. ◯ Medication‑induced lupus erythematosus can be caused by medications (procainamide, hydralazine, isoniazid). Findings resolve when the medication is discontinued. ● Lupus can be difficult to diagnose because of the vague nature of early manifestations. LABORATORY TESTS Skin biopsy: Used to diagnose DLE by confirming the presence of lupus cells and cellular inflammation. Immunologic tests: Used to diagnose SLE ● Antinuclear antibodies (ANAs): antibodies produced against one's own DNA; positive titers in 95% of clients who have lupus ◯ SLE prep ◯ dsDNA (very specific for SLE; assists with differentiation between SLE and medication‑induced lupus) ◯ ssDNA ◯ Anti‑DNP ● Serum complement (C3, C4): decreased ◯ The complement system is made of proteins (there are nine major complement proteins). These proteins affect the immune system's development of inflammation. C3 and C4 are diagnostic for SLE because the exaggerated immune response in SLE depletes C3 and C4, leading to a decrease from the expected amount. ● Erythrocyte sedimentation rate (ESR): elevated due to systemic inflammation ● Anti-SS-a ● Anti-SS-b ● Anti-Smith ● Extractable nuclear antigens (ENAs) BUN and blood creatinine: Increased (with kidney involvement) Urinalysis: Positive for protein and RBCs (kidney involvement) CBC: Pancytopenia PATIENT‑CENTERED CARE NURSING CARE ● Assess/monitor the following. ◯ Pain, mobility, and fatigue ◯ Vital signs (especially blood pressure) ◯ Systemic manifestations ■ Hypertension and edema (renal compromise) ■ Urine output (renal compromise) ■ Diminished breath sounds (pleural effusion) ■ Tachycardia and sharp inspiratory chest pain (pericarditis) ■ Rubor, pallor, and cyanosis of hands/feet (vasculitis/ vasospasm, Raynaud's phenomenon) ■ Arthralgias, myalgias, and polyarthritis (joint and connective tissue involvement) ■ Changes in mental status that indicate neurologic involvement (psychoses, paresis, seizures) ■ BUN, blood creatinine level, and urinary output for renal involvement ■ Nutritional status ● Provide small, frequent meals if anorexia is a concern. Offer between‑meal supplements. ● Encourage the client to limit salt intake for fluid retention secondary to steroid therapy. ● Provide emotional support to the client and family. MEDICATIONS NSAIDs ● Used to reduce inflammation and arthritic pain. ● Contraindicated for clients who have impaired kidney function. NURSING ACTIONS: Monitor for NSAID‑induced hepatitis. Corticosteroids Prednisone is used for immunosuppression and to reduce inflammation. NURSING ACTIONS: Monitor for fluid retention, hypertension, and impaired kidney function. CLIENT EDUCATION ● Do not stop taking steroids abruptly. Gradually taper the dosage as prescribed. ● Older adult clients are at an increased risk for fractures if corticosteroid therapy is used. Immunosuppressant agents ● Methotrexate and azathioprine are used to suppress the immune response. ● Belimumab is a human monoclonal antibody administered with other medications for SLE that inhibits the stimulation of B-cells, reducing the autoimmune response. NURSING ACTIONS: Monitor for toxic effects and infection (bone marrow suppression, increased liver enzymes). CLIENT EDUCATION: Avoid live vaccine administration for 30 days before beginning immunosuppressant therapies. Antimalarial Hydroxychloroquine is used for suppression of synovitis, fever, and fatigue, and decreases the risk of developing skin lesions from the absorption of ultraviolet light from sun exposure. NURSING ACTIONS: Encourage frequent eye examinations. INTERPROFESSIONAL CARE ● Physical and occupational therapy services can be used for strengthening exercises and adaptive devices as needed. ● Refer clients to support groups as appropriate. CLIENT EDUCATION ● Wear a wide-brimmed hat, long-sleeve shirt, and long pants when outdoors. ● Avoid UV and prolonged sun exposure. Use sunscreen when outside and exposed to sunlight. ● Use mild protein shampoo and avoid harsh hair treatments. ● Use steroid creams for skin rash. ● Report peripheral and periorbital edema promptly. ● Report evidence of infection related to immunosuppression. ● Avoid crowds and individuals who are sick, because illness can precipitate an exacerbation. ● Understand the risks of pregnancy with lupus and treatment medications. ● Cleanse skin with mild soap, and inspect for open areas and rashes daily. ● Apply lotion to dry skin. ● Avoid applying drying agents to skin, such as powder or rubbing alcohol. ● Pat skin dry rather than rubbing. ● Understand the effect of the disease on lifestyle. COMPLICATIONS Lupus nephritis Clients whose SLE cannot be managed with immunosuppressants and corticosteroids can experience chronic kidney disease, resulting in the possible need for a kidney transplant. Lupus nephritis is the leading cause of death related to SLE. NURSING ACTIONS: Monitor for periorbital and lower extremity swelling and hypertension. Monitor renal status (creatinine, BUN). CLIENT EDUCATION ● Take immunosuppressants and corticosteroids as prescribed. ● Avoid stress and illness. Pericarditis and myocarditis Inflammation of the heart, its vessels, and the surrounding sac can occur secondary to SLE. NURSING ACTIONS: Monitor for chest pain, fatigue, arrhythmias, and fever.

A nurse is transfusing a unit of O-negative fresh frozen plasma to a client whose blood type is B positive. Which of the following actions should the nurse take? a) Continue to monitor for manifestations of a transfusion reaction b) Remove the unit of plasma immediately and start an IV infusion of normal saline solution c) Continue the transfusion and repeat the type and crossmatch d) Prepare to administer a dose of diphenhydramine IV

b) Remove the unit of plasma immediately and start an IV infusion of normal saline solution A client who receives FFB that is not compatible can experience a hemolytic transfusion reaction. The nurse should stop the transfusion and infuse 0.9% sodium chloride solution with new tubing.

A nurse is suctioning a patient's airway using in-line suctioning. When using this method, it is appropriate for the nurse to: · hyperoxygenate the patient before disconnecting the ventilator. · apply suction pressure while advancing the catheter. · wear a face shield during the procedure. · reuse the catheter repeatedly.

hyperoxygenate the patient before disconnecting the ventilator. With in-line suctioning, it is not necessary to disconnect the patient from the ventilator. apply suction pressure while advancing the catheter. For any method of endotracheal or tracheostomy suctioning, applying suction when inserting the catheter is inappropriate as it could cause tissue trauma and oxygen depletion. wear a face shield during the procedure. With in-line suctioning, the nurse is not exposed to airway secretions because the catheter is enclosed in a plastic sheath. Therefore, a face shield is not necessary. reuse the catheter repeatedly. MY ANSWER With in-line suctioning, the catheter attaches to the ventilator tubing and does not have to be replaced until the system is replaced. It can be used repeatedly.