Final Exam Study Guide Acute Med/Surg

A nurse is caring for a client with a blocked bile duct from a stone. What manifestation of obstructive jaundice should the nurse anticipate?

dark orange, frothy urine

A participant in a heath fair had asked a nurse about the role of drugs in liver disease. What health teaching has the most potential to prevent drug-induced hepatitis?

Adhere to dosing recommendation of OTC analgesics.

A patient who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response?

"To detect and treat dysrhythmias such as as ventricular fibrillation and ventricular tachycardia." The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or tachycardia.

A nurse that provides care in a walk-in clinic assess a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis?

A 39-yo man with chronic alcoholism

A client's physician has ordered a liver panel in response to the client's development of jaundice. When reviewing the results of the lab findings, the nurse should expect to review what blood tests? (SATA)

AST ALT GGT

A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in the patient's immediate care? (SATA)

Administering beta blockers to reduce heart rate Applying interventions to reduce the patient's heart rate

A patient is brought to the ED by the paramedics, who report that the patient has partial thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the of care in a patient who has been burned and suffered smoke inhalation?

Airway management

What should a nurse teach a client on corticosteroid therapy in order to reduce the risk of adrenal insufficiency?

Always have enough medication on hand to avoid running out. The client and family should be informed that acute adrenal insufficiency and underlying symptoms will recur if corticosteroid therapy is stopped abruptly without medical supervision. The client should be instructed to have an adequate supply of corticosteroid medication always on hand to avoid running out. Doses should not be skipped or added without explicit instructions to do so. Corticosteroids should normally be taken in the morning to mimic the natural rhythms.

Which one of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelytis?

An elderly client with an infected pressure ulcer in the sacral area

The nurse is developing a teaching plan for a male client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with DI?

Anti-diuretic Hormone

The nurse is caring for a client with mitral valve prolapse. Most people with mitral valve prolapse never have symptoms, though this is not the case for every client. What symptoms would be consistent with this diagnosis? SATA

Anxiety Fatigue Palpitations Most people who have Mitral valve prolapse never have symptoms. A few have symptoms of fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. Hyperpnea and shoulder pain are not characteristic symptoms of mitral valve prolapse.

The community heath nurse is caring for a client whose multiple health problems include chronic pancreatitis. During the most recent home visit, the nurse learns that the client is experiencing severe abdominal pain and has vomited 3x in the past several hours. What is the nurse's most appropriate action?

Arrange for the client to be transported to the hospital.

A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, What action should be included in the plan of care?

Assess the pin insertion site every 8 hours

A client is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Asterixis

A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery?

Bile-duct injury

A client is reporting pain in her casted leg. The nurse has administer analgesics and elevated the limb. Thirty minutes after administering analgesics, the client states the pain was unrelieved. The nurse should identify the signs of what complication?

Compartment Syndrome

A patient converts from a normal sinus rhythm at 80bpm to atrial fibrillation with a ventricular response at 166bpm. BP=164/74 mmHg, RR= 20bpm, with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what?

Control Ventricular Heart rate Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anti-coagulation with heparin and Coumadin.

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what?

Defibrillation Any type of VT in a patient who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD angioplasty does not address the dysrhythmia.

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring Hep C in the workplace?

Disposing of sharps appropriately and not recapping needles.

A client diagnosed with meningitis says," I'm just so thirsty, I can't seem to get enough to drink. I've been urinating a lot too." The nurse checks the clients urine specific gravity and finds it to be very dilute. The nurse suspects that the client may be developing DI. Which assessment finding would support the nurse's suspicion? (SATA)

Dry Mucous Membranes Poor skin turgor Hypotension With DI, daily output of very dilute urine (3-20L) with nocturia, frequency, and a urine specific gravity of 1.000-1.005 occurs. Signs and symptoms of fluid volume deficit that occur as clients are unable to compensate for the massive urinary loss include weight loss, poor skin turgor, dry mucous membranes, increased heart rate and hypotension.

A nurse is in a busy ED provides care for many clients who present with contusions, strains, or sprains. What are medical treatment modalities that are common to all of these injuries?

Elevate the injured limb Resting the effected extremity Compression dressings Apply ice

A nurse is caring for a client who has a leg cast. The nurse observes that the client uses a pencil to scratch the skin under the edge of cast. How should the nurse respond to this observation?

Encourage the client to avoid scratching, and obtain a prescription for an antihistamine if severe itching persists.

The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse preform?

Ensure no one is touching the patient at the time shock is delivered In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads, or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads/paddles and the patient's skin to prevent leaking. Second, ensure that no one is in contact with the patient or with anything that is touching the patient when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the patient. Ventilation should be stopped during defibrillation.

Following an Addisonian crisis, a patient's adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances? A) Episodes of high psychosocial stress B) Periods of dehydration C) Episodes of physical exertion D) Administration of a vaccine

Episodes of high psychosocial stress

A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patient's pain, the nurse should anticipate that it may radiate to what region?

Right shoulder

The first line of treatment for Asystole is defibrillation.

False

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. What early complications should the nurse monitor for this client?

Fat Embolism Compartment Syndrome DVT

A nurse is preforming a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, increase heart rate and respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick white sputum. The nurse recognizes that this is a medical emergency and calls for assistance recognizing that this patient is demonstrating symptoms of what complication?

Fat embolism syndrome

The nurse is caring for a client who has hypothyroidism secondary to Hashimoto's thyroiditis. When assessing this client, what sign/symptom would the nurse expect?

Fatigue Symptoms of hypothyroidism include extreme fatigue, hair loss, brittle nails, voice huskiness or hoarseness, menstrual disturbance, and numbness/ tingling of the fingers. Bulging eyes, palpitations and flushed skin would be signs/symptoms of hyperthyroidism.

During a heath education session, a participant has asked about Hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with the virus?

Follow proper hand washing techniques

The nurse is auscultating the breath sounds of an adult with pericarditis. What finding is most consistent with this diagnosis?

Friction rub A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema and fluid accumulation, whereas wheezes signal airway constriction; neither of which occur with pericarditis.

A nurse is assisting with serving dinner trays on a unit. Upon receiving the tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Fried Chicken

A nurse has entered the room of a client with cirrhosis and found the client on the floor. The client states that she fell while transferring to the commode. The client's vital signs are within reference range and the nurse observes no apparent injuries. What is the nurse's most appropriate action?

Have the client assessed by the PCP due to the risk of internal bleeding.

A client diagnosed with thyroid cancer has undergone a thyroidectomy and is returning to the unit. When developing the client's plan of care, which action would be a priority?

Having a tracheostomy tray at the bedside Although ensuring adequate hydration with IV fluids, monitoring frequent vital signs and administering analgesics for pain are important, the priority would be to ensure that a tracheostomy tray is at the bedside. respiratory difficulties can occur as a result of edema of the glottis, hematoma formation, or injury to the recurrent laryngeal nerve. This complication requires insertion of an airway. It is vital to have a tracheostomy set at the bedside at all times, in the event of significant edema, placement of an endotracheal tube is unlikely.

A 17-yo boy is being treated in the ICU after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest. What type of cardiomyopathy is particularly common among young people who appear otherwise healthy?

Hypertrophic Cardiomyopathy (HCM) With HCM, cardiac arrest (i.e. sudden cardiac death) may be the initial manifestation in young people, including athletes, DCM, ARVC, and RCM are not typically present in younger adults who appear otherwise healthy.

The nurse is caring for a patient who is at risk for addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient for? (SATA)

Hypotension Rapid Respiratory Rate Pallor The patient at risk is monitored for signs and symptoms of addisonian crisis, which can include: shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and bounding pulse are not signs/symptoms of addisonian crisis.

Following a thyroidectomy, a client exhibits tetany. The nurse anticipates administering which medication?

IV Calcium Gluconate Usually tetany is treated with Calcium Gluconate. Methimazole. Propylthiouricil, and potassium iodide are agents used to treat hyperthyroidism.

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased bleeding risk. The nurse realizes this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?

Inability of the liver to use vitamin K

A client has come to the orthopedic clinic for a follow up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union isn't taking place. What factor may have contributed to this complication?

Inadequate immobilization

A client's ultrasound indicates cholelithiasis. when the nurse is reviewing the client's labs, which finding is most closely associated with this diagnosis?

Increased Bilirubin

The nursing care plan for a client in traction specifies regular assessments for venous thromboemboli. When assessing a client's lower limbs, what sign/symptom is suggestive of DVT?

Increased warmth of the calf

A nurse is emptying an orthopedic surgery patient's closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse's best action?

Inform the surgeon of this finding

A patient with cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?

Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure

The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation the educator points out the need to emphasize that aortic regurgitation causes what?

Left ventricular hypertrophy Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood from the aorta returns to the left ventricle during diastole in addition to the blood normally delivered by the left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. Aortic regurgitation does not cause cardiac tamponade, right sided heart failure, or ventricular insufficiency.

A nurse is reviewing the heath record of a patient who has SIADH. Which of the following lab findings should the nurse anticipate? (SATA)

Low serum Na+ High urine Na+ Increased Urine Specific Gravity

A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of ineffective breathing pattern related to pain. What interventions should the nurse preform in order to best address this diagnosis?

Maintain the patient in a semi-Fowler's position whenever possible.

An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 min before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?

Morphine, Oxygen, Nitroglycerin, Bed rest The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces pre-load and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, the provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.

A cardiac telemetry charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first?

Patient with tetany who has a new order for IV calcium gluconate

A client with diabetes is attending a class on the prevention of associated diseases. What action should the client preform to reduce the risk of osteomyelitis?

Perform meticulous foot care

A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease?

Recognizing and promptly treating streptococcal infections Group A streptococcus can cause rheumatic heart fever, resulting in rheumatic endocarditis. Being aware of signs and symptoms of streptococcal infections, identifying them quickly, and treating them promptly, are the best preventative techniques for rheumatic endocarditis. Smoking cessation, immunizations, and calcium channel blockers will not prevent rheumatic heart disease.

A nurse is providing care to a client diagnosed with syndrome of inappropriate anti-diuretic hormone. The nurse understand that the primary problem involves the:

Posterior pituitary gland The posterior lobe of the pituitary gland secreted ADH (AKA vasopressin); too little ADH results in DI, too much results in SIADH. SIADH is not involved with the anterior pituitary, adrenal or thyroid glands.

A cardiac surgery patient's new onset of symptoms is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action?

Prepare to assist with pericardocentesis Cardiac tamponade requires immediate pericardiocentesis. Beta blockers and fluid boluses will not relieve pressure on the heart and prone positioning would likely exacerbate symptoms.

A patient who has had an amputation is being cared for by a multidisciplinary rehab team. What is the goal of this team?

Promote the patient's highest level of function

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the dorsalis pedis or posterior tibial pulse, and the client's foot is pale. What is the nurse's most appropriate action?

Promptly inform the primary provider

The nurse educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. The pathologic change is most evident in which component of the ECG?

QRS Complex The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle.

An adult patient with a third degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What characteristic will the ECG most likely show?

QRS complexes are not in relation/rhythm to the P waves. In the third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result, there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural nodes (pacemakers) rates of the heart. The other ECG changes are not consistent with this diagnosis.

The nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response?

Report his finding to the PCP due to the possibility of hepatic encephalopathy.

A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session?

Reporting signs of impaired circulation

A nurse is writing a care plan for a patient admitted to the ED with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius?

Risk for infection

You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have highest priority in this care plan?

Risk for injury related to weakness The nursing priority is to decrease the risk of injury by establishing a protective environment. The patient who is weak and may require assistance from the nurse in ambulating to prevent falls or bumping corners of furniture. The patient's breathing will not be affected and autonomic dysreflexia is not a plausable risk. Loniliness may or may not be an issue for the patient, but the risk of injury is the priority.

A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient?

Semi-fowler's with the head supported on two pillows When moving and turning the patient, the nurse carefully supports the patient's head and avoids tension on the sutures. The most comfortable position is semi-fowler's position with the head supported by pillows.

A 37-yo Male client presents to the ED reporting nausea and vomiting with severe abdominal pain. The client's abdomen is rigid and there is bruising to the client's flank. The client's wife says he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problems?

Severe pancreatitis with possible peritonitis

A nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the management of activity and mobility in this patient?

Stress on the weakened bone must be avoided

The nurse is providing education to a patient who is on Corticosteroid steroid therapy. Patient education should include: (SATA)

Take Medication with food Do not stop medication suddenly Signs of Hyperglycemia Perform weight bearing exercise

A nurse is caring for a patient who just had a plaster cast applied. Immediately post-application the nurse should provide which teaching to the client?

The cast will only have full strength when dry.

A client with suspected adrenal insufficiency has been ordered an ACTH stimulation test. Administration of ACTH caused a marked increase in the client's cortisol levels. How should the nurse interpret this finding?

The client's pituitary function is compromised. An adrenal response to the administration of a stimulating hormone suggests inadequate production of a hormone. In this case ACTH is produced by the pituitary gland and, consequently, pituitary hypofunction is suggested. Hypothalmic function is not relevant to the physiology of this problem. Treatment exists, although surgery is not likely indicated.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response?

The difference is the timing of the delivery of the electrical current. One major difference between cardioversion and defibrillation is the timing of delivery of electrical current. In cardioversion, the electrical current is synchronized with the patient's electrical events; in defibrillation, the electrical current is immediate and unsynchronized. Both can be done on a beating heart (i.e. dysrhythmia). Cardioversion is not necessarily attempted first.

The nurse is caring for a client with Addison disease who is scheduled for discharge. When teaching the client about hormone replacement therapy, the nurse should address which topic?

The need for lifelong steroid replacement.

The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs?

The patient experiences chest pain, palpitations, or dyspnea. Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients a respiratory rate that exceeds 30 breaths/minute is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.

Most patients tolerate PAC's with no necessary interventions.

True

Signs of symptomatic bradycardia can include dizziness or syncope; confusion or disorientation; and shortness of breath.

True

The client has returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse should assess for indications of what potential complications? SATA

Ventricular Dysrhythmia Emboli Bleeding at catheter insertion site Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, and bleeding from the catheter insertion sites. Atrial-septal defect and plaque formation are not complications of a balloon valvuloplasty.

While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma near at the surgical site. The affected leg has a decreased pedal pulse. what would be the priority nursing diagnosis for this client?

risk for ineffective peripheral tissue perfusion

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on a medical unit. The patient's current medication regimen includes lactulose 4x/day. What desired outcome should the nurse relate to this pharmacologic intervention?

2-3 soft bowel movements/day

A nurse has reported for a shift at a busy burns and plastic unit in a large university hospital. which client is most likely to have life-threatening conditions?

A 4 yo scald victim burned 24% of her body

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first?

A 70-yo female taking levothyroxine who has an irregular pulse of 164bpm.

A client reports that she has gained weight and her body and face are "rounder", while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. The nurse should assess further for:

Bruised areas on the skin

The nurse is assessing a client diagnosed with Grave's disease. What physical characteristics of Grave's disease would the nurse expect to find?

Bulging Eyes

A patient has been living with dilated cardiomyopathy for several years but had experienced worsening symptoms despite aggressive medical management. The nurse should anticipate which potential treatment?

Heart Transplant When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplant, is considered. Valvuloplasty, stent placement, and cardiac catheterization will not address the pathophysiology of cardiomyopathy.

A client comes to the clinic for an evaluation. During the health history, the client reports feeling tired all the time and feeling overall sluggish. The nurse suspects that the client may be experiencing hypothyroidism. Which assessment findings would the nurse expect to identify to confirm this suspicion? (SATA)

brittle nails peripheral edema coarse, dry hair

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

daily weights and abdominal girth assessments