med surg 2 unit exam 1
A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?
"Are the burns associated with chemicals used in the plant?"
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
"I will receive parenteral vitamin B12 therapy for the rest of my life."
A nurse is conducting a presentation about brain cancer for a local community group. During the presentation, one of the group members asks, "What causes brain tumors?" Which response by the nurse would be most appropriate?
"The cause of most brain tumors is still really not known."
malignant hyperthermia
-A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. -life-threatening -s/s: 1. High ETCO2 (ET > 50-60) <- first S/S 2. Tachycardia 3. Hypertension 4. Dysrhythmias 5. Muscle rigidity 6. tachypnea 7. fever 8. metabolic acidosis treatment: -d/c surgery -antidote: dantrolene -100% oxygen -cold IV fluids, ice packs -sodium bicarb for metabolic acidosis
amyotrophic lateral sclerosis (ALS)
-Advanced Life Support: patients usually die within 3-5 years -degeneration of brain and spinal cord motor neurons -age >40 -progressive weakness leading to total body paralysis, resp failure, and death dx: -based on symptoms s/s: -dysphagia -dysphasia -increased respiratory secretions -Bulbar: inappropriate laughter/crying management: -riluzole: delays progression and need for tracheostomy -monitor airway -keep HOB up to prevent aspiration -monitor swallowing -rest -prevent pneumonia
rheumatoid arthritis
-autoimmune d/o involving swelling, inflammation, and destruction of joint cartilage -exacerbation and remission -females more like (20-50) -family hx s/s -bilateral, symmetrical joint pain and swelling -morning stiffness -swan neck -ankylosis: joint fixation and deformity -subcutaneous nodules -fever -red sclera -lymph adenopathy labs: -+ rheumatoid factor -+ ANA factor treatment: -prednisone, methotrexate -NSAIDs -hydroxychloroquine -plasmapheresis
Toxic Epidermal Necrolysis (TEN)
-autoimmune, toxic skin reaction to medications with sloughing of skin and mucous membranes on >30% body -flu like symptoms -begins on face and chest -redness, then blistering, then sheets of skin falling off -dx: skin biopsy -CD48 cells and natural killer cells attacking skin -d/c medication -causative drugs: sulfas, anticonvulsants -monitor for infection
hypermagnesemia
-bradycardia -hypotension -hyporeflexia -depressed respirations -hypoactive bowel sounds
metastatic brain tumors
-brain tumors that develop when cancer cells from other parts of the body travel through the bloodstream to the brain -come from lungs, kidneys, skin, breast, colon, thyroid treatment (palliative): -whole brain radiation therapy -intrathecal chemotherapy (injected directly into brain or spinal cord) management: -ADLs -promote independence -nutrition, relieve n/v
hypercalcemia
-constipation -bone pain -kidney stones -decreased DTRs -muscle weakness
Hodgkins lymphoma
-distinguished from other lymphomas by the presence of large, cancerous lymphocytes known as Reed-Sternberg cells -idiopathic -adenopathy (local) -contagious -no hepatosplenomegaly or leukemic phase -young adults -most treatable -radiation + chemo
benign paroxysmal positional vertigo (BPPV)
-ear rocks get out of place -causes vertigo, nausea -NO hearing loss (unlike Meniere's) -intermittent s/s management: -treat underlying cause -safety/fall risk/bed rest -Epley maneuver -meds for vertigo
Myasthenia gravis
-eyes and dry -gravity = muscle weakness management: -cholinergics (-stigmine) to add secretions myasthenic crisis: -diaphragm weakness and respiratory arrest -airway -have intubation set up at bedside -give -stigmine meds before meals -semi solid foods
hypernatremia
-flushed skin -edema -fever -polydipsia -swollen dry tongue -nausea/vomiting -increased muscle tone
gout
-metabolic disorder that causes hyperuricemia (increased uric acid crystals) s/s: -joint pain -redness and swelling -tophi: enlarged painful areas on joints -usually affects great toe labs: -uric acid (2.6-7.2) -uric crystals in arthrocentesis management -colchicine: decreases pain and inflammation during acute attack -NSAIDs -ice -allopurinol (chronic) -avoid alcohol -avoid purine rich foods: red meat, shellfish, fructose rich drinks -avoid fasting -reduce stress
Non Hodgkins
-painless enlarged lymph nodes -extranodal sites -not contagious -hepatosplenomegaly and leukemic phase -No Reed Sternberg cells -mid 50s adults -pancytopenia: anemia, infection, bleeding
hypocalcemia
-positive Chvosteks and Trousseau signs -diarrhea -facial tingling
Meniere's disease
-problem with balance due to inner ear fluid imbalance s/s: -sudden attacks of vertigo -nausea/vomiting -sweating, pallor -ear fullness -tinnitus -hearing loss -"drop attacks:" being pulled to the ground dx: -audiogram -vestibular test -glycerol test management: -fall risk/safety/bed rest -minimize stimulation -avoid *sudden* head movements -antihistamines during attacks -antiemetics -anticholinergics -valium/benzos/fentanyl to reduce vertigo -hydrops diet: low sodium/caffeine/nicotine/alcohol/MSG -diuretics
Huntington's
-progressive, neurodegenerative, autosomal dominant disease affecting the brain and nervous system s/s: -chorea -confusion, mood swings -memory loss -poor impulse control -depression -mania dx: -genetic testing management: -psych meds -tetrabenazine for chorea
s/s of respiratory alkalosis
-seizures -deep, rapid breathing -hyperventilation -tachycardia -decreased or normal BP -hypokalemia -numbness and tingling of extremities -lethargy and confusion -light headedness -nausea, vomiting
hyponatremia
-seizures and coma -tachycardia -weak thready pulse -respiratory arrest
acute phase of burns
-silver sulfadazine -mafenide acetate
ARDS
-sudden and progressive pulmonary edema -bilateral infiltrates on chest xray -hypoxemia unresponsive to oxygen -absence of elevated left atrial pressure
hypomagnesemia
-torsades des pointes -v fib -tachycardia -increased DTR -nystagmus -diarrhea
urine output/hour goal for burns
0.5 ml/kg/hr
Scleroderma (systemic sclerosis)
1. Autoimmune disorder causing overproduction of collagen leading to hardening, thickening, and stiffening of connective tissues 2. Porcelain doll appearance 3. Raynaud's Phenomenon: Episodic vasoconstriction of digits, white discoloration, related to cold *wear gloves* 4. Oral finding: Widening of PDL space all teeth 5. Joint pain 6. Pitting edema in hands with taut, shiny skin 7. Acid reflux or dysphagia 8. Dyspnea (due to fibrosis of lung tissue) 9. Malignant hypertension (due to fibrosis of kidneys) labs: -+ ANA titer -ESR treatment: -prednisone or methotrexate -ACE inhibitors i.e. captopril -moisturize -rest -avoid stress and cold
interventions during burns
1. maintain airway 2. fluid resuscitation 3. oxygenation 4. monitor urine output 5. give tetanus vacc
chest tubes
3 chambers: -drainage collection: chart amount and color, report >100 mL/hour -water seal: sterile fluid >2 cm line, keep below chest insertion site, tidaling expected (rise on inhale lower on exhale), lack of tidaling could be obstruction, continuous bubbling means air leak -suction control: continuous bubbling expected management: -chest xray to confirm placement -occlusive dressing -monitor site for infection and subcutaneous emphysema -only clamp if ordered -deep breathing and coughing -if tube becomes disconnected, place end in sterile water
parkland formula for burns
4 ml x Kg x % burn surface area give 1/2 fluids in first 8 hours. remaining 1/2 in last 16 hours.
hypokalemia s/s
A SIC WALT Alkalosis Shallow respiration Irritability Confusion and drowsiness Weakness and fatigue Arrhythmias- irregular heart rate, tachycardia Lethargy Thready pulse decrease intestinal mobility, nausea and vomiting paralytic ileus (paralyzed intestine) decreased DTRs
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?
A urinary output of 30 mL/hr For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).
systemic lupus erythematosus (SLE)
chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs dx criteria (4 or more) 1. malar (butterfly) rash 2. ulcers 3. arthritis 4. pancytopenia management 1. avoid sunlight 2. corticosteroids 3. immunosuppressants
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to
decrease catabolism.
factors that affect severity of burns
depth location age agent
deep partial thickness burn (2nd degree)
extends deep into dermis red or white color soft or dry eschar
s/s of metabolic alkalosis
headache, irritability, lethargy, changes in lvevel on consciousness, confusion, changes in heart rate, slow shallow resp. with periods of apnea; nausea & vomiting, hyperactive reflexes and numbness of extremities.
thoracotomy
incision into the chest cavity, done when a patient has a pneumothorax and more than 1500 mL of blood is aspirated or chest tube is draining > 200 mL blood/hour
Clients diagnosed with hypervolemia should avoid sweet or dry food because it
increases the client's desire to consume fluid.
deep full thickness burn
involves injury to the muscle, bone, and tendons. appears black and eschar is hard and inelastic
Lithotomy
legs up, back flat position for perineal, rectal, and vaginal surgeries
A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include?
located over bony prominence
Sims
lying on side position used for renal surgery
A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:
pain management
contractures in burns
passive ROM exercises
brachytherapy
radiation therapy in which the source of radiation is implanted in the tissue to be treated
superficial or partial thickness burn, 2nd degree
red or pink color mild-mod edema blisters upper layer of dermis
multiple myeloma
s/s CRAB: -calcium elevated >11 -renal insufficiency -anemia (RBCs lowered) -bone lesions first s/s back or rib pain, weakness >10% plasma cells in bone marrow biopsy risk for infection as WBCs are lowered
3rd degree burn
severe edema, no blisters, hard and inelastic eschar, nerve endings destroyed, into subQ tissue
inhalation injury
singed eyebrows or nasal hairs sooty sputum
CPAP
treatment for hypoxemia and respiratory acidosis
What assessment method would the nurse use to determine the areas of the lungs that need draining?
Auscultation
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?
Blood-tinged sputum
Which of the following are complications related to polycythemia vera (PV)? Select all that apply.
CVA MI Ulcers Hematuria
s/s of metabolic acidosis
Changing leves of consciousness, ranging from fatigue, & confusion to stupor & coma, headache, vomiting & diarrhea, anorexia, muscle weakness & cardiac dysrhythmias.
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?
Confusion
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:
Continue to take antibiotics for 10 days
A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?
Cough or change in chronic cough
A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication?
Employs the Z-track technique When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 18- or 20-gauge needle.
Rule of 9's for burns
Head = 9% Arms = 18% (9% each) Back = 18%, Front/chest 18% Legs 36% (18% each) Genitalia = 1
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?
Hypercalcemia Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?
Instruct the client to breathe into a paper bag.
What is the only known risk factor for brain tumors?
Ionizing radiation
A client has a serum study that is positive for the rheumatoid factor. What will the nurse tell the client about the significance of this test result?
It is suggestive of rheumatoid arthritis. Rheumatoid factor is present in about 70% to 80% of patients with rheumatoid arthritis, but its presence alone is not diagnostic of rheumatoid arthritis, and its absence does not rule out the diagnosis.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
Kinking of the ventilator tubing
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?
Lactated Ringer's
hyperkalemia s/s
M.U.R.D.E.R. M - Muscle weakness U - Urine, oliguria, anuria R- Respiratory distress D - Decreased cardiac contractility E - ECG changes R - Reflexes, hyperreflexia, or areflexia (flaccid)
A client diagnosed with benign paroxysmal positional vertigo is experiencing an acute attack. The client is prescribed a vestibular suppressant. Which medication would the nurse anticipate being used?
Meclizine Clients with acute vertigo are treated with medications that target vertigo and its related symptoms of nausea, vomiting, and anxiety. Vestibular suppressants that are commonly used originate from classes of anticholinergics (scopolamine), antihistamines (meclizine, dimenhydrinate), and benzodiazepines. Meclizine is often the drug of choice, with clients treated for a 1- to 2- week course of therapy. Antiemetic medications, such as phenothiazines, are used to treat nausea.
The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has?
Multiple myeloma Any older adult with unprovoked or unexplained back pain and increased protein in the serum should be assessed for multiple myeloma. Bone pain occurs because of bone breakdown and the malignant cells of multiple myeloma increase the serum protein levels.
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms?
Multiple myeloma The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia.
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
s/s of respiratory acidosis
Pulmonary s/s - dyspnea, rapid, shallow respirations Skin- cyanotic, pallor Nervous system s/s - headache, restlessness, confusion, may progress to drowsiness and unresponsiveness if CO2 levels are too high. Cardio s/s - tachycardia, dysrhythmias, high bp, increased cardiac output Other: headache, muscle weakness, disorientation, hyperkalemia, hypoxia
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Record the observation The nurse should record the observation. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. It is unnecessary to report the finding to the physician or apply a compression dressing because subcutaneous emphysema is an expected finding at this stage of recovery. Subcutaneous emphysema is not an explicit risk factor for hypoxemia, so no extraordinary monitoring of pulse oximetry is necessary.
stages of burns
STAGE ONE--EMERGENT PHASE STAGE TWO---INTERMEDIATE OR ACUTE OR DIURETIC PHASE STAGE THREE---LONG TERM REHABILITATION PHASE
Scleroderma typically starts with which type of organ involvement?
Skin Scleroderma commonly begins with skin involvement. Mononuclear cells cluster on the skin and stimulate lymphokines to stimulate procollagen. Scleroderma does not commonly begin in the lung, brain, or kidney.
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?
Stabbing pain during respiratory movement
A client is newly diagnosed with Hodgkin lymphoma. The nurse understands that the client's treatment will be based on what concept?
Staging of the disease
Which of the following disorders is characterized by an increased autoantibody production?
Systemic lupus erythematosus (SLE) SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.
The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?
The client with enlarged lymph nodes in the neck. Lymph node enlargement in Hodgkin lymphoma is not painful. The client with enlarged lymph nodes in the neck is most likely to have Hodgkin lymphoma if the enlarged nodes are painless. Sore throat is not a sign for this disorder.
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove air from the pleural space
When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that all leukemias have which common feature?
Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements