Med Surg Exam #1 (Ch 17, 19, 21, 22, 23 & 64)

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem? a. Assisting the client to pre-plan for this event b. Reassuring the client that alopecia is temporary c. Teaching the client ways to protect the scalp d. Telling the client that there are worse side effects

ANS: A Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the client's own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.

The nurse working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves

ANS: A As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best? a. Call the client at home the next day to review teaching. b. Give the client information about a cancer support group. c. Provide all the preoperative instructions in writing. d. Reassure the client that surgery will be over soon.

ANS: A Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the client's ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.

A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse? a. Allowing a very tired client to skip oral hygiene and sleep b. Assisting clients with washing the perianal area every 12 hours c. Helping the client use a soft-bristled toothbrush for oral care d. Reminding the client to rinse the mouth with water or saline

ANS: A Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.

A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority? a. Blood pressure b. Lung assessment c. Oral mucous membranes d. Skin integrity

ANS: A Interleukins can cause capillary leak syndrome and fluid shifting, leading to intravascular volume depletion. Although all assessments are important in caring for clients with cancer, blood pressure and other assessments of fluid status take priority

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Assessing the IV site every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort

ANS: A Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the nurse needs to assess further.

A nurse reads on a hospitalized client's chart that the client is receiving teletherapy. What action by the nurse is best? a. Coordinate continuation of the therapy. b. Place the client on radiation precautions. c. No action by the nurse is needed at this time. d. Restrict visitors to only adults over age 18.

ANS: A The client needs to continue with radiation therapy, and the nurse can coordinate this with the appropriate department. The client is not radioactive, so radiation precautions and limiting visitors are not necessary.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? a. Epoetin alfa (Epogen) b. Filgrastim (Neupogen) c. Mesna (Mesnex) d. Oprelvekin (Neumega)

ANS: A The client's hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the client's gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the client's job risks.

ANS: A This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.

A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is the priority? a. Assess blood pressure and pulse. b. Attach the client to a pulse oximeter. c. Have the client rate his or her pain. d. Start high-dose steroid therapy.

ANS: A This client has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked. Decreased cardiac output can occur. The nurse should assess indicators of cardiac output, including blood pressure and pulse, as the priority. The other actions are also appropriate but are not the priority.

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. "Chemo" gloves b. Facemask c. Isolation gown d. N95 respirator e. Shoe covers

ANS: A, B, C The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or "chemo" gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required.

A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the client's right to know and ask for their assistance. d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will not be kept from the client.

ANS: A, B, C The client's right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the client's right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.

A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care.

ANS: A, B, D Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client's shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care.

A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.) a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. d. Provide local anesthetic medications to swish and spit. e. Remind the client to brush teeth gently after each meal.

ANS: A, B, D, E Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids would be painful for the client.

A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client with a hot water bath. e. Teach the client to avoid sunlight.

ANS: A, C The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.

A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.

ANS: A, C, D, E Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.

A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate? a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facility's standing policy. d. Place the client on protective isolation precautions.

ANS: B A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client should be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

Protease Inhibitors: Examples

***navir*** saquinavir (Invirase) indinavir (Crixivan) nelfinavir (Viracept)

Physical assessment/clinical manifestations

*Dependent upon pathogen and site of infection* - S/S of inflammation -Lymphadenopathy

TRANSMISSION OF INFECTIOUS AGENTS

*Requires these factors:* • Reservoir (or source) of infectious agents • Susceptible host with a portal of entry • Mode of transmission

Managing hyperthermia

- *Eliminate underlying cause of fever (hyperthermia)*- Destroy causative microorganism - *Drug therapy *(antipyretic) •Acetaminophin •NSAIDS - External cooling (e.g. cold washcloths) *avoid shivering* - Fluid administration -24 hrs after fever: no longer contagious

VANCOMYCIN-RESISTANT ENTEROCOCCUS (VRET) Treatment

- Doxycycline, chloramphenicol, linezolid and rifampin - If susceptible: penicillin and ampicillin- Contact precautions - Decontaminate patient's room with UV light or bleach

Exogenous infection

- From outside the patient, often from tubes, implants, or health care workers' hands

Endogenous infection

- From patient flora

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS(MRSA): Spread by

- Indwelling urinary catheters - Vascular access devices - Endotracheal tubes

Factors that Influence Infection

- Normal flora -Age -Hormones - Skin/mucous membranes/normal excretory secretions - Nutrition - Drug, alcohol, tobacco use - Medical interventions

COMMUNITY-ASSOCIATED MRSA (CA-MRSA): Health teaching

- Perform frequent hand hygiene, including use of hand sanitizers - Avoid close contact with people with infectious wounds - Avoid large crowds - Avoid contaminated surfaces - Use good overall hygiene

CARBAPENUM-RESISTANT ENTEROBACTERIACEAE (CRE): Treatment

- Polymyxins -aminoglycosides -tigecycline -fosfomycin -temocillin

ROUTES OF TRANSMISSION: Genitourinary tract

- UTIs commonly caused by normal flora (such as Escherichia coli)

features of cancer cells

- anaplasia - larger nuclear-cytoplasmic ration - specific functions are lost - loose adherence - migration - no contact inhibition - rapid or continuous cell division - abnormal chromosomes

"red flags" for genetic predisposition to cancer

- cancer of any type appears in multiple members of every generation of family - similar cancers appear in multiple first-degree relatives - multiple instance of rare cancer types occur within a family - cancer occurs at ages several decades younger than the national average - cancer develops in both of paired organs (e.g. bi-lateral breast cancer) - breast cancer is present in a genetic male adult, regardless of gender identity

CLOSTRIDIUM DIFFICILE (C. DIFFICILE): Treatment

- metronidazole (Flagyl) - vancomycin - Fecal transplant

features of benign tumor cells

- specific morphology - smaller nuclear-to-cytoplasmic ratio - differentiated function - tight adherence - orderly growth - euploidy

biology of normal cells

- specific morphology - smaller nuclear-to-cytoplasmic ratio - differentiated function - tight adherence - nonmigratory - orderly & well-regulated growth - contact inhibition - apoptosis - euploidy

Pandemic

-An infection or disease that occurs throughout the population of a country or the world -Leads a vast number of people to seek medical care, even the "worried well." -E.g. influenza outbreak, such as the 2009-2010 swine flu outbreak caused by the H1N1 virus.

ROUTES OF TRANSMISSION: Bloodstream

-Bacteremia

Congenital (Primary) Immune Deficiencies

-Congenital, or primary, immune deficiencies are disorders in which the person is born with a defect in the development or function of one or more immune components. -The patient's immunity does not adequately protect him or her from infection or cancer

Laboratory Assessment

-Culture and antibiotic sensitivity- collect before administering Abx *CBC with differential*: Left shift or bandemia -ESR (inflammation pathway) -Serologic testing (antibodies present, have they been exposed prior?)

Enhancing nutrition

-Drug therapy (ketoconazole (Nizoral), fluconazole (Diflucan), amphotericin B (Fungizone) -Nutrition therapy (monitoring weight, I&O, calorie count, assessment of food preferences, dietary/culture/religious preferences -Mouth care (improves appetite, rinse mouth every 2 hours) -Complementary therapies (lemon juice/lemongrass infusions for oral flush)

Therapy-Induced Immune Deficiencies

-Drug-induced immune deficiencies -Radiation-induced immune deficiencies

CLOSTRIDIUM DIFFICILE (C. DIFFICILE) Toxin: S/S

-Frequent watery diarrhea (10-15 x day) -Abdominal cramping -Fever

History

-Ill contacts, immunocompromised, recent travel, animal contact, sexual history or drug use

Selective Immunoglobulin A Deficiency

-Is the most common congenital immune deficiency seen in adults. -The patient may be asymptomatic or have chronic recurrent infections of the upper respiratory tract, skin, urinary tract, and vagina, and diarrhea-associated infections. -Treatment of IgA deficiency is limited to vigorous treatment of infections. Unlike other immunoglobulin deficiencies, IgA deficiency is not managed with exogenous immune globulin.

Examples of Enterobacteriaceae

-Klebsiella pneumonia -Escherichia coli

Active immunity

-Lasts for years and is natural by infection or artificial by stimulation of the body's immune defenses (e.g., vaccination).

Psychosocial assessment

-Malaise, fatigue -Social stigma associated with some diseases

ROUTES OF TRANSMISSION: Respiratory tract

-Mycobacterium tuberculosis, Streptococcus pneumoniae

Epidemic

-Occurs when new cases of a certain disease substantially exceed expectation during a given period. -E.g. Ebola virus outbreak in West Africa became a concern within the United States when an individual who flew back from Liberia was diagnosed.

Immunity

-Resistance to infection. -Active or passive

Passive immunity

-Short duration (days or months) and either natural by transplacental transfer from the mother or artificial by injection of antibodies (e.g., immunoglobulin).

ROUTES OF TRANSMISSION: Skin/mucous membranes

-Treponema pallidum

Imaging Assessment

-Xray (e.g. chest x-ray for pneumonia) -MRI -CT -Ultrasonography

Health care-associated infection (HAI)

-acquired in inpatient setting that is not present at admission

Minimizing diarrhea

-antidiarrheal drugs -avoid roughage foods in diet -assessment of perineal skin every 8 - 12 hours

Neutropenic Diet

-avoid all fresh fruits and veggies -avoid raw/raw-cooked meat, fish and eggs -avoid raw nuts -make sure all dairy products are pasteurized -avoid yogurts with live and active cultures

Effective antimicrobial therapy requires

-delivery of an appropriate drug -sufficient dosage -proper administration route -sufficient therapy duration

Restoring skin integrity

-local radiation, intralesional/systemic chemotherapy, cryotherapy, topical retinoids -analgesics -good skin care

Fungal Infections

1. Candida albicans *Frequent finding* Especially stomatitis or esophagitis Caused by overgrowth of normal flora in AIDS patients S/S: food tastes funny, mouth pain, difficulty swallowing, retrosternal pain 2. Cryptococcis (debilitating meningitis) Caused by Cryptococcis neoformans S/S: (Increased ICP), fever, HA, N/V, blurred vision, nuchal rigidity, mild confusion, seizures, focal neuro problems, malaise, fever w/o HA 3. Histoplasmosis Caused by histoplasma capsulatum=begins as a respiratory infection and progresses widespread infection S/S: dyspnea, fever, cough, wt loss, spleen, liver and lymph node enlargement

Bacterial Infections

1. Myobacterium avium complex *MOST COMMON* Caused by myobacterium intracellulare or avium= infects respiratory or GI tract Is systemic =Positive cultures from lymph nodes, bone marrow and blood S/S: fever, debility, wt loss, anorexia, malaise, swollen lymph glands or organ disease 2. Tuburculosis Caused by mycobacterium tuberculosis Occurs in 2-10% of AIDS pts S/S: fever, chills, night sweats, wt loss, anorexia, cough, dyspnea, chest pain NOTE: Pt's with CD4+ counts below 200 cells/mm3 may not test positive with the TB skin test d/t inability to mount an immune response to the antigen 3. Recurrent pneumonia from bacterial infections, 2 or more episodes a year

Protozoal Infections

1. Pneumocystitis jiroveci Pneumonia (PCP) **MOST COMMON** S/S: Dyspnea on exertion, tachypnea, persistent dry cough, fever-low grade & persistent, fatigue, wt loss, crackles on lung auscultation 2. Toxoplasmosis encephalitis via contact with cat feces and undercooked meat S/S: (Increased ICP), subtle changes in mental status, neruo deficits, HA, N/V, fever, speech difficulty, gait & vision issues, lethargy and confusion 3. Cryptosporidium organisms S/S: mild to severe diarrhea wasting with electrolyte imbalances, diarrhea may results in fluid loss up to 15-20 L/day

Immunity changes during an adults life as a result of . . .

1. nutritional status 2. environmental conditions 3. drugs

Normal blood glucose range

60-100 mg/dl

21. A 63-year-old patient is newly diagnosed with type 2 diabetes. When developing an education plan, the nurse's first action should be to a. assess the patient's perception of what it means to have type 2 diabetes. b. demonstrate how to check glucose using capillary blood glucose monitoring. c. ask the patient's family to participate in the diabetes education program. d. discuss the need for the patient to actively participate in diabetes management.

A Rationale: Before planning education, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient. Cognitive Level: Application Text Reference: p.1264 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

18. A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). During an acute exacerbation of the patient's arthritis, the health care provider prescribes prednisone (Deltasone) to control inflammation. The nurse will anticipate that the patient may a. require administration of insulin while taking prednisone. b. develop acute hypoglycemia during the RA exacerbation. c. have rashes caused by metformin-prednisone interactions. d. need a diet higher in calories while receiving prednisone.

A Rationale: Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a complication of RA exacerbation or prednisone use. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient is likely to have an increased appetite when taking prednisone, but it will be important to avoid weight gain for the patient with RA. Cognitive Level: Application Text Reference: pp. 1258, 1267 Nursing Process: Planning NCLEX: Physiological Integrity

36. After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely, which action by the patient indicates that the teaching has been successful? a. The patient disposes of the open insulin vials after 4 weeks. b. The patient draws up the regular insulin in the syringe and then draws up the glargine. c. The patient stores extra vials of both types of insulin in the freezer until needed. d. The patient's family prefills the syringes weekly and stores them in the refrigerator.

A Rationale: Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Freezing alters the insulin molecule and should not be done. Cognitive Level: Application Text Reference: p. 1261 Nursing Process: Evaluation NCLEX: Physiological Integrity

14. A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. The nurse should teach the patient that a. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin. b. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis. c. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes. d. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy.

A Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly. A previous episode of ketoacidosis is not a contraindication for intensive insulin therapy. Intensive insulin therapy is not confined to type 2 diabetics and would prevent microvascular changes as well as macrovascular changes. Intensive insulin therapy and an insulin pump are comparable in glucose control. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Implementation NCLEX: Physiological Integrity

28. Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness? a. Give the patient a snack of cheese and crackers. b. Have the patient drink a glass of orange juice or nonfat milk. c. Administer a continuous infusion of 5% dextrose for 24 hours. d. Assess the patient for symptoms of hyperglycemia.

A Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity

11. The nurse has been teaching the patient to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. The statement by the patient that indicates a need for additional instruction is, a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I will buy the 0.5-ml syringes because the line markings will be easier to see." c. "I should draw up the regular insulin first after injecting air into the NPH bottle." d. "I do not need to aspirate the plunger to check for blood before I inject the insulin."

A Rationale: Rotating sites is no longer necessary because all insulin is now purified human insulin, and the risk for lipodystrophy is low. The other patient statements are accurate and indicate that no additional instruction is needed. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

22. Cardiac monitoring is initiated for a patient in diabetic ketoacidosis (DKA). The nurse recognizes that this measure is important to identify a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia. b. fluid overload resulting from aggressive fluid replacement. c. the presence of hypovolemic shock related to osmotic diuresis. d. cardiovascular collapse resulting from the effects of hyperglycemia.

A Rationale: The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Fluid overload, hypovolemia, and cardiovascular collapse are possible complications of DKA, but cardiac monitoring would not detect theses. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity

20. A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient's technique of SMBG, the nurse identifies a need for additional teaching when the patient a. chooses a puncture site in the center of the finger pad. b. washes the puncture site using soap and water. c. says the result of 130 mg indicates good blood sugar control. d. hangs the arm down for a minute before puncturing the site.

A Rationale: The patient is taught to choose a puncture site at the side of the finger pad. The other patient actions indicate that teaching has been effective. Cognitive Level: Application Text Reference: p. 1270 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

17. When teaching a patient with type 2 diabetes about taking glipizide (Glucotrol), the nurse determines that additional teaching about the medication is needed when the patient says, a. "Since I can take oral drugs rather than insulin, my diabetes is not serious and won't cause many complications." b. "If I overeat at a meal, I will still take just the usual dose of medication." c. "If I become ill, I may have to take insulin to control my blood sugar." d. "I should check with my doctor before taking any other medications because there are many that will affect glucose levels."

A Rationale: The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide. Cognitive Level: Application Text Reference: p. 1275 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

26. While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, the nurse should a. obtain a glucose reading using a finger stick. b. administer 1 mg glucagon subcutaneously. c. have the patient eat a candy bar. d. have the patient drink 4 ounces of orange juice.

A Rationale: The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity

16. Glyburide (Micronase, DiaBeta, Glynase) is prescribed for a patient whose type 2 diabetes has not been controlled with diet and exercise. When teaching the patient about glyburide, the nurse explains that a. glyburide stimulates insulin production and release from the pancreas. b. the patient should not take glyburide for 48 hours after receiving IV contrast media. c. glyburide should be taken even when the blood glucose level is low in the morning. d. glyburide decreases glucagon secretion.

A Rationale: The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, since hypoglycemia can occur with this category of medication. Metformin should be held for 48 hours after administration of IV contract, but this is not necessary for glyburide. Cognitive Level: Application Text Reference: pp. 1265-1266 Nursing Process: Implementation NCLEX: Physiological Integrity

32. Amitriptyline (Elavil) is prescribed for a diabetic patient with peripheral neuropathy who has burning foot pain occurring mostly at night. Which information should the nurse include when teaching the patient about the new medication? a. Amitriptyline will help prevent the transmission of pain impulses to the brain. b. Amitriptyline will improve sleep and make you less aware of nighttime pain. c. Amitriptyline will decrease the depression caused by the pain. d. Amitriptyline will correct some of the blood vessel changes that cause pain.

A Rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclics. Cognitive Level: Application Text Reference: p. 1285 Nursing Process: Implementation NCLEX: Physiological Integrity

5. When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately?" b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic?" d. "Is your urine unusually dark-colored?"

A Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar- containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. Cognitive Level: Application Text Reference: pp. 1255, 1258 Nursing Process: Assessment NCLEX: Physiological Integrity

Normal membrane proteins

A person's ____ ____ ____ would be antigens in another person.

A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best? a. Explain the pathophysiologic reasons behind the client not eating. b. Help the family show other ways to demonstrate love and caring. c. Suggest foods and liquids the client might be willing to try to eat. d. Tell the family the client isn't able to eat now no matter what they bring.

ANS: B Families often become distressed when their loved ones won't eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.

After receiving the hand-off report, which client should the oncology nurse see first? a. Client who is afebrile with a heart rate of 108 beats/min b. Older client on chemotherapy with mental status changes c. Client who is neutropenic and in protective isolation d. Client scheduled for radiation therapy today

ANS: B Older clients often do not exhibit classic signs of infection, and often mental status changes are the first observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of infection. The nurse should assess the older client first. The other clients can be seen afterward.

A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important? a. Assess the client for a headache. b. Assist the client in getting out of bed. c. Instruct the client to reduce salt intake. d. Weigh the client daily before the client eats.

ANS: B Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the client's risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention are not side effects of this drug.

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. "Are you getting adequate rest and sleep each day?" b. "It is normal to be fatigued even for years afterward." c. "This is not normal and I'll let the provider know." d. "Try adding more vitamins B and C to your diet."

ANS: B Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months or years after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client understands this is normal

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? a. "Avoid getting salt water on the radiation site." b. "Do not expose the radiation area to direct sunlight." c. "Have a wonderful time and enjoy your vacation!" d. "Remember you should not drink alcohol for a year."

ANS: B The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate

A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important? a. Assessing the client's abdomen beforehand b. Ensuring that informed consent is on the chart c. Marking the client's bilateral pedal pulses d. Reviewing client teaching done previously

ANS: B This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.

The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits

ANS: B, C, D, E The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).

A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best? a. "It causes rapid lysis of the cancer cell membranes." b. "It destroys the enzymes needed to create cancer cells." c. "It prevents the start of cell division in the cancer cells." d. "It sensitizes certain cancer cells to chemotherapy."

ANS: C Rituxan prevents the initiation of cancer cell division. The other statements are not accurate.

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? a. Administer a dose of allopurinol (Aloprim). b. Assess the client's serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery.

ANS: C Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first? a. Client with dry, itchy, peeling skin b. Client with a serum calcium of 9.2 mg/dL c. Client with a serum potassium of 2.8 mEq/L d. Client with a weight gain of 0.5 pound (1.1 kg) in 1 day

ANS: C TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.

A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to notify the provider immediately? a. Irregular menses b. Edema in the lower extremities c. Ongoing breast tenderness d. Red, warm, swollen calf

ANS: D All clients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are common side effects of the therapy.

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? a. Helping clients adjust to their appearance b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury

ANS: D All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.

The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed? a. "I should take my temperature daily and when I don't feel well." b. "I will wash my toothbrush in the dishwasher once a week." c. "I won't let anyone share any of my personal items or dishes." d. "It's alright for me to keep my pets and change the litter box."

ANS: D Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The other statements are appropriate for self-management.

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications.

ANS: D During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.

A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best? a. Ensure the client is placed in protective isolation. b. Hand off a pregnant client to another nurse. c. No special action is necessary to care for this client. d. Read the policy on handling radioactive excreta.

ANS: D This type of radioisotope is excreted in body fluids and excreta (urine and feces) and should not be handled directly. The nurse should read the facility's policy for handling and disposing of this type of waste. The other actions are not warranted.

Pathogenicity

Ability to cause disease

What is the ABC of safer sex

Abstinence Be faithful Condom use

Nonadherence

Accidental failure to take the drug

Inhibiting nucleic acid synthesis

Actinomycin

Cardiovascular autonomic neuropathy in DM

Affects sympathetic and parasympathetic nerves to the heart and blood vessels. Contributes to left ventricular dysfunction, painless MI, and exercise intolerance. Most often leads to orthostatic hypotension and syncope, both of which increase fall risk.

Kidney function tests in DM

Albumin in urine Serum creatinine

Non-nucleoside reverse transcriptase inhibitors: Side Effects

Allergic reactions Liver toxicity

Injuring the cytoplasmic membrane

Antifungal agents

Preventing HIV infection Drug therapy

Antiretroviral drugs Multiple drugs used together in combinations (CART)

31. A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Which teaching will the nurse implement about exercise for this patient? a. "You should not take the morning NPH insulin before you run." b. "Plan to eat breakfast about an hour before your run." c. "Afternoon running is less likely to cause hypoglycemia." d. "You may want to run a little farther if your glucose is very high."

B Rationale: Blood sugar increases after meals, so this will be the best time to exercise. NPH insulin will not peak until mid-afternoon and is safe to take before a morning run. Running can be done in either the morning or afternoon. If the glucose is very elevated, the patient should postpone the run. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity

10. A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The patient tells the nurse, "I hate to exercise! Can't I just follow the diet to keep my glucose under control?" The nurse teaches the patient that the major purpose of exercise for diabetics is to a. increase energy and sense of well-being, which will help with body image. b. facilitate weight loss, which will decrease peripheral insulin resistance. c. improve cardiovascular endurance, which is important for diabetics. d. set a successful pattern, which will help in making other needed changes.

B Rationale: Exercise is essential to decrease insulin resistance and improve blood glucose control. Increased energy, improved cardiovascular endurance, and setting a pattern of success are secondary benefits of exercise, but they are not the major reason. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity

12. A patient with type 1 diabetes has an unusually high morning glucose measurement, and the health care provider wants the patient evaluated for possible Somogyi effect. The nurse will plan to a. administer an increased dose of NPH insulin in the evening. b. obtain the patient's blood glucose at 3:00 in the morning. c. withhold the nighttime snack and check the glucose at 6:00 AM. d. check the patient for symptoms of hypoglycemia at 2:00 to 4:00 AM.

B Rationale: In the Somogyi effect, the patient's blood glucose drops in the early morning hours (in response to excess insulin administration), which causes the release of hormones that result in a rebound hyperglycemia. It is important to check the blood glucose in the early morning hours to detect the initial hypoglycemia. An increased evening NPH dose or holding the nighttime snack will further increase the risk for early morning hypoglycemia. Information about symptoms of hypoglycemia will not be as accurate as checking the patient's blood glucose in determining whether the patient has the Somogyi effect. Cognitive Level: Application Text Reference: pp. 1263-1264 Nursing Process: Planning NCLEX: Physiological Integrity

1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes a. the patient is totally dependent on an outside source of insulin. b. there is decreased insulin secretion and cellular resistance to insulin that is produced. c. the immune system destroys the pancreatic insulin-producing cells. d. the insulin precursor that is secreted by the pancreas is not activated by the liver.

B Rationale: In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately. The other information describes the physiology of type 1 diabetes. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity

24. A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to a. administer glargine (Lantus) insulin. b. initiate oxygen by nasal cannula. c. insert a large-bore IV catheter. d. give 50% dextrose as a bolus.

C Rationale: HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient's blood glucose and would be contraindicated. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Planning NCLEX: Physiological Integrity

29. A type 1 diabetic patient who was admitted with severe hypoglycemia and treated tells the nurse, "I did not have any of the usual symptoms of hypoglycemia." Which question by the nurse will help identify a possible reason for the patient's hypoglycemic unawareness? a. "Do you use any calcium-channel blocking drugs for blood pressure?" b. "Have you observed any recent skin changes?" c. "Do you notice any bloating feeling after eating?" d. "Have you noticed any painful new ulcerations or sores on your feet?"

C Rationale: Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause delayed gastric emptying. Calcium-channel blockers are not associated with hypoglycemic unawareness, although -adrenergic blockers can prevent patients from having symptoms of hypoglycemia. Skin changes can occur with diabetes, but these are not associated with autonomic neuropathy. If the patient can feel painful areas on the feet, neuropathy has not occurred. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity

7. A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. Which patient outcome is most important for this patient? a. The patient will have a diet and exercise plan that results in weight loss. b. The patient will state the reasons for eliminating simple sugars in the diet. c. The patient will have a glycosylated hemoglobin level of less than 7%. d. The patient will choose a diet that distributes calories throughout the day.

C Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes are also appropriate but are not as high in priority. Cognitive Level: Application Text Reference: p. 1273 Nursing Process: Planning NCLEX: Physiological Integrity

6. During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n) a. fasting blood glucose level. b. urine dipstick for glucose. c. glycosylated hemoglobin level. d. oral glucose tolerance test.

C Rationale: The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed. Cognitive Level: Application Text Reference: pp. 1258-1259 Nursing Process: Planning NCLEX: Physiological Integrity

23. A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. Which order should the nurse implement first? a. Start an infusion of regular insulin at 50 U/hr. b. Give sodium bicarbonate 50 mEq IV push. c. Infuse 1 liter of normal saline per hour. d. Administer regular IV insulin 30 U.

C Rationale: The most urgent patient problem is the hypovolemia associated with DKA, and the priority is to infuse IV fluids. The other actions can be accomplished after the infusion of normal saline is initiated. Cognitive Level: Application Text Reference: p. 1280 Nursing Process: Implementation NCLEX: Physiological Integrity

seven warning signs of cancer

CAUTION C- changes in bowel or bladder habits A- a sore that does not heal U- unusual bleeding or discharge T- thickening or lump in breast or somewhere else I- indigestion or difficulty swallowing O- obvious change in wart or mole N- nagging cough or hoarseness

HIV is not transmitted by

Casually By sharing household utensils, towels, linens, toilets via mosquitoes or insects

Human Immune Deficiency Virus (HIV)

Causes AIDS Is a parasite looking for a way into a cell to take over the cell and to force the cell into replicating itself.

COMMUNITY-ASSOCIATED MRSA (CA-MRSA)

Causes infections in healthy, non-hospitalized people -less virulent than hospital associated

Nonproliferative diabetic retinopathy

Causes structural problems in the retinal vessels, including areas of poor circulation, edema, hard fatty deposits, and retinal hemorrhages. Fluid and blood leak from the retinal vessels and cause retinal edema and hard exudates. Main source of vision loss is from macular edema, increased blood vessel permeability and deposits of hard exudates at the center of the retina.

Normal flora

Characteristic bacteria of a body location; often compete with other microorganisms to prevent infections

ROUTES OF TRANSMISSION: GI tract

Clostridium difficile, Salmonella enteritidis, Hepatitis A virus

Managing pain

Comfort measures:pressure relieving mattress pads, warm baths, massage, heat/cold therapy, use life sheets, help change positions often Drug therapy: NSAIDS, tricyclic antidepressants, opiods. Complementary and integrative therapies: acupuncture, massage, relaxation, body talk, distraction.

Autonomic neuropathy in DM

Common GI problems include gastroesophageal reflux, delayed gastric emptying, gastric retention, early satiety, heartburn, nausea, vomiting, and anorexia. Slowed small intestinal movement increases rush of bacterial overgrowth, causing bloating, gas, and diarrhea. Gastroparesis (delayed gastric emptying) may cause hypoglycemia.

Macrovascular complications of diabetes mellitus

Coronary heart disease Cerebrovascular disease Peripheral vascular disease

Glucagon

Counterregulatory hormone, triggers release of glucose from storage sites to increase blood glucose levels. Opposite effects of insulin.

9. A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, a. "I may have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories."

D Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. Cognitive Level: Application Text Reference: p. 1268 Nursing Process: Evaluation NCLEX: Physiological Integrity

37. The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the a. thigh. b. buttock. c. arm. d. abdomen.

D Rationale: Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Implementation NCLEX: Physiological Integrity

8. A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to a. delay eating the noon meal until after the swimming class. b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class. c. time the morning insulin injection so that the peak occurs while swimming. d. check glucose level before, during, and after swimming.

D Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

19. A hospitalized diabetic patient receives 12 U of regular insulin mixed with 34 U of NPH insulin at 7:00 AM. The patient is away from the nursing unit for diagnostic testing at noon, when lunch trays are distributed. The most appropriate action by the nurse is to a. save the lunch tray to be provided upon the patient's return to the unit. b. call the diagnostic testing area and ask that a 5% dextrose IV be started. c. ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area. d. request that the patient be returned to the unit to eat lunch if testing will not be completed promptly.

D Rationale: Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. Cognitive Level: Analysis Text Reference: p. 1268 Nursing Process: Implementation NCLEX: Physiological Integrity

27. A patient recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood. b. when an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products. c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic. d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones.

D Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. The other responses are inaccurate. Cognitive Level: Application Text Reference: pp. 1278-1279 Nursing Process: Implementation NCLEX: Physiological Integrity

20s & 30s

Immune function is most efficient when people are in their ____ &____ and slowly declines with increasing age, making the older adult at increased risk for infection and cancer development

Nutritional status, environmental conditions, drugs, disease and age

Immune function is variable during life related to (5 variables)

Alpha cells

In the endocrine portion of the pancreas, in the islets of Langerhans. Secrete glucagon.

Beta cells

In the endocrine portion of the pancreas, in the islets of Langerhans. Secrete insulin.

Kassmaul respiration

Increased respiratory rate and depth, body's attempt to blow off carbon dioxide. Breath has a rotting fruit odor from exhaled acetone.

Glycosylated serum albumin, glycosylated serum protein, and fructosamine tests

Indicate short term glucose control for short term follow-up or in those with hemoglobin abnormalities.

Drug therapy in DM

Indicated when a patient with T2DM does not achieve glucose control with dietary, exercise and stress management. Not a substitute for dietary modification and exercise!

Communicable

Infection transmitted from person to person

Injury or tissue damage

Inflammation & Immunity help body recover after _________ or _______ _______.

White blood cells, also called Leukocytes

Inflammation and immunity are provided through the actions and products of _________ _________ _______, also called _________

Non-nucleoside reverse transcriptase inhibitors: Mechanism of Action

Inhibit synthesis of reverse transcriptase =suppress viral replication but does NOT kill the virus

Ranibizumab (Lucentis)

Injections into the vitreous humor can improve vision for some with macular edema.

What happens when more glucose is present in the liver than can be used for energy or stored as glycogen?

Insulin causes the excess glucose to be converted to free fatty acids (FFAs) and deposited in fat cells.

Proper immune function

Invasion of the body's internal environment occurs much more often than does an actual disease or illness because of _______ _______ _________.

Stage 4 Centers for Disease Control and Prevention (CDC) Case Definition:

Is used to describe any patient with a confirmed HIV infection, but no information regarding CD4+ T-cells, CD4+ T-cell percentages, and AIDS-defining illness is available.

Urine tests in DM

Ketone bodies: product of fat metabolism, indicative of lack of insulin. Albumin: persistent albuminuria indicates early stage diabetic nephropathy.

Eye and vision problems and DM

Legal blindness is 25 times more common in patients with DM. Diabetic retinopathy is related to the duration of diabetes and has few signs until vision loss occurs. Hyperglycemia may cause blurred vision. Hypoglycemia may cause double vision.

Neurogenic bladder

Loss of bladder tone, urinary retention

Anesthesia

Loss of sensation

Insulin secretogogues: Meglitinide analogs

Lower fasting BG by triggering release of insulin from beta cells. Repaglinide (Prandin) Nateglinide (Starlix)

Pre-exposure prophylaxis (PrEP) Used for high risk populations

Men who have sex with men Heterosexually active men and women Injecting drug users Serodiscordant relationships

Metabolic syndrome

Metabolic factors known to increase risk of type 2 DM and cardiovascular disease. ▪ Abdominal circumference of 40 inches or more (men) or 35 inches or more (women) ▪ Hyperglycemia ▪ Abnormal A1C ▪ Hypertension ▪ Hyperlipidemia

Pathogen (agent)

Microorganism capable of producing disease -most common is bacterial, fungal or viral

Cardiovascular disease and DM

Most DM patients die of a thrombotic effect, usually MI. Heart failure is also associated with DM.

Multidrug-Resistant Organism (MDROS)

Most common: - Methicillin-resistant Staphylococcus aureus - Vancomycin-resistant Enterococcus - Carbapenum-resistant Enterococcus •Tracked by CDC and investigation will occur if a facility has high occurrence

Oral glucose tolerance testing

Most sensitive test for the diagnosis of diabetes. Often used to diagnose gestational DM.

Redness, warmth, swelling, pain, and loss of function

Name the 5 cardinal manifestations of inflammation

Proliferative diabetic retinopathy

Neovascularization: growth of new retinal blood vessels in response to poor blood flow and hypoxemia. New vessels are thin and fragile, leading to eye hemorrhage and vision loss.

Microvascular complications of diabetes mellitus

Nephropathy Neuropathy Retinopathy

Fusion Inhibitors: Side Effects

Nursing interventions need to rotate injection sites d/t lipodystrophy and infection risks

Nonsurgical management of DM

Nutritional intervention BG monitoring Exercise program Drugs to lower BG levels

Immunosuppressive drugs

Patient who receive transplanted organs (unless from an identical sibling) need to take ___________ _________________ daily to prevent transplant rejection

Bacterial and fungal infections, cardiovascular disease, and cancer development

Patient who take immunosupressive drugs have an increased risk for _____ &____ infections, _____ disease, and ________ development

Cognitive dysfunction in DM

People 65+ with diabetes have significantly higher risk of developing all types of dementia. Chronic hyperglycemia and microvascular disease contribute to neuron damage, brain atrophy, and cognitive impairment. Depression is highly prevalent in DM and associated with worse outcomes.

Classic clinical manifestations of diabetes

Polyuria, polydipsia, polyphagia

Fusion Inhibitors: Mechanism of Action

Prevents cellular fusion between HIV and CD4 T-cell without fusion=infection of new cells does not occur

Diabetic peripheral neuropathy

Progressive deterioration of nerve function resulting in loss of sensory perception. Damage may manifest as pain or loss of sensation. Factors: hyperglycemia, long duration of DM, hyperlipidemia, damaged blood vessels leading to reduce neuronal oxygen and nutrients, autoimmune neuronal inflammation, increased generic susceptibility, smoking and alcohol use. Hyperglycemia leads to DPN via reduced tissue perfusion, nerve hypoxia, resulting in blocked nerve transmission.

parenteral transmission

Proper cleaning of needles and syringes Needle exchange programs

Type 2 Diabetes Mellitus

Ranges from insulin resistance with relative insulin deficiency to secretory deficit with insulin resistance

Inflammation

Remember, __________________ & infection are not the same

Enhancing cognition

Reorientation psychotropic drugs Safety measures Support- family and call social worker

Cerebrovascular disease and DM

Risk of stroke is 2-4 times higher with DM. High BG at the time of a stroke may lead to greater brain injury and increased mortality.

Why are we screenings so important for people with DM?

Routine ophthalmic exams can detect vision problems early, before vision loss occurs. Yearly eye exams are recommended for those with type 2 DM and those who have had type 1 DM for more than 5 years.

Insulin

Secreted at low levels during fasting. Increased levels after eating (prandial). Insulin is like a key that opens locked membranes to glucose. Stimulates glucose uptake in skeletal and cardiac muscle. Suppresses liver production of glucose and very low density lipoprotein (VLDL). Promotes glycogenesis. Inhibits glycogenolysis. Inhibits ketogenesis (conversion of fats to acids) and gluconeogenesis (conversion of proteins to glucose). Promotes storage of protein and glycogen in muscle. Promotors triglyceride storage in fat cells.

Insulin secretogogues: Sulfonylurea agents

Simulate insulin release from pancreatic beta cells. Used in patients who are still able to produce insulin. Glipizide (Glucotrol) Glimepiride (Amaryl) ⚠Many drug interactions!

Focal neuropathy in DM

Single nerve or group are affected, usually caused by an acute ischemic event. Most commonly affecting the nerves that control eye muscles. Manifestations include double vision from paralyzed eye muscles. Usually resolves in 2-3 months.

Risk factors contributing to poor health outcomes for people with DM

Smoking Physical inactivity Obesity Hypertension High blood fat and cholesterol levels

Leukocyte antigens

Solid organ transplanted into recipients seldom are a perfectly identical match of human ____ _____, unless the organ is obtained from an identical sibling.

Glycosylated hemoglobin (A1C)

Standardized test for how much glucose is permanently attached to hemoglobin--Hyperglycemia over time causes more glycosylated hemoglobin. A1C>6.5% is diagnostic of DM. Ongoing assessment of A1C is a good indicator of long term glycemic control.

Self-Tolerance is. . .

The action of recognizing self versus non-self

Cell-mediated immunity

The cells and actions of ____ _______ ____________ control and coordinate the entire inflammatory and immune responses

WBC count

The differential of the ______________ can be used to determine the patient's risk for infection, the presence of absence of infection, the presence of absence of an allergic reaction, and whether an infection is bacterial or viral.

WBC's

The only body cells able to recognize non self cells and to attack them

Neutralizing, eliminating, or destroying organisms

The purpose of inflammation and immunity is to meet the human need for protection by _______________,_________________, or_______________ ____________ that invade the internal environment

Attenuated

When antigens have been processed to make them less likely to grow in the body, this type of exposure usually doesn't cause the disease.

Immune System Cells

_____ _____ _____ distinguish between the body's own health self cells and other, non-self proteins and cells.

Inflammation and Immunity

________ & _______ are critical to maintaining health and preventing disease as the two major defenses that protect a person against diseases and other problems.

Infection

____________ is frequently accompanied by inflammation, but inflammation often occurs without infection

Kaposi's sarcoma

a cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat, or in other organs; frequently associated with HIV S/S: small, purplish-brown raise skin lesions that are not painful or itchy, anywhere on body

Antiretroviral therapy (ART)

a combination of several medications prescribed for people who are HIV-positive to delay the onset of AIDS

grading

a method for evaluating a tumor based on microscopic examination of the cells. poorly differentiated vs. well differentiated cells

Human leukocyte antigens (HLA's)

a person's tissue type and are inherited from parents

Self-Tolerance

ability to recognize self versus non-self, which is necessary to prevent health body cells from being destroyed along with the invaders is called....

aneuploidy

abnormal chromosomes; chromosomes are lost, gained, or broken (common in cancer)

Passive Immunity

an immediate, short term protection against a specific antigen

clinical staging

asses patient's symptoms and evaluates tumor size and possible spread

surgical staging

assesses the tumor size, number, sites, and spread by inspection at surgery

Passive Immunity

body receives antibodies that were developed in another person's body. These antibodies are recognized as foreign and are eliminated quickly

prostate cancer common sites for metastasis (*=most common)

bone (especially spine and legs)*, pelvic nodes

breast cancer common sites for metastasis (*=most common)

bone*, lung*, liver, brain

lung cancer common sites for metastasis (*=most common)

brain*, bone, liver, lymph nodes, pancreas

carcinogenesis/oncogenesis

cancer development

chemical carcinogenesis

cancer occurs from exposures to many known chemicals, drugs, and other products used in every day life (e.g. tobacco, alcohol)

Inflammation

cannot be transferred from one person to another

Tis (in TNM staging of cancer)

carcinoma in situ

Vaccinations

cause artificial active immunity and require boosters for best long term effects.

Opportunistic Infection

caused by organisms that are present as part of the body's microbiome and are kept in check by normal IMMUNE function.

Acquired Immune Deficiency (AIDS)

caused by the human immunodeficiency virus (HIV) and suppresses the immune system *most common secondary immune disease in the world

tight adherence

cells bind closely and tightly

nonmigratory

cells stay in specific areas, do not wander throughout body

contact inhibition

cellular regulation that stops further rounds of division when cell is completely surrounded and in contact with other cells

primary brain cancer common site for metastasis

central nervous system

external factors causing cancer

chemical carcinogenesis, physical carcinogenesis, viral carcinogenesis, dietary factors

ploidy

description of cancer sell based on number and appearance of chromosomes

staging

determines exact location of cancer and whether metastasis has occured, done by clinical, surgical, and pathological

M1 (in TNM staging of cancer)

distant metastasis

specific morphology

each normal cell has a distinct and recognizable appearance, size, and shape

Fusion Inhibitors: Examples

enfuvirtide (Fuzeon)

differential function

every normal cell has at least one function it performs to contribute to whole body function

initiation

first step in carcinogenesis, a change in gene expression caused by anything that can damage cellular DNA, leading to the loss of cellular regulation.

Inflammation

general, non specific protective response that provides immediate, short term protection against injury or invasion

Gx cellular characteristics (in grading of malignant tumors)

grade of tumor cannot be determined

Self- tolerance prevents immunity from . . .

harming healthy body cells

euploidy

having a complete set of chromosomes

personal factors of cancer development

immunity, age, and genetic risk

N1, N2, N3 (in TNM staging of cancer)

increasing involvement of regional lymph nodes

T1, T2, T3, T4 (in TNM staging of cancer)

increasing size and/or local extent of the primary tumor

Immunity

is an adaptive internal protection that results in long-term resistance to the effects of invading microorganisms. This means that the responses are NOT automatic.

Innate-Native immunity

is any natural protective feature of a person. It can be a barrier to prevent organisms from entering the body or can be an attacking force that eliminates organisms that have already entered the body

Postexposure prophylaxis Occupational exposure

is defined as contact between blood tissue or selected body fluids from a patient who is positive for HIV and the blood, broken skin, or mucous membranes of a health care professional

Natural, Active immunity

is the most beneficial and long- lasting type of immunity

colorectal cancer common sites for metastasis (*=most common)

liver*, lymph nodes, adjacent structures

suspected dietary causes of cancer

low intake of fiber, high intake of red meat and animal fat, nitrites, preservatives and additives

oncogene activation

main mechanism of carcinogenesis regardless of the specific cause

Monotherapy

medication therapy with a single medication, promotes drug resistance and does not improve the duration or quality of life of patient

COMMUNITY-ASSOCIATED MRSA (CA-MRSA): Treatment

minocycline and doxyxycline

pathological staging

most definitive type of staging, determines the tumor size, number, sites, and spread by pathological examination of tissues

Transmission and health care workers

needle stick or sharp injuries exposure to non intact skin/mucous membranes to blood and bodily fluids. Standard precautions is the best prevention Postexposure prophylaxis is recommended

Non-nucleoside reverse transcriptase inhibitors: Examples

nevirapine (Viramune) efavirenz (Sustiva) delavirdine (Rescriptor)

M0 (in TNM staging of cancer)

no distant metastasis

T0 (in TNM staging of cancer)

no evidence of primary tumor

N0 (in TNM staging of cancer)

no regional lymph node metastasis

benign tumor cells

normal calls growing in the wrong place or at the wrong time as a result of a problem with cellular regulation

Transplant Rejection

normal response of the immune system that can damage or destroy the transplanted organ

viral carcinogenesis

occurs when viruses infect body cells and break DNA strands inserting their own genetic material, causing mutation.

primary tumor

original tumor; the source of metastasis

Inhibiting cell wall synthesis

penicillins and cephalosporins

mitotic index

percentage of actively dividing cells within a tumor.

physical carcinogenesis

physical agents or events cause cancer by DNA damage (e.g. radiation, chronic irritation, ionizing and ultraviolet radiation)

Mx (in TNM staging of cancer)

presence of distant metastasis cannot be assessed

Tx (in TNM staging of cancer)

primary tumor cannot be assessed

apoptosis

programmed cell death

Cell-mediated immunity

protects the body through differentiation of self from non-self. These are important in preventing the development of cancer and metastasis after exposure to carcinogens.

Antigens are . . .

proteins capable of stimulating an immune response

PEP: non-occupational exposure

refers to consensual and non consensual sexual exposures, involving insertive and receptive types of sex, oral, vaginal, anal contact. other types of contact can include the sharing of needles and inadvertent percutaneous or mucosal contact in the home.

Nx (in TNM staging of cancer)

regional lymph nodes cannot be assessed

Immunocompetence

requires that all three parts of inflammation and immunity have optimal functioning

Protease Inhibitors: Side Effects

saquinavir (Invirase) -absorbed best with a fatty meal, photosensitivity indinavir (Crixivan) -hyperbilirumia, nephrolithiasis nelfinavir (Viracept) -diarrhea, hyperglycemia

promotion

second step in carcinogenesis, enhanced growth of an initiated cell by substances known as promoters (e.g insuling, estrogen)

malignant cells

serve no useful function, are harmful to normal body tissues

HIV usually transmitted via

sexual contact parenterally perinatally

"HAART" Therapy

slows down and reduces viral levels in the blood, improves CD4+ and lymph counts

Self-tolerance

special ability of WBC's to recognize health self cells and not attempt to attack or destroy them

These HLAs serve as a "universal product code" for that person and are identical only to. . .

the HLAs of an indentical sibling

doubling time

the amount of time it takes for a tumor to double in size

Intact skin, mucous membranes, skin surface normal flora, and natural chemicals that inhibit bacterial growth

the body has some defenses to prevent organisms from gaining access to the internal environment (4)

anaplasia

the cancer cells' loss of the specific appearance of their parent cells

Self-tolerance is possible because of . . . .

the different proteins present on cell membranes

malignant transformation

the process of changing a normal cell into a cancer cell

latency period

the time between a cell's initiation and the development of an overt tumor (can be months to years)

Acute Phase

the tissue response to inflammation are helpful if they are confined to the area of invasion or infection and do not extend beyond the _________ phase.

progression

third step in carcinogenesis, continued change of cancer making it more malignant over time

Anti-body mediated immunity (AMI)

this is also known as humoral immunity, and CAN be transferred from one person or animal to another

Chronic Inflammation

this type of inflammation can damage tissues and reduce function

A key element for recognition of non-self by cells involved in general immunity and those involved in specific immunity is the presence of. . .

toll-like receptors (TLRs) on these cells

bloodborne metastasis

tumor cell release into blood

G4 cellular characteristics (in grading of malignant tumors)

tumor cells are poorly differentiated and retain no normal cell characteristics, difficult or impossible to determine tissue of origin

G2 cellular characteristics (in grading of malignant tumors)

tumor cells moderately differentiated, retain some characteristics of normal cell, have more malignant characteristics than G1

G3 cellular characteristics (in grading of malignant tumors)

tumor cells poorly differentiated, but tissue of origin can be established, have few normal cell characterisitcs

G1 cellular characteristics (in grading of malignant tumors0

tumor cells well differentiated, low grade malignant change, malignant but relatively slow growing

Hyperacute, acute or chronic

types of transplant rejection (3)

secondary prevention

use of screening strategies to detect cancer early, at a time when cure or control is more likely.

primary prevention

use of strategies to prevent the actual occurrence of cancer -avoidance of known or potential carcinogens - modifying associated factors - removal of "at-risk" tissue - chemoprevention - vaccination

tumor-node-metastasis (TNM) system

used to describe anatomic extent of cancers. T- primary tumor, N- regional lymph nodes, M- distant metastasis (not useful for leukemia or lymphomas)

Artificial passive immunity

used to present disease or death from rabies, tetanus, and poisonous snakebites

Ebstein-Barr virus

virus associated with Burkitt's lymphoma, B-cell lymphomas, nasopharyngeal carcinoma

Human lymphotropic virus type I

virus associated with adult T-cell leukemia

Human papilloma virus

virus associated with cervical carcinoma, vulvar carcinoma, penile carcinoma, and other anogenital carcinomas

Human lymphotropic virus type II

virus associated with hairy cell leukemia

Hepatitis B virus

virus associated with liver carcinoma

Hepatitis C virus

virus associated with primary liver carcinoma, possible B-cell carcinoma

oncoviruses

viruses that cause cancer

Short term

what kind of effect does antibodies transferred from one person into another person have?

metastasize

when cancer cells migrate or spread to other tissues and body sites

Natural Passive immunity

would be when antibodies are passed from mother to infant via the placenta or through colostrum and breast milk

Nucleoside Analog Reverse Transcriptase Inhibitors: Side Effects

zidovudine (Retrovir, ZDV) -dizziness, bone marrow suppression, hepatotoxicities, nephrotoxicities aidanosine (DDL, Videx) -peripheral neuropathy, bone marrow suppression, severe pancreatitis abacavir (Ziogen) -Hypersensitivity reactions

Nucleoside Analog Reverse Transcriptase Inhibitors: Examples

zidovudine (Retrovir, ZDV) aidanosine (DDL, Videx) abacavir (Ziogen)

Factors That May Increase Risk for Infection in the Older Patient

• *Immune system:* Decreased antibody production, lymphocytes, and fever response • *Integumentary system*: Thinning skin, decreased subcutaneous tissue, decreased vascularity, slower wound healing • *Respiratory system:* Decreased cough and gag reflexes • *Gastrointestinal system*: Decreased gastric acid and intestinal motility • *Chronic illness*: Diabetes mellitus, chronic obstructive pulmonary disease, neurologic impairments • *Functional/cognitive impairments*: Immobility, incontinence, dementia • *Invasive devices:* Urinary catheters, feeding tubes, IV devices, tracheostomy tubes • *Institutionalization*: Increased person-to-person contact and transmission

Possible Allergic Reactions to Antibiotic Therapy

• Nausea and/or vomiting • Flushing • Wheezing • Sneezing • Pruritus • Urticaria • Rashes • Maculopapular to exfoliative dermatitis • Vascular eruptions • Erythema multiforme (Stevens-Johnson syndrome) • Angioneurotic edema • Serum sickness (headache, fever, chills, hives, malaise, conjunctivitis) • Anaphylaxis (laryngeal edema, bronchospasm, hypotension, vascular collapse, cardiac arrest) • Death

COMMUNITY-BASED CARE

•*Home care management* - Self care, handwashing facilities •*Self-management education* - Completing drug regimen as ordered •*Health care resources* - Long term antibiotic treatment may require stays at SNFs

AIRBORNE DISEASES

•Anthrax •Tuberculosis •Measels (rubeola) •Chickenpox (varicella) •Disseminated zoster (shingles)

PHYSIOLOGIC DEFENSES AGAINST INFECTION

•Body tissues •Phagocytosis •Inflammation •Immune systems: Antibody-mediated or Cell-mediated

CARBAPENUM-RESISTANT ENTEROBACTERIACEAE (CRE)

•Carbapenum is used to treat abdominal infections •Mortality rate is >40% •https://www.cdc.gov/hai/organisms/cre/trackingcre.html

METHODS OF TRANSMISSION

•Contact - Direct or indirect •Droplet •Airborne •Vector-borne (for example, insects/animals) •Environment (for example, contaminated food, water) •Portal of exit- how the microbe leaves the host's body

VANCOMYCIN-RESISTANT ENTEROCOCCUS (VRET)

•Found in GI tract -Enterococus faecium

INFECTION CONTROL AND PREVENTION

•Hand hygiene •Disinfection/sterilization •Standard precautions •*Transmission-based precautions* -Airborne -Droplet -Contact •Staff and patient placement and cohorting

NANDA-I NURSING DIAGNOSIS

•Hyperthermia related to the immune response triggered by pathogenic invasion -38-38.5 C- administer antipyretic >40 C or 104 F- emergency because it denatures proteins

DROPLET DISEASES

•Influenza •Mumps •Pertussis •Meningitis •Streptococcal pharyngitis

EMERGING INFECTIONS AND GLOBAL BIOTERRORISM

•Multidrug-resistant organisms (MDROs) •Endemic vs Epidemic vs Pandemic •Contaminated food- Mad cow disease •Bioterrorism Agents

PROBLEMS FROM INADEQUATE ANTIMICROBIAL THERAPY

•Noncompliance/nonadherence •Legal sanctions compelling a patient to complete treatment (for example, TB) •Septicemia or bloodstream infection (BSI) •Septic shock ---> Multi Organ Failure

CLOSTRIDIUM DIFFICILE (C. DIFFICILE)

•Pathogen which causes C. difficile-associated disease (CDAD) •Associated with use of antibiotics •Toxins released from active C. difficile cause S/S

AIRBORNE PRECAUTIONS

•Prevent spread of disease through airborne droplets •Patient is in a private room with negative air pressure and the use of a HEPA (high-efficiency particulate air) filtration •*Everyone entering must wear respiratory devices*: - N95 mask (ultra filtration device, makes it difficult to breathe) - PAPR- powered air purifying respirator •Patient must wear mask if leaving room

DROPLET PRECAUTIONS

•Prevent spread of disease through large-particle droplets •Patient may be in a room with a cohort (same organism) •Everyone entering room or w/in 3 feet must wear mask •Patient wears mask if leaving room

CONTACT PRECAUTIONS

•Prevents spread of disease through contact with patient or items in environment •Patient may be in room with cohort (same organism) •Use individual equipment when possible •Clean equipment after use with disinfectant •If MDRO, patient will be isolated and equipment cannot be shared

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS(MRSA)

•S. aureus that does not respond to methicillin or other penicillin-based drug •Susceptible to vancomycin, linezolid, ceftarolinefosamil

INFLUENZA

•Seasonal virus that constantly changes (antigenic drift) •Vaccination is best, but developed from previous year's influenza •Contraindications to flu vaccine •Dispel myths!

Protease Inhibitors: Mechanism of Action

Block the HIV protease enzyme-Protease =preventing viral replication and release of viral particles =thus active proteins are not produced and the viral particles cannot leave the cell to infect others

Ketoacidosis

Buildup of ketone bodies, small acids that are the breakdown product of fatty acids. Insulin deficiency causes lipolysis and release of FFAs which are broken down into ketones.

Dysesthesias

Burning, stinging, or stabbing pains

Paresthesias

Burning/tingling sensations, starting in toes and moving up legs

38. A diabetic patient has a new order for inhaled insulin (Exubera). Which information about the patient indicates that the nurse should contact the patient before administering the Exubera? a. The patient has a history of a recent myocardial infarction. b. The patient's blood glucose is 224 mg/dl. c. The patient uses a bronchodilator to treat emphysema. d. The patient's temperature is 101.4° F.

C Rationale: Exubera is not recommended for patients with emphysema. The other data do not indicate any contraindication to using Exubera. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Assessment NCLEX: Physiological Integrity

25. A patient with type 1 diabetes who uses glargine (Lantus) and lispro (Humalog) insulin develops a sore throat, cough, and fever. When the patient calls the clinic to report the symptoms and a blood glucose level of 210 mg/dl, the nurse advises the patient to a. use only the lispro insulin until the symptoms of infection are resolved. b. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. c. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. d. limit intake to non-calorie-containing liquids until the glucose is within the usual range.

B Rationale: Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to DKA. Decreasing carbohydrate or caloric intake is not appropriate as the patient will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose. Cognitive Level: Application Text Reference: p. 1272 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

3. During a diabetes screening program, a patient tells the nurse, "My mother died of complications of type 2 diabetes. Can I inherit diabetes?" The nurse explains that a. as long as the patient maintains normal weight and exercises, type 2 diabetes can be prevented. b. the patient is at a higher than normal risk for type 2 diabetes and should have periodic blood glucose level testing. c. there is a greater risk for children developing type 2 diabetes when the father has type 2 diabetes. d. although there is a tendency for children of people with type 2 diabetes to develop diabetes, the risk is higher for those with type 1 diabetes.

B Rationale: Offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes. The risk can be decreased, but not prevented, by maintenance of normal weight and exercising. The risk for children of a person with type 1 diabetes to develop diabetes is higher when it is the father who has the disease. Offspring of people with type 2 diabetes are more likely to develop diabetes than offspring of those with type 1 diabetes. Cognitive Level: Application Text Reference: p. 1256 Nursing Process: Implementation NCLEX: Physiological Integrity

34. The health care provider orders oral glucose tolerance testing for a patient seen in the clinic. Which information from the patient's health history is most important for the nurse to communicate to the health care provider? a. The patient had a viral illness 2 months ago. b. The patient uses oral contraceptives. c. The patient runs several days a week. d. The patient has a family history of diabetes.

B Rationale: Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. A viral 2 months previously illness may be associated with the onset of type 1 diabetes but will not falsely impact the OGTT. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. Cognitive Level: Application Text Reference: p. 1267 Nursing Process: Assessment NCLEX: Physiological Integrity

15. A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin. a. NPH b. lispro c. detemir d. glargine

B Rationale: Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin. Cognitive Level: Application Text Reference: p. 1260 Nursing Process: Planning NCLEX: Physiological Integrity

13. A patient receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between a. 8:00 and 10:00 AM. b. 4:00 and 6:00 PM. c. 7:00 and 9:00 PM. d. 10:00 PM and 12:00 AM.

B Rationale: The greatest insulin effect with this combination occurs mid afternoon. The patient is not at a high risk at the other listed times, although hypoglycemia may occur. Cognitive Level: Comprehension Text Reference: p. 1260 Nursing Process: Evaluation NCLEX: Physiological Integrity

35. Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient? a. Fasting blood glucose of 130 mg/dl b. Noon blood glucose of 52 mg/dl c. Glycosylated hemoglobin of 6.9% d. Hemoglobin A1C of 5.8%

B Rationale: The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient. Cognitive Level: Application Text Reference: pp. 1281-1282 Nursing Process: Assessment NCLEX: Physiological Integrity

30. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. The nurse teaches the patient that a. the feet should be soaked in warm water on a daily basis. b. flat-soled leather shoes are the best choice to protect the feet from injury. c. heating pads should always be set at a very low temperature. d. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure.

B Rationale: The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided; the patient should see a specialist to treat these problems. Cognitive Level: Application Text Reference: p. 1287 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

33. A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? a. The patient's most recent hemoglobin A1C was 6%. b. The patient takes metformin (Glucophage) every morning. c. The patient uses captopril (Capoten) for hypertension. d. The patient's admission blood glucose is 128 mg/dl.

B Rationale: To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast media are administered. The other patient data indicate that the patient is managing the diabetes appropriately. Cognitive Level: Application Text Reference: p. 1266 Nursing Process: Assessment NCLEX: Physiological Integrity

Fasting blood/plasma glucose

BG taken after no caloric intake for at least 8 hours. BG>126mg/dl on two separate occasions is diagnostic of DM.

Type 1 Diabetes Mellitus

Beta cell destruction Absolute insulin deficiency Autoimmune Idiopathic

In addition, each person's cells have unique surface proteins that are specific to that person known as. . .

Human Leukocyte Antigens (HLAs)

4. A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). When teaching the patient about the reason for these lifestyle changes, the nurse will tell the patient that a. the high insulin levels associated with this syndrome damage the lining of blood vessels, leading to vascular disease. b. although the fasting plasma glucose levels do not currently indicate diabetes, the glycosylated hemoglobin will be elevated. c. the liver is producing excessive glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production. d. the onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise.

D Rationale: The patient with IFG is at risk for developing type 2 diabetes, but this risk can be decreased with lifestyle changes. Glycosylated hemoglobin levels will not be elevated in IFG and the Hb A1C test is not included in prediabetes testing. Elevated insulin levels do not cause the damage to blood vessels that can occur with IFG. The liver does not produce increased levels of glucose in IFG. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl (6.7 mmol/L). The nurse will plan to teach the patient about a. use of low doses of regular insulin. b. self-monitoring of blood glucose. c. oral hypoglycemic medications. d. maintenance of a healthy weight.

D Rationale: The patient's impaired fasting glucose indicates prediabetes and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Planning NCLEX: Physiological Integrity

Diabetic nephropathy

DM is the leading cause of CKD and end stage kidney disease in the US. Risk factors: genetic predisposition, 10-15 year history of DM, poor blood glucose control, and uncontrolled hypertension. Drugs that protect the kidneys are ACE inhibitors and angiotensin receptor blockers (ABRs). Chronic hyperglycemia causes hypertension in the kidney blood vessels, leading to leaky vessels and albumin deposits in the kidney. Vessels narrow, causing kidney cell hypoxia and cell death. Scarring and loss of urine filtration ability leads to kidney failure.

Virulence

Degree of communicability

Drug regimen noncompliance

Deliberate failure to take the drug

Stage 2 Centers for Disease Control and Prevention (CDC) Case Definition:

Describes any patient with a confirmed HIV infection and a CD4+ T-cell count between 200 and 499 cells/mm3 or a CD4+ T-cell percentage between 14% and 28%. A person at this stage has no AIDS-defining illness.

Stage 3 Centers for Disease Control and Prevention (CDC) Case Definition:

Describes any patient with a confirmed HIV infection and a CD4+ T-cell count of less than 200 cells/mm3 or a CD4+ T-cell percentage of less than 14%. A person who has a higher CD4+ T-cell counts or percentages but who also has a documented AIDS-defining illness meets the requirements of the Stage 3 CDC Case Definition.

Stage 1 Centers for Disease Control and Prevention (CDC) Case Definition:

Describes any patient with confirmed HIV infection a CD4+ T-cell count of greater than 500 cells/mm3 or a CD4+ T-cell percentage of 29% or greater. A person at this stage has no AIDS-defining illness.

Immune or inflammatory protection

Different types of WBC's provide different types of _________ or _________ __________.

Most common type of diabetic peripheral neuropathy

Diffuse neuropathy, widespread loss of nerve function and sensory perception. Slow, symmetrical onset. Progresses slowly, and is permanent. Includes autonomic nerve dysfunction. Late complications include foot ulcers and deformities.

orderly and well-regulated growth

Divide for two specific reasons - to develop normal tissue - to replace lost or damaged normal tissue (aka cellular regulation)

Specimens for peak levels

Drawn 30 to 60 minutes after medication administration

Specimens for trough levels

Drawn about 30 minutes prior to the next scheduled vancomycin dose.

Enhancing gas exchange

Drug therapy: trimethoprim with sulfamethoxazole Resp support and maintenance: asses resp rate rhythm, vital signs and give oxygen if needed. Comfort: raise head of bed Rest and activity changes: pace activities cause patients can/are faitgued

Anhidrosis

Drying, cracking of skin

Male erectile dysfunction in DM

ED occurs at a much higher rate and earlier in patients with DM. Related to poor blood glucose regulation, obesity, hypertension, heavy cigarette smoking, and other vascular complications.

Inhibiting biosynthesis, or reproduction

Erythromycin and gentamicin

PEP: Sexual assault

Exposure to HIV as a result of sexual assault also includes testing for STI

Prediabetes

Fasting BG between 100-125 mg/dl or A1C between 5.5% and 6.0%

melanoma common sites for metastasis

GI tract, lymph nodes, lung, brain

Nucleoside Analog Reverse Transcriptase Inhibitors: Mechanism of Action

Generates bad nucleoside/nucleotide building blocks for HIV. Acts as "counterfeit" form. Thus they suppress production of reverse transcriptase (RT) and inhibit viral DNA synthesis & replication =Virus cannot leave the cell

Hormones that increase blood glucose

Glucagon (primary) Epinephrine Norepinephrine Growth hormone Cortisol

cell cycle

G₀- resting cycle G₁ - Metabolic changes prepare cells to divide S- DNA synthesis replicates the genetic material G₂- Metabolic changes assemble the cytoplasmic materials needed for mitosis M- Division occurs with nucleus and cell

Foot deformities in DM

High arch, claw toes, hammer toes, shift of weight bearing to metatarsal heads and tips of toes

Non-self

The transplant recipient's immune system cells recognize a newly transplanted organ's cells as...

Surveillance

Tracking and reporting of infections by the CDC

Perinatal Transmission

Transmission can occur across the placenta during pregnancy Infant exposure at birth to blood and vaginal secretions Exposure after birth through breast milk

Insulin therapy indications

Type 1 DM T2DM patients on 2-3 antidiabetic drugs with uncontrolled BG levels

HIV genotype test

Used to determine whether any mutations exist in the strain of HIV that has infected the patient. This test is useful before starting antiretroviral therapy to learn whether the patient is infected with a resistant strain of HIV.

Immunocompetent

When all the functions of inflammation and immunity are working well, the individual is...

Inflammatory and immunologic

Without interventions, the host's immune system starts _____________ & _______________ actions to destroy or eliminate these non-self cells. Causing rejection of the transplant graft.