NSG 252 Exam 3, Intercranial, inflammation, mobility

A person who has hepatitis b can donate their organs. true or false?

false A decedent who had a hepatitis B infection cannot donate organs because the organ recipient may contract the infection.

what are the types of hepatitis?

HEP A - spreads fecal- orally (contaminated food and water). HEP B - Bloodborne ( sex, needles, birth, IV) usually asymptomatic and most common. HEP C - occurs mostly parenterally ( needle sharing, tattoos, organ transplant). #1 cause of end-stage liver disease. HEP D - is caused by a defective RNA virus that needs HEP B to replicate. Mostly spread parenterally. HEP E - most common endemically and spreads enterally (fecal-oral) HEP G - bloodborne

What is cirrhosis?

It is the chronic irreversible scarring of the liver caused by chronic hepatic inflammation and necrosis.

IMPORTANT LABS

- alt - ast - albumin - ammonia - bilirubin - alp - PT/INR - PLT - BUN/CREATININE - NA - H&H - SERUM PROTEIN Early staged biomarkers such as ALT, & AST is elevated, however in the late stages of the disease/ when there is no function they go down (that does not mean they are improving).

what are some nursing interventions for cirrhosis of the liver?

- check daily weights to determine fluid retention. - monitor neuro function and for signs of hep encephalopathy. - monitor F&E balance - monitor for bleeding - elevate the feet to decrease dependent edema - at risk for FALLS - after paracentesis, hold the site for 5 minutes d/t bleeding risk. - teach pt to use cold compress, warm baths, corticosteroid creams, and SSRIs to relieve pruritus'. - cirrhosis doesn't= liver failure when there is decompensation then there is failure (monitor for S&S such as those complications above). - teach pt that plant protein is better than animal protein for hepatic encephalopathy. - teach pt to adhere to a low sodium diet because NA pulls water (1-2g or 2000 mg/day). No table salts. - ABSOLUTELY NO ALCOHOL!!

Nursing interventions for Pancreatitis

- monitor vitals for indications of shock (low BP, high HR) - monitor LOC - monitor for alcohol withdrawal - keep pt hydrated, give IV fluids. - treat pain (morphine, hydromorphone) - NPO in the acute phase to allow the pancreas to rest. Give IV isotonic fluids. - replace magnesium and calcium (give supplements) - place on ng tube with low intermittent suctioning to prevent paralytic ileus. - give histamine receptor blockers, PPI, and antacids to decrease gastric secretions. - teach the patient to lie in the fetal position to relieve pain. - Monitor ABC's - observe for signs of hypocalcemia/tetany (muscle twitching, paresthesia). - teach them to eat a high protein, moderate carb, low-fat diet. - teach to avoid triggers such as caffeine, alcohol, nicotine, and spicy foods. - in chronic disease, the patient may need pancrelipase to help prevent malnutrition, malabsorption, and weight loss. - take pancrelipase with foods or snacks. - take pancrelipase after taking an H2 blocker. - do not take pancrelipase with protein-containing food.

Nursing Interventions for Hepatitis.

- use standard precautions. - Hep B vaccines are given in a series of 3 injections. - report all hepatitis cases to the health department. - teach patients to wash their hands, boil water before drinking, and DO NOT COOK FOOD TO SERVE OTHERS (hep A, and E). - teach the patient to eat small frequent meals, after the acute phase. - teach to avoid alcohol and avoid sexual contact if infected. - teach pt. to stay hydrated. - teach patients to avoid the use of over-the-counter drugs, because most of them contain acetaminophen. - avoid aspirin and any sedatives. - USE GLOVES when touching bodily fluids. TEACH THE infected pt to use a separate towel, eating utensils, dishes, and toilets. If only one toilet is available clean using BLEACH. - teach pt to wash clothes separately.

what are the 2 classifications of cirrhosis of the liver?

1. Compensated - there is some liver function left with no major signs and symptoms. 2. Decompensated - there are significant signs of liver failure.

what are the treatments for cirrhosis?

1. Diuretics - for ascites and edema to prevent respiratory and cardiac complications. SPIRILACTALONE. 2. Antibiotics- for spontaneous bacterial peritonitis caused by bacteria in the ascites fluid. - Also treats confusion caused by hepatic encephalopathy. 3. Paracentesis - to remove the fluid in the abdomen. - Measure the abdomen before and after. 4. Vitamins - to replace those due to deficiency. 5. Lactulose - a diuretic used to decrease serum ammonia through the stool (2-3 stools/ day). 6. Shunt - used if paracentesis doesn't work. It diverts ascitic fluid into venous circulation. 7. Nonselective beta-blockers - such as Propranolol. It is used to prevent bleeding by reducing the HR and hepatic venous pressure gradient. - Do not give if the pt is not alert. 8. Vasoactive drugs - drugs such as octreotide acetate and vasopressors to decrease the blood flow and portal pressure. 9. TRANSPLANTATION- is the only cure for end stage liver disease.

what are the types of cirrhosis?

1. Post necrotic - which is caused by viral hepatitis especially Hep C, and certain drugs or toxins. 2. Laennec's AKA Alcoholic - which is caused by chronic alcoholism. 3. Biliary or Cholestatic - which is caused by chronic biliary obstruction or autoimmune diseases.

Risk factors for Pancreatitis include:

1. gallstones/biliary disease- it blocks the bile ducts. 2. alcohol- they damage the acinar cells. 3. infection- such as HIV, Coxsackievirus 4. medications 5. trauma- stab wounds, gunshot wounds 6. drug use 7. metabolic issues- hyperlipidemia, hyperparathyroidism, hypercalcemia 8. family hx 9. cystic fibrosis 10. cholecystitis/ERCP trauma 11. men- common during the holidays or vacations when alcohol consumption is the greatest.

Question 10 part 2. Use the info in part 1 to select the best choices. The nurse determines that the client is at risk for -------if the client were to be administered tissue plasminogen activator (1-PA) when experiencing a(n) ------ stroke because the blood vessels of the brain have already ----- Choose 1 option for each choice. Choice 1- cranial hemorrhage, clotting, paralysis. Choice 2- ischemic, hemorrhagic, transient. Choice 3- ruptured, clotted, narrowed.

Correct options- The nurse determines that the client is at risk for cranial hemorrhaging if the client were to be administered tissue plasminogen activator (1-PA) when experiencing a(n) hemorrhagic stroke because the blood vessels of the brain have already ruptured.

Signs and Symptoms of pancreatitis include?

S &S OF ACUTE PANCREATITIS - mid epigastric LUQ pain (may radiate to the back, shoulders and flank). - Jaundice - abdominal tenderness - guarding - tachycardia - ascites - low BP - hyperglycemia - nausea/vomiting - hemoconcentration (d/t 3rd spacing) - thrombocytopenia - fever - confusion - agitation - Cullens sign (bluish discoloration around the belly button) - Turner's sign (bluish discoloration towards the back) - LABS such as lipase and amylase WILL BE ELEVATED - low calcium magnesium, and albumin. COMPLICATIONS OF PANCREATITIS - SHOCK d/t necrosis of the blood vessels. - DIC d/t necrosis of the blood vessels. - ARDS - ABDOMINAL COMPARTMENT SYNDROME - AKI - SIRS - CANCER (CHRONIC) - SEPSIS d/t bacterial abscesses - Jaundice d/t swelling of the head of the pancreas causing bile flow obstruction. - DIABETES CHRONIC S&S - low bicarbonate - steatorrhea d/t fat malabsorption - weight loss, muscle wasting - starvation edema d/t protein malabsorption caused by low albumin levels. - diabetes d/t impaired insulin production pleuritic pain/ pleural effusion/ ARDS d/t pancreatitis ascites that impair lung expansion. - continuous burning, gnawing pain in the abdomen. - jaundice - ascites - orthopnea/dyspnea - dark urine - clay colred stools - LABS such as lipase and amylase WILL APPEAR NORMAL OR SLIGHTLY ELEVATED.

what are the signs and symptoms of hepatitis?

SIGNS & SYMPTOMS OF HEPATITIS - RUQ abdominal pain - Jaundice (bilirubin >3mg/dL) - icterus (yellow sclera) - liver tenderness - dark urine - clay-colored stools - pruritus - diarrhea/ constipation - fever, fatigue - malaise - anorexia, nausea, vomiting - dry skin - weight loss - flu like symptoms for hep c that disappear and then reappear in the 3rd decade. COMPLICATIONS OF HEPATITIS - Cirrhosis/ liver failure (B, C, D) - Chronic Hepatitis (> than 6 months [B, C]) - Fulminant Hepatitis (severe acute often fatal form of hepatitis d/t failure of the liver cells to regenerate). - myalgia - polyarthritis - renal insufficiency - cognitive impairment - cardiovascular issues

List the signs and symptoms of Cirrhosis.

Signs & and Symptoms of Cirrhosis EARLY SIGNS - thrombocytopenia - fatigue - anorexia - vomiting - LUQ abdominal pain LATE SIGNS - Jaundice - ascites - bruising - pruritus - purpuric lesions - palmer erythema - peripheral edema - vitamin A, D, E, and K deficiency - esophageal varices - hernia - hemorrhoids - change in mental status - DIC - gynecomastia (breast in males) - impotence - hirsutism - amenorrhea - peripheral neuropathy - asterixis (hand flapping) - leukopenia - spider angiomas - BLEEDING Complications of Cirrhosis (also late signs) 1. Hepatic encephalopathy - d/t too much ammonia in the blood. S&S include mental changes, motor disturbances, asterixis, and fetor hepaticus. - it is treated with LACTULOSE. 2. Hepatorenal Syndrome - It is often fatal (high bun, creatinine, urine osmolality) 3. Portal HTN - d/t increased pressure in the portal vein. - causes collateral circulation to forming order to reduce pressure. examples of collateral circulation are esophageal varices. 4. Ascites - caused by an increase in the hydrostatic pressure from portal HTN. - d/t low albumin - fluid goes into the abdominal cavity. - causes the retention of sodium and water. 5. Hepatopulmonary Syndrome - d/t increased pressure from the ascites which reduces lung expansion and can cause ARDS. 6. Esophageal Varices - a type of collateral circulation that develops as a result of the increased pressure caused by portal HTN. - bleeding is life-threatening. - give meds to prevent vomiting or anything that can cause it to rupture. 7. Spleenomegaly - caused by too much blood backing up in the spleen causing enlargement. - an enlarged spleen destroys platelets and causes thrombocytopenia. - at risk for BLEEDING. 8. Spontaneous bacterial peritonitis

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. What does the nurse identify as the primary safety precaution to use? a. Wear a patch over one eye. b. Place personal items on the sighted side. c. Lie in bed with the unaffected side toward the door. d. Turn the head from side to side when walking.

To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking (scanning). Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking Presents the primary safety hazard.

The nurse is providing home care dietary instructions to a client who has been hospitalized for pancreatitis. Which food would the nurse instruct the client to avoid to prevent recurrence? a. chili b. bagels c. lentil soup d. watermelon

answer is a. Pancreatitis is the acute or chronic inflammation of the pancreas with the associated escape of pancreatic enzymes into surrounding tissue. The client must avoid spicy foods such as chili, alcohol, coffee, tea, and heavy meals because they stimulate pancreatic secretions and produce attacks of pancreatitis. The client is instructed regarding the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

Part 5 Today: 1300 The client is transferred to the med-surg after receiving t-PA in the ED. The client was found to have an ischemic stroke. The client is noted to have regained some resistance to gravity with the RUE; however, they continue to exhibit some dysarthria with slight drooling. The nurse is developing a plan of care to prevent the client from aspirating. Which step(s) can the nurse take to prevent aspiration? SATA a. Raise the head of the bed above 90 degrees. b. Complete a dysphagia screening before providing the client with solids or fluids. c. Liquify solid foods. d. Introduce foods on the unaffected side when the client first takes food. e. Request a consultation with occupational therapy. f. Teach the client to tuck their chin before swallowing.

answer is b, d, e, f Typically the patient will remain NPO until a swallow test is done. The nurse should obtain a dysphagia screening before introducing any solids or liquids to prevent aspiration. If it is safe for the client to be presented with solids and liquids, the nurse should introduce the foods on the unaffected side. The nurse can contact occupational therapy to request they work with the client to improve their swallowing technique. The nurse can teach the client to tuck their chin (chin tuck) to improve swallowing. The client does not need to sit up above 90 degrees; the head of the bed should be raised above 30 degrees. A client with dysphagia commonly has more difficulty swallowing fluids than solids; liquids should be thickened to avoid aspiration.

The nurse is planning care for a client in the first 24 hours after admission for a thrombotic stroke. Which assessment is a priority for the nurse to make during this time? a. cholesterol level b. pupil size and response c. bowel sounds d. echocardiogram

answer is b. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, though it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for a client with a thrombotic stroke without heart problems.

A client with a hemorrhagic stroke is slightly agitated and has a heart rate of 118 bpm and a respiration rate of 22 breaths/min. Bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 mm Hg, and the client has copious amounts of oral secretions. In which order, from first to last, should the nurse suction the client's mouth and airway to prevent increased intracranial pressure (ICP)? All options must be used. a. Suction the airway. b. Hyperoxygenate. c. Suction the mouth. d. Explain the procedure.

answer order d, b, a, c. Increased agitation with suctioning will increase ICP, and the nurse should explain the procedure and calm the patient first. The nurse should then hyperoxygenate the client before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.

The nursing student knows that which type of stroke is caused by a rupture of a blood vessel in the brain? a. TIA b. Ischemic stroke c. hemorrhagic stroke

c. hemorrhagic stroke

which types of hepatitis have vaccines available?

hep A, and hep B.

what is the gold standard for detecting hepatitis?

liver biopsy

A client arrives at the emergency department complaining of severe abdominal pain. During a quick assessment, the nurse observes that the client has both Cullen's sign and Grey Turner's sign. In which priority order would the nurse perform the actions? Arrange the actions in the order that they should be performed. All options must be used. 1. Assess vital signs and draw blood for prescribed laboratory tests. 2.Hydrate the client with intravenous fluids. 3.Administer prescribed pain medications intravenously. 4. Place a nasogastric tube; client is NPO (nothing by mouth). 5.Inquire about when pain occurs and previous history, including medications and alcohol.

the answer is 1, 3, 2, 4, 5.

The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which? a. positions the client on the back with a small pillow under the head b. keeps portable suctioning equipment at the bedside c. opens the client's mouth with a padded tongue blade d. cleans the client's mouth and teeth with a toothbrush

the answer is A. The UAP should position an unconscious client on the side, not on the back, with the head flat. A lateral position helps secretions escape from the throat and mouth, minimizing the risk for aspiration. It may be necessary to suction the client if they aspirate. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush. 8 CN: Reduction of risk potential;

a client is admitted with a possible ischemic stroke has been aphasic for 3 hours and has a blood pressure of 220/120 mmHg. Which prescription by the health care provider should the nurse question? a. labetalol infusion to keep the BP lower than 120/80 mmHg. b. tissue plasminogen activator per protocol. c. normal saline intravenously at 75 ml/hr. d. bed elevated 30 degrees.

the answer is A. The nurse should question the prescription to administer labetalol to decrease the BP to less than 120/80 mm Hg. It is not recommended that diastolic blood pressure is less than 90 mm Hg. Mean arterial pressure (MAP) should be kept between 80- and 110-mm Hg. The client's presenting BP is 220/120 mm Hg, which would indicate a MAP of 146 mm Hg. When a client has a stroke, autoregulation is a protective mechanism used to protect the brain. Elevated blood pressure helps increase cerebral perfusion. The standard of care is to administer t-PA within 4.5 hours of signs and symptoms of a stroke. Normal saline is an isotonic solution recommended for a client experiencing an ischemic stroke. Keeping the head of the bed at 30 degrees helps decrease intracranial pressure.

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)? a. Ask what medications the client is taking. b. Complete a history and health assessment. c. Identify the time of onset of the stroke. d. Determine if the client is scheduled for any surgical procedures.

the answer is C. Studies show that clients who receive ' recombinant tPA treatment within 3 hours after the onset of a stroke has better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history are not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? a. pulse b. respirations c. blood pressure d. temperature

the answer is C. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the HCP and specific to the client's ischemic tissue needs and risk for bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

The nurse instructing a client with chronic pancreatitis about measures to prevent its exacerbation would provide which information? Select all that apply. a. Eat bland foods. b. Avoid alcohol ingestion. c. Avoid cigarette smoking. d. Avoid caffeinated beverages. e. Eat small meals and snacks high in calories. f. Eat high-fat, low-protein, high-carbohydrate meals.

the answer is a, b, c, d, e. Chronic pancreatitis is a progressive, destructive disease of the pancreas, characterized by remissions and exacerbations (recurrence). Measures to prevent an exacerbation include eating bland, low-fat, high-protein, moderate-carbohydrate meals; avoiding alcohol ingestion, nicotine, and caffeinated beverages; eating small meals and snacks high in calories; and avoiding gastric stimulants such as spices.

Cholecystitis is more common in? SATA a. thin women b. obese women c. athletes d. height e. women using birth control or pregnant f. high cholesterol

the answer is a, b, c, e, f Risk factors for cholecystitis include increased cholesterol in the diet, sedentary lifestyle, obesity, young thin women, athletes, gyminist, hormone replacement, pregnancy, family hx, prolonged TPN, >WOMEN, American Indian, Mexican American.

The nurse is reviewing the record of a child with a head injury exhibiting increased intracranial pressure and notes that the child shows signs of decerebrate posturing. On assessment of the child, what additional signs would the nurse expect to note if this type of posturing is present? Select all that apply. a. Vomiting b. Decreased consciousness c. Alteration in pupil size and reactivity d. Abnormal flexion of the upper extremities and extension of the lower extremities

the answer is a, b, c. Decerebrate (extension) posturing is an abnormal extension of the upper extremities with internal rotation of the upper arm and wrist and extension of the lower extremities with some internal rotation. It is a late sign, and it means that there is too much pressure on the brain stem. Options 1, 2, and 3 will be seen with decerebrate posturing. Option 4 is decorticate posturing.

The nurse is providing care to a client whose seizures are being control with phenytoin. Which observation made by the nurse would require primary health care provider notification to discontinue the medication? a. Diplopia b. Bleeding gums c. Diffuse body rash d. Mental impairment

the answer is c. Stevens-Johnson syndrome is a rash indicating an allergy, and if this occurs, the primary health care provider needs to be notified as soon as possible. Although the remaining options are also side effects of the medication, they may be reversed with medication dose alteration rather than medication discontinuation.

After a cervical spine fracture, this device (halo vest) is placed on the client. The nurse creates a discharge plan for the client to ensure safety and includes which measures? Select all that apply. a. Teach the client how to ambulate with a walker. b. Instruct the client to bend at the waist to pick up needed items. c. Demonstrate the procedure for scanning the environment for vision. d. Inform the client about the importance of wearing rubber-soled shoes. e. Teach the spouse to use the metal frame to assist the client to turn in bed.

the answer is a, c, d. The client with a halo fixation device should be taught that the use of a walker and rubber-soled shoes may help prevent falls and injury and are therefore also helpful. It is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. The client with a halo fixation device should avoid bending at the waist because the halo vest is heavy, and the client's trunk is limited in flexibility. The nurse instructs the client and family that the metal frame on the device is never used to move or lift the client because this will disrupt the attachment to the client's skull, which is stabilizing the fracture.

The nurse is teaching the family of a client with dysphagia about decreasing the risk for aspiration while eating. Which measure(s) should the nurse include in the teaching plan? Select all that apply. a. maintaining an upright position while eating. b. restricting the diet to liquids until swallowing improves. c. introducing foods on the unaffected side of the mouth d. keeping distractions to a minimum. e. cutting food into large pieces of finger food

the answer is a, c, d. A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk for aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cut into bite-sized pieces.

The nurse monitors a client with a spinal cord injury for signs of autonomic dysreflexia. Which are indications of this life-threatening syndrome? Select all that apply. a. Piloerection b. Tachycardia c. Nasal stuffiness d. Severe hypotension e. Severe throbbing headache f. Flushing above the level of the lesion

the answer is a, c, e, f. Autonomic dysreflexia is characterized by a cluster of clinical manifestations that results when multiple spinal cord autonomic responses discharge simultaneously. The manifestations result from an exaggerated sympathetic response to a noxious stimulus below the level of the cord lesion. Manifestations include piloerection, nasal stuffiness, severe hypertension, a sudden severe throbbing headache, flushing above the level of the lesion (face and chest), bradycardia, sweating, nausea, blurred vision, and a feeling of apprehension.

A client is diagnosed with cholecystitis. The nurse reviews the client's medical record, expecting to note documentation of which manifestations of this disorder? Select all that apply. a. Dyspepsia b. Dark stools c. Light-colored and clear urine d. Feelings of abdominal fullness e. Rebound tenderness in the abdomen f. Upper abdominal pain that radiates to the right shoulder

the answer is a, d, e, f. Cholecystitis is an inflammation of the gallbladder. Manifestations include dyspepsia; feelings of abdominal fullness; rebound tenderness (Blumberg's sign); upper abdominal pain or discomfort that can radiate to the right shoulder; pain triggered by a high-fat meal; clay-colored stools, dark urine, and possible steatorrhea; anorexia, nausea, and vomiting; eructation; flatulence; fever; and jaundice.

PART 3 The nurse has received orders from the health care provider. Which three orders should the nurse perform right away? a. CT scan stat b. Cranial x-ray c. Potassium Chloride d. Neurologic assessment every 15 minutes e. Blood glucose stat f. t-PA stat

the answer is a, d, e. The client needs a CT scan as soon as possible to determine if they are experiencing a stroke and the type of stroke. The nurse should perform neurologic assessments every 15 minutes, and a blood glucose check should be obtained to ensure the client is not exhibiting signs and symptoms of hypoglycemia, which could mimic a stroke. An X-ray is not needed at this time because the CT scan allows more views of the anatomy being scanned. Potassium is not needed until a laboratory report indicates a low potassium level. t-PA may be required, but it should not be administered before determining the type of stroke because of the risk for hemorrhage.

The nurse is planning the care of a client with hemiplegia to prevent joint deformities of the arm and hand. Which position(s) would be appropriate? Select all that apply. a. placing a pillow in the axilla, so the arm is away from the body. b. inserting a pillow under the slightly flexed arm, so the hand is higher than the elbow. c. immobilizing the extremity in a sling. d. positioning a hand cone in the hand, so the fingers are barely flexed. e. keeping the arm at the side using a pillow.

the answer is a,b, d. Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures.

A client with cirrhosis has a serum sodium level of 129 mEq/L (129 mmol/L) as a result of hypervolemia. The nurse reviews the primary health care provider's prescriptions to determine whether which most appropriate measure would be instituted? a. Restrict fluids. b. Restrict intake to 2 g of sodium per day. c. Restrict intake to 4 g of sodium per day. d. Administer intravenous (IV) hypertonic saline.

the answer is a. Hyponatremia is defined as a serum sodium level of less than 135 mEq/L (135 mmol/L). When it is caused by hypervolemia, it may be treated with fluid restriction because the low serum sodium value is a result of hemodilution. A diet restricted to 4 g of sodium a day is a no-added-salt diet; this diet and a diet restricted to 2 g of sodium a day would not raise the serum sodium level. IV hypertonic saline (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L (125 mmol/L).

hepatitis must be reported to the local public health department. true or false?

the answer is true.

true or false, jaundice may look like it is getting worse before it resolves?

the answer is true. jaundice may appear to get worse before it resolves. The danger signs that could indicate a worsening of jaundice includes changes in neurological status, bleeding, and fluid retention.

Part 6 Today:2000 The nurse is evaluating the client after receiving t-PA 12 hours ago. Which findings indicate that the t-PA has been effective? Select all that apply. a. Headache pain rated as 1 on a scale of 0 to 10. b. Slightly slurred speech c. Blood glucose 105 mg/dL (5.83 mmol/L) d. Client exhibiting resistance to gravity. e. Pupils are equal and respond to light and accommodation. (PERRLA) f. Temperature 98.1°F (36.7°C)

the answer is a,b,d The client's headache pain is significantly less indicating that blood flow has returned in the brain. The blood pressure has lowered. The client's slurred speech is found to be improving, also indicating that the medication is having the intended action. The client is now exhibiting resistance against gravity with the right upper extremity, indicating the medication is improving blood flow in the brain. The pupillary response is critical to monitor for changes in the cranial nerves caused by the stroke; however, the client's pupils were not found to be affected by the client's ischemic stroke. If the client began to experience any signs of cerebral edema, having a valid assessment of the pupil size and pupillary response could help detect these changes. The glucose level is important to monitor after medication administration because the levels may become erratic as a response to a stroke, but the blood glucose levels were both within normal limits. The client's temperature has not changed but the nurse should continue to monitor the temperature to determine if the increase is becoming a trend.

The nurse is caring for a 50-year old male client in the emergency department ED): Nurse's Notes Today: 0800 The patient presented to the ED with a headache, slurred speech, and right-sided arm weakness. The client began to show symptoms. about 30 minutes ago. The patient is alert and oriented to person, place, time, and situation. vital signs are temperature 97.7°F (36,5°C); heart rate 89 bpm respiration rate 22 breaths/min; blood pressure 170/89 mm Hg; and oxygen saturation Coas on room air. PERRLA assessment reveals a 4-mm pupil size. The pt reports a headache pain of 8 on a scale of 0 to 10. The client has a medical history of high blood pressure, diabetes, and high cholesterol. Which four findings require immediate follow-up? a. Right-sided arm weakness b. Slurred speech c. Heart rate of 89 bpm d. Headache e. Confusion f. Respiration rate of 22 breaths/min

the answer is a,b,d,e. The client has right-sided arm weakness, headache, and notable slurred speech, which are findings that indicate the client may be having a stroke. The heart rate and the respiration rate are within normal limits.

The nurse is developing a care plan to help a client with expressive aphasia communicate. Which action (s) would be helpful? Select all that apply. a. Present one thought at a time. b. Avoid writing messages. c. Speak at a normal volume. d. Make use of gestures. e. Encourage pointing to the needed object.

the answer is a,c, d, e. The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.

Mannitol is administered intravenously to a client admitted to the hospital with loss of consciousness and a closed head injury. The nurse determines that the medication achieved its priority effect if which outcome is noted? a. Improved level of consciousness and normal intracranial pressure b. Weight loss of 1 kg and a serum creatinine of 0.8 mg/dL (70.66 mcmol/L) c. Serum creatinine of 1.2 mg/dL (106 mcmol/L) and normal intracranial pressure d. Diuresis of 500 mL in 2 hours and a blood urea nitrogen of 15 mg/dL (5.4 mmol/L)

the answer is a. Mannitol, an osmotic diuretic, is often used to treat cerebral edema by pulling fluid out of the extracellular space of the edematous brain tissue. It improves the client's level of consciousness and normalizes intracranial pressure. It works best when given in boluses rather than as a continuous infusion. Monitor for fluid and electrolyte imbalances if the client is receiving mannitol

The nurse has implemented a plan of care for a client diagnosed with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome indicates the effectiveness of the plan? a. Maintenance of intact skin b. Regaining of bladder and bowel control c. Performance of activities of daily living independently d. Independent transfer of self to and from the wheelchair

the answer is a. A C5 spinal cord injury results in quadriplegia with no sensation below the clavicle, including most of the arms and hands. The client maintains the partial movement of the shoulders and elbows. Maintaining intact skin is an outcome for spinal cord injury clients. The remaining options are inappropriate for this client.

The nurse is caring for a client who sustained a spinal cord injury that has resulted in spinal shock. Which assessment will provide relevant information about recovery from spinal shock? a. reflexes b. pulse rate c. temperature d. blood pressure

the answer is a. Areflexia characterizes spinal shock; therefore, reflexes would provide the best information about recovery. Vital sign changes (options 2, 3, and 4) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about spinal shock recovery. Blood pressure would provide good information about recovery from other types of shock, but not spinal shock.

The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse would include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)? a. Assist the client to develop a daily bowel routine to prevent constipation. b. Teach the client to manage emotional stressors by using mental imaging. c. Assess vital signs and observe for hypotension, tachycardia, and tachypnea. d. Administer dexamethasone orally per the primary health care provider's prescription.

the answer is a. Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.

The nurse is administering a thrombolytic drug to a client who has had a stroke. What is the expected outcome of this drug? a. increased vascular permeability. b. vasoconstriction c. dissolved blood clot d. prevention of hemorrhage

the answer is c. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

A patient is being transferred to your unit with acute cholecystitis. In report the transferring nurse tells you that the patient has a positive Murphy's Sign. You know that this means: a. The patient stops breathing in when the examiner palpates under the ribs on the right upper side of the abdomen at the midclavicular line. b. The patient stops breathing out when the examiner palpates under the ribs on the right upper side of the abdomen at the midclavicular line. c. The patient verbalizes pain when the lower right quadrant is palpated. d. The patient reports pain when pressure is applied to the right lower quadrant but then reports an increase in pain intensity when the pressure is released.

the answer is a. Murphy's Sign can occur with cholecystitis. This occurs when the patient is placed in the supine position and the examiner palpates under the ribs on the right upper side of the abdomen. The examiner will have the patient breathe out and then take a deep breath in. The examiner will simultaneously (while the patient is breathing in) palpate on this area under the ribs at the midclavicular line (hence the location of the gallbladder). It is a POSITIVE Murphy's Sign when the patient stops breathing in during palpation due to pain.

A client is receiving phenobarbital orally for the treatment of a seizure disorder. The nurse would assess the client for which common side effect of this medication? a. Drowsiness b. Hypocalcemia c. Blurred vision d. Seizure activity

the answer is a. Phenobarbital is a barbiturate used to manage seizure disorders. Drowsiness is a common side effect of phenobarbital. Hypocalcemia is a rare toxic effect. Blurred vision is not a side effect of this medication. Seizure activity could occur from abrupt withdrawal of medication therapy or as a toxic effect.

The nurse monitors a patient diagnosed with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed? a. Inability to pass flatus b. Loss of anal sphincter control c. Severe, constant pain with rapid onset d. Firm, non-tender mass palpable at the lower right costal margin

the answer is a. Rationale:An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Option 4 is the description of the physical finding of liver enlargement. The liver is usually enlarged in the client with cirrhosis or hepatitis. An enlarged liver is not a sign of paralytic ileus.

The nurse is positioning a client who has hemiparalysis. Which technique is most effective when there is only one person to assist the client to move from the left side to the right side? a. rolling the client onto the side. b. sliding the client to move up in bed. c. lifting the client when moving the client up in bed. d. having the client help lift off the bed using a trapeze.

the answer is a. Rolling the client with hemiparalysis is the most effective method to use when there is only one person to help the client change positions from one side to another. The nurse must keep the client in anatomically neutral positions and ensure that the limbs are properly supported. Sliding a client on a sheet causes friction and is to be avoided. Friction injures the skin and predisposes to pressure ulcer formation. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury. Before asking the client to use a trapeze to use the bedpan, the nurse should assess the client's strength and ability to assist.

The nurse is caring for a client who is receiving selegiline hydrochloride. Which finding indicates that the client is experiencing an adverse effect of the medication? a. tremors b. confusion c. light-headedness d. abdominal discomfort

the answer is a. Selegiline hydrochloride is an antiparkinsonian medication. Side effects of the medication include confusion, lightheadedness, abdominal discomfort, nausea, dizziness, and faintness. Adverse effects and toxic effects vary, from central nervous system depression (sedation, apnea, cardiovascular collapse, death) to severe paradoxical reaction (hallucinations, tremors, seizures).

The nurse caring for a client with a diagnosis of chronic pancreatitis collects data on the client, knowing that which sign/symptom indicates poor absorption of dietary fats? a. Steatorrhea b. Bloody diarrhea c. Electrolyte disturbances d. Gastrointestinal reflux disease

the answer is a. Steatorrhea by definition means fatty stools, often caused by malabsorption of dietary fats. The pancreas makes digestive enzymes that aid in absorption. Chronic pancreatitis interferes with absorption of nutrients. Fat absorption is limited because of the lack of pancreatic lipase. The other signs/symptoms are not associated with the poor absorption of fats.

The nurse is developing a care plan for a client who has had a stroke. The nurse asks about the client's functional status before the stroke. How will the nurse incorporate this information into the care plan? The client's functional status before the stroke will: a. guides the rehabilitation plan. b. help predict outcomes. c. helps the client recognize physical limitations. d. determines if the client can be expected to regain most functional status.

the answer is a. The primary reason for the nursing assessment of a client's functional status before the stroke is to guide the rehabilitation plan. The assessment does not help predict how far the rehabilitation team can help the client recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status does not help the client recognize limitations.

After medicating a client with a diagnosis of acute pancreatitis for pain, the nurse would evaluate for relief of pain in which anatomical area? a. Epigastric area and radiating to the back b. Left lower quadrant and radiating to the hip c. Epigastric area and radiating to the umbilicus d. Left lower quadrant and radiating to the groin

the answer is a. The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other areas are incorrect, because they do not portray the accurate location of the pain experienced by the client with pancreatitis. Tip for the Nursing Student:In acute pancreatitis, the amylase level is greatly increased. The level starts rising 3 to 6 hours after the onset of pain, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of pain.

The nurse is providing teaching regarding the prevention of hepatitis A to a client who will be traveling overseas. The nurse determines that additional teaching is needed if the client makes which statement? a. "No type of immunization exists against hepatitis A." b. "Handwashing is one of the best methods to prevent infection." c. "I should boil all of the water that I drink and avoid ice cubes." d. "I should be cautious with contact with animals since they can carry hepatitis A."

the answer is a. A hepatitis A vaccine is available for administration to protect against the infection. In addition, a standard immunoglobulin for passive immunization can be given prophylactically or after exposure. The immunoglobulin for passive immunization provides protection from infection for approximately 2 months. Hepatitis A is transmitted via the fecal-oral route; thus, the statements in the remaining options are correct.

The nurse caring for a child who has sustained a head injury notes that the primary health care provider (PHCP) has documented decorticate posturing. During the assessment, the nurse notes the extension of the upper extremities and the internal rotation of the upper arms and wrists and that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, what is the initial nursing action? a. Notify the PHCP of the change in posturing. b. Document that the original positioning is unchanged. c. Attempt to assess the flexibility of the child's lower extremities. d. Plan to continue to monitor the child for posturing every 2 hours.

the answer is a. Decorticate (flexion) posturing refers to the flexion of the upper extremities and the extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate (extension) posturing involves the extension of the upper extremities with the internal rotation of the upper arms and wrists. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Although documentation is appropriate, it is not the initial action in this situation. The other options are not appropriate.

A client admitted to the hospital with a diagnosis of Laënnec's cirrhosis is ready for discharge and expresses the motivation to prevent this condition from worsening. To assist this client, which resource would the nurse inform the client about? a. Alcoholics Anonymous b. Overeaters Anonymous c. American Heart Association d. American Cancer Society

the answer is a. Laënnec's cirrhosis results from chronic alcoholism. This client may benefit from a support group that concentrates on the source of the medical problem, alcoholism. Referrals to agencies for psychosocial support are best provided when the client is motivated. The other resources would not help the client to avoid the source of the medical problem. The American Heart Association would not be a source for the management of an alcohol-related condition. Overeaters Anonymous is a support system for individuals who have an eating disorder. The American Cancer Society is a resource for clients who have cancer.

The nurse, while caring for a hospitalized infant being monitored for hydrocephalus, notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion would the nurse draw? a. No action is required. b. The head of the bed needs to be lowered. c. The infant needs to be placed on nothing by mouth (NPO) status. d. The primary health care provider should be notified immediately.

the answer is a. The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased intracranial pressure (ICP). Noting a bulging fontanel when the infant cries is a normal finding that requires no action. It is not necessary to notify the primary health care provider.

The nurse is caring for an infant diagnosed with hydrocephalus. Which manifestation would the nurse interpret as the earliest finding of increased intracranial pressure (ICP)? a. Irritability b. Sunset sign c. Sluggish pupils d. Depressed eyes

the answer is a. The earliest finding associated with increased intracranial pressure (ICP) would be irritability. Options 2, 3, and 4 are findings of increased ICP, but they are likely to develop slowly and are later signs over a longer time. Additional findings include poor feeding or vomiting, lethargy, a bulging fontanel, a high-pitched cry, increased head circumference, distended scalp veins, and an increased or decreased response to pain.

A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which would the nurse expect to observe in the child? a. Bruising behind the ear b. The presence of epistaxis c. A bruised periorbital area d. An edematous periorbital area

the answer is a. The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle's sign and raccoon eyes. Battle's sign is the presence of bruising or ecchymosis behind the ear caused by a leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and causing an edematous and bruised periorbital area.

The nurse is caring for a patient who has just been admitted after suffering a cerebrovascular accident (CVA). When prioritizing care for the patient, which actions should the nurse take? Select all that apply: a) Prepare the patient for a CT scan with contrast to confirm the diagnosis and assess the extent of the damage. b) Draw APTT and INR levels before starting fibrinolytic therapy to ensure the patient's blood clotting levels are within a safe range. c) Draw APTT and INR levels only after starting fibrinolytic therapy to monitor the patient's response to treatment. d) Administer aspirin PO initially before the patient receives fibrinolytic therapy to help prevent further clotting.

the answer is b you first do CT without contrast in patients who are suspected of having a CVA because if it is a hemorrhagic stroke the dye will kill the patient. You only give contrast after determining the type of stroke. You must draw the PT and INR levels before starting fibrinolytic therapy. You do want to monitor it after but not only after starting therapy. Do not give your patient with a CVA aspirin or any PO med before doing a swallow test, because they are at risk for aspiration. SIDE NOTE: Asprin should be avoided if TPA is ALREADY started. it is delayed for 24 hrs after starting tpa

Your patient is diagnosed with acute cholecystitis. The patient is extremely nauseous. A nasogastric tube is inserted with GI decompression. The patient reports a pain rating of 9 on 1-10 scale and states the pain radiates to the shoulder blade. Select all the appropriate nursing interventions for the patient: A. Encourage the patient to consume clear liquids. B. Administered IV fluids per MD order. C. Provide mouth care routinely. D. Keep the patient NPO. E. Administer analgesic as ordered. F. Maintain low intermittent suction to NG tube.

the answer is b, c, d, e, f. The treatment for cholecystitis includes managing pain, managing nausea/vomiting (a NG tube with GI decompression (removal of stomach contents) to low intermittent suction may be ordered to help severe cases), keep patient NPO until signs and symptoms subside, mouth care from vomiting and nasogastric tube, and administer IV fluids to keep the patient hydrated.

A client begins to experience a tonic-clonic seizure. Which actions would the nurse take to assure client safety? Select all that apply. a. Restrict the client's movements. b. Turn the supine client to the side. c. Open the unconscious client's airway. d. Gently guide the standing client to the floor. e. Place a padded tongue blade into the client's mouth. f. Loosen any restrictive clothing that the client is wearing.

the answer is b, c, d, f. Precautions are taken to prevent a client from sustaining injury during a seizure. The nurse would maintain the client's airway and turn the client to the side. The nurse would also protect the client from injury, guide the client's movements, and loosen any restrictive clothing. Restraints are never used because they could injure the client during the seizure. A padded tongue blade or any other object is never placed into the client's mouth after a seizure begins because the jaw may clench down.

The nurse is caring for a client diagnosed with a seizure disorder who is taking valproic acid 250 mg orally daily. Which findings indicate that the client is experiencing adverse effects of this medication? Select all that apply. a., nausea b. vomiting c. lethargy d. increased appetite e. frequent urination

the answer is b, c. Valproic acid is an anticonvulsant. An adverse effect is hepatotoxicity that may not be preceded by abnormal liver function tests but may be noted as loss of seizure control, vomiting, lethargy, malaise, weakness, and anorexia. Blood dyscrasias also may occur. Frequent side effects include nausea and indigestion. A decreased rather than increased appetite may occur. Frequent urination is not an associated side effect or adverse effect.

The nurse preparing to administer medications to a client diagnosed with hepatic encephalopathy expects to note which medication prescription? a. Docusate b. Lactulose syrup c. Magnesium hydroxide d. Psyllium hydrophilic mucilloid

the answer is b. Lactulose syrup is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH, which aids in the conversion of ammonia in the gut to the ammonium ion, which is poorly absorbed. Docusate is a stool softener. Magnesium hydroxide is a saline laxative. Psyllium hydrophilic mucilloid is a bulk laxative.

The nurse is caring for a client diagnosed with a seizure disorder who is receiving phenytoin 100 mg three times daily. Which finding would indicate to the nurse that the client is experiencing a side effect of the medication? a. constipation b. bleeding gums c. difficulty swallowing d. brown-appearing urine

the answer is b. Phenytoin sodium is an anticonvulsant. Frequent side effects include drowsiness, lethargy, irritability, headache, restlessness, joint aches, vertigo, anorexia, nausea, gastric distress, and gingival hyperplasia. Gingival hyperplasia is indicated by bleeding, tenderness, or swelling of the gums. The urine may appear pink, red, or red-brown while taking this medication, but this is not a side effect of the medication. Constipation and difficulty swallowing are not side effects of the medication.

The nurse is measuring the head circumference of an infant on the fifth postoperative day after surgical placement of a ventricular peritoneal shunt for the correction of hydrocephalus. The nurse notes that the head circumference measurement has increased by 1 cm over the past 24 hours. The nurse analyzes this assessment data as which finding after this surgical procedure? a. Normal for this postoperative period b. A complication related to the functioning of the shunt c. Subcutaneous tissue swelling as a result of the surgical procedure d. Insignificant and unrelated to the patency of the ventricular peritoneal shunt

the answer is b. The head circumference should decrease slightly every day as the superficial tissue fluid is reabsorbed after the surgical trauma. An increase in the head circumference indicates a lack of proper shunting of cerebrospinal fluid caused by either a blockage or a defect in the ventricular peritoneal shunt apparatus. Medical or surgical intervention is required. Options 1, 3, and 4 are incorrect interpretations.

The nurse would question which medication if prescribed for a client diagnosed with an inoperable ruptured intracranial aneurysm? a. Nicardipine b. Heparin sodium c. Docusate sodium d. Aminocaproic acid

the answer is b. The nurse should question a prescription for heparin sodium, which is an anticoagulant. This medication could place the client at risk for rebleeding. Nicardipine is a calcium channel-blocking agent that is useful in the management of vasospasm associated with cerebral hemorrhage. Docusate sodium is a stool softener, which helps prevent straining. Straining would raise intracranial pressure. Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It may be prescribed after ruptured intracranial aneurysm and subarachnoid hemorrhage if surgery is delayed or contraindicated.

The nurse prepares for the admission of the child with a diagnosis of tonic-clonic seizures and plans to place which items at the bedside? a. A tracheotomy set and oxygen b. Suction apparatus and oxygen c. An endotracheal tube and an airway d. An emergency cart and laryngoscope

the answer is b. Tonic-clonic seizures cause tightening of all body muscles followed by tremors. Obstructed airway and increased oral secretions are the major complications during and after a seizure. Suction is helpful to prevent choking and oxygen is helpful to prevent cyanosis. Options 1 and 3 are incorrect because inserting an endotracheal tube or a tracheostomy is not performed. It is not necessary to have an emergency cart (which contains a laryngoscope) at the bedside, but a cart should be available in the treatment room or on the nursing unit.

A child diagnosed with seizures is being treated with carbamazepine. The nurse reviews the laboratory report for the results of the drug plasma level and determines that the plasma level is in a therapeutic range if which is noted? a. 1 mcg/mL (4.2 mcmol/L) b. 10 mcg/mL (42.3 mcmol/L) c. 18 mcg/mL (76.1 mcmol/L) d. 20 mcg/mL (84.6 mcmol/L)

the answer is b. it is an anticonvulsant. When carbamazepine is administered, plasma levels of the medication need to be monitored periodically to check for the child's absorption of the medication. The amount of the medication prescribed is based on the results of this laboratory test. The therapeutic plasma level of carbamazepine is 5 to 12 mcg/mL (21.16 to 50.80 mcmol/L). Option 1 indicates a low level that possibly necessitates an increased medication dose. Options 3 and 4 identify elevated levels that indicate the need to decrease the medication dose.

Your patient is post-op day 3 from a cholecystectomy due to cholecystitis and has a T-Tube. Which finding during your assessment of the T-Tube requires immediate nursing intervention? A. The drainage from the T-Tube is yellowish/green in color. B. There is approximately 750 cc of drainage within the past 24 hours. C. The drainage bag and tubing is at the patient's waist. D. The patient is in the Semi-Fowler's position.

the answer is b. A T-Tube should not drain more than about 500 cc of drainage per day (within 24 hours). A T-Tube's drainage will go from bloody tinged (fresh post-op) to yellowish/green within 2-3 days. The drainage bag and tubing should be below the site of insertion (at or below the patient's waist so gravity can help drainage the bile), and the patient should be in Semi-Fowler's to Fowler's position to help with draining the bile.

The mother whose child is generally alert and participates well in classroom activities is concerned that the teacher now reported that the child has frequent periods during the day when he appears to be staring off into space. The nurse would suspect that the child has which problem? a. School phobia b. Absence seizures c. Behavioral problem d. Attention-deficit/hyperactivity syndrome

the answer is b. Absence seizures are a type of generalized seizure. They consist of a sudden, brief (usually 5 to 10 seconds) arrest of the child's motor activities accompanied by a blank stare and a loss of awareness. The child's posture is maintained at the end of the seizure, and the child returns to activity that was in process as though nothing has happened.

While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the client is exhibiting? a. Flaccidity b. Decorticate posturing. c. Decerebrate posturing. d. Rigidity in the upper extremities

the answer is b. Decortication is abnormal posturing seen in the client with lesions that interrupt the corticospinal pathways. In this posturing, the client's arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the feet and legs extended. Flaccidity indicates weak, soft, and flabby muscles that lack normal muscle tone. Decerebration is abnormal posturing and rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos. Decerebration is usually associated with dysfunction in the brainstem area. Rigidity indicates hardness, stiffness, or inflexibility. Decerebrate posturing is associated with rigidity.

The nurse is planning care for a client who is experiencing expressive aphasia. Which nursing action is most helpful in promoting communication? a. speaking loudly and slowly. b. using a "picture board" for the client to point to pictures. c. writing directions so the client can read them. d. speaking in short sentences

the answer is b. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what they want to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that they desire. Receptive aphasia is a condition in which the client does not comprehend what is being said. For this client, it is helpful to speak clearly, using short sentences or writing out directions.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do what when eating? The client will: a. have a preference for foods high in salt. b. eat food on only half of the plate. c. forget the names of foods. d. be unable to swallow liquids.

the answer is b. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid would the nurse anticipate being prescribed? a. Dextran b. 0.9% Normal saline c. 5% Dextrose in water d. 5% Dextrose in 0.9% normal saline

the answer is b. Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. It is not given in brain injury because it decreases the body's plasma osmolality which increases cerebral fluid causing cerebral edema. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.

The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury? a. Abnormal involuntary flexion of the extremities b. Abnormal involuntary extension of the extremities c. Upper extremity extension with lower extremity flexion d. Upper extremity flexion with lower extremity extension

the answer is b. Rationale: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities

Hep B vaccine protects against Hep D. true or false?

true because hep D needs B to replicate. If you are protected against hep B then Hep D cannot replicate.

A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea. The nurse performs which intervention as a priority measure to assist the client with this complication? a. Repositions side to side every 2 hours b. Elevates the head of the bed to 60 degrees c. Auscultates the lung fields every 4 hours d. Encourages deep breathing exercises every 2 hours

the answer is b. The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid in the abdomen. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. Although assessment is the first step of the nursing process, the stem of the question identifies the assessment findings ascites and difficulty breathing, so the best answer is to intervene based on the assessment data, by elevating the head of the bed to make the client's breathing easier. The other options are general measures in the care of a client with ascites, but the priority measure is the one that relieves diaphragmatic pressure thus assisting effective respirations.

The nurse is reviewing the laboratory results on an adult client admitted with a diagnosis of acute abdominal pain. The nurse would determine that the serum amylase level is normal after noting which result? a. 10 Somogyi units/dL (5 U/L) b. 100 Somogyi units/dL (50 U/L) c. 300 Somogyi units/dL (150 U/L) d. 500 Somogyi units/dL (250 U/L)

the answer is b. The normal serum amylase level is 60 to 120 Somogyi units/dL (30 to 220 U/L) in the adult and slightly higher in the older adult. The rest of the options are abnormal values for serum amylase.

A client diagnosed with seizures is taking the prescribed dose of phenytoin to control seizures. A phenytoin blood level is drawn, and the results reveal a level of 35 mcg/mL (138.88 mcmol/L). Which effect would the nurse expect to note, based on this laboratory finding? a. diarrhea b. nystagmus c. tachycardia no effects, this is the therapeutic level

the answer is b. The therapeutic phenytoin level is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L). Blood levels above 30 mcg/mL (119.04 mcmol/L) produce nystagmus (rhythmic oscillation of eyes). The remaining options suggest incorrect information. TIP: Monitor the client taking phenytoin for gingival hyperplasia (reddened gums that bleed). Contact the primary health care provider if this adverse effect occurs.

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? a. Sit quietly with the client until the episode is over. b. Ignore the behavior. c. Attempt to divert the client's attention. d. Tell the client that this behavior is unacceptable.

the answer is c. A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swings or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.

The physician orders a patient's T-Tube to be clamped 1 hour before and 1 hour after meals. You clamp the T-Tube as prescribed. While the tube is clamped which finding requires you to notify the physician? A. The T-Tube is not draining. B. The T-Tube tubing is below the patient's waist. C. The patient reports nausea and abdominal pain. D. The patient's stool is brown and formed.

the answer is c. A nurse should ONLY clamp a T-Tube with a physician's order. Most physicians will prescribe to clamp the T-tube 1 hour before and 1 hour after meals. WHY? So, bile will flow down into the small intestine (instead out of the body) during times when food is in the small intestine to help with the digestion of fats. This is to help the small intestine adjust to flow of bile (remember normally it received bile when the gallbladder contracted but now it will flow from the liver to the small intestine continuously). Option C is an abnormal finding. The patient should not report nausea or abdominal pain when the tube is blocked. This could indicate a serious problem. Option A is correct because the T-tube should not be draining because it's clamped. Option B is correct because the T-tube tubing should be below or at the patient's waist level. Option D is correct because this shows the body is digesting fats and bilirubin is exiting the body through the stool (remember bilirubin is found in the bile and gives stool its brown color...it would be light colored if the bilirubin was not present). You would NOT want to see steatorrhea (fat/greasy liquid stools) because this shows the bile isn't being delivered to help digest the fats.

The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What would the nurse do to appropriately test for asterixis? a. Examine the client's handwriting movements. b. Check the stool for clay-colored pigmentation. c. Ask the client to extend the wrist and the fingers. d. Check the serum bilirubin and liver enzyme levels.

the answer is c. Asterixis is a rapid, nonrhythmic, abnormal muscle tremor of the wrists and fingers that is commonly associated with hepatic encephalopathy and referred to as "liver flap." Handwriting is a nonspecific and insensitive test of motor function, so the nurse avoids using this to assess for asterixis. Clients with hepatic encephalopathy can experience changes in bowel habits and flatulence but should not experience a color change. The nurse expects the liver function studies of a client with hepatic encephalopathy to have above-normal results.

A client diagnosed with a spinal cord injury reports a severe pounding headache, nausea, and nasal congestion. The client is observed to be diaphoretic, hypertensive, and bradycardic. The nurse suspects that the client is experiencing autonomic hyperreflexia (autonomic dysreflexia). Which action would the nurse take first? a. Document the findings. b. Perform a rectal examination. c. Place the client in a sitting position. d. Notify the primary health care provider.

the answer is c. Autonomic hyperreflexia is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A number of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin. When autonomic hyperreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse would then perform a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately via a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or broken skin. The primary health care provider is notified, and the nurse documents the occurrence and the actions taken.

The home care nurse visits a client who was recently diagnosed with cirrhosis and provides home care management instructions to the client. Which statement by the client indicates the need for further teaching? a. "I will obtain adequate rest." b. "I should monitor my weight regularly." c. "I will take acetaminophen if I get a headache." d. "I should include sufficient carbohydrates in my diet."

the answer is c. Cirrhosis is a chronic progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored regularly. The diet should supply sufficient carbohydrates with a total daily intake of 2000 to 3000 calories.

The nurse is providing discharge instructions to a client with Parkinson's who has been prescribed rasagiline. The client indicates an understanding of the instructions provided when confirming that it is appropriate to eat which food? a. raisins b. yogurt c. chicken d. sour cream

the answer is c. Focus on the subject, an understanding of the discharge instructions for a client taking rasagiline. Recalling that this medication cannot be taken concurrently with foods containing tyramine will assist you in eliminating the incorrect options. In addition, recall that foods that require bacteria and molds to prepare typically contain tyramine. Caffeine containing foods may also contain tyramine.

The home care nurse provides instructions about the management of pruritus to a client with hepatitis who developed jaundice. Which statement made by the client suggests to the nurse that the client needs further teaching? a. "I need to wear loose cotton clothing." b. "A tepid water bath should help stop the itching." c. "Keeping the house warmer is likely to lessen the itching" d. "I need to take the prescribed antihistamines as I'm supposed to."

the answer is c. Pruritus is caused by the accumulation of bile salts in the skin and results from obstructed biliary excretion. The client would be instructed to keep the house temperature cool in order to minimize the itching. The client should avoid the use of alkaline soap, and he or she (client) should wear loose, soft, cotton clothing. Antihistamines may relieve the itching, as will tepid water and emollient baths.

A client is brought into the emergency department after sustaining a possible closed head injury. Which assessment would the nurse perform first? a. Level of consciousness b. Pulse and blood pressure c. Respiratory rate and depth d. Ability to move extremities

the answer is c. The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated by assessing pulse and blood pressure, followed by evaluation of the status of the cardiovascular and neurological systems.

The nurse is monitoring the intracranial pressure (ICP) of a client with a head injury and notes that the ICP is averaging 25 mm Hg. What is the nurse's best action? a. Document result as normal. b. Place client in Trendelenburg's position. c. Notify the primary health care provider. d. Advise the family of client's decline.

the answer is c. The normal ICP is 0 to 15 mm Hg. A pressure of 25 mm Hg is increased and may require intervention if this pressure is sustained. The nurse should notify the primary health care provider. A Trendelenburg's position could increase ICP. Advising the family of the client's decline is neither appropriate nor the priority action before consulting with the provider.

A client with a history of chronic alcoholism has been diagnosed with acute pancreatitis. On reviewing the results of serum laboratory studies, the nurse determines that which finding is unexpected? a. Serum lipase, 260 U/L (260 U/L) b. Blood glucose, 228 mg/dL (13 mmol/L) c. Serum magnesium, 2.9 mEq/L (1.45 mmol/L) d. Serum amylase, 335 Somogyi units/dL (167.5 U/L)

the answer is c. The normal magnesium level is 1.3 to 2.1 mEq/L (0.65-1.05 mmol/L). An unexpected finding in a client with acute pancreatitis and a history of chronic alcoholism is a serum magnesium level of 2.9 mEq/L (1.45 mmol/L). The client with alcoholism typically has low magnesium levels. A high reading of 2.9 mEq/L (1.45 mmol/L) does not correlate with the clinical picture of this client, and the result should be further evaluated. The client with chronic alcoholism who is experiencing acute pancreatitis is expected to show elevations in serum blood glucose, lipase, and amylase. The normal blood glucose is 70 to 110 mg/dL (4-6 mmol/L). The normal serum lipase is 0 to 160 U/L (0 to 160 U/L). The normal serum amylase is 60 to 120 Somogyi units/dL (30 to 220 U/L)

The nurse is reviewing the laboratory results of a client seen in the health care clinic. The nurse would determine that the serum ammonia level is within normal limits if which test result was noted? a. 5 mcg/dL (3 mcmol/L) b. 8 mcg/dL (4.8 mcmol/L) c. 40 mcg/dL (24 mcmol/L) d. 95 mcg/dL (57 mcmol/L)

the answer is c. The normal serum ammonia level is 10 to 80 mcg/dL (6 to 47 mcmol/L). The remaining options identify abnormal serum ammonia levels.

The nurse is reviewing the results of a client's phenytoin level that was drawn that morning. The nurse is preparing to discharge once the level is therapeutic. Which result indicates that this goal has been met? a. 3 mcg/mL (11.9 mcmol/L) b. 8 mcg/mL (31.7 mcmol/L) c. 15 mcg/mL (59.5 mcmol/L) d. 24 mcg/mL (95.2 mcmol/L)

the answer is c. The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L) in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above the therapeutic range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication. In this case, the dose should be adjusted downward.

The nurse is planning care for a client who has had a stroke. Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? a. Place the client's feet against a firm footboard. b. Reposition the client every 2 hours. c. Have the client wear ankle-high tennis shoes at intervals throughout the day. d. Massage the client's feet and ankles regularly.

the answer is c. The use of ankle-high tennis shoes is most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-motion exercises are important interventions, but the client's foot needs to be in the correct anatomic position to prevent overextension of the muscle and tendon. Massaging does not prevent plantar flexion and, if rigorous, could release emboli.

The nurse is creating a teaching plan for the parents of an infant with a ventricular peritoneal shunt who will be discharged from the hospital. Which instruction would the nurse include in the plan of care? a. Expect an increased urine output from the shunt. b. Call the primary health care provider if the infant is fussy. c. Call the primary health care provider if the infant has a high-pitched cry. d. Position the infant on the side of the shunt when the infant is put to bed.

the answer is c. A ventricular peritoneal shunt may be used to treat hydrocephalus. If the shunt is broken or malfunctioning, the fluid from the ventricular part of the brain will not be diverted to the peritoneal cavity, and the cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which then causes a high-pitched cry in the infant. This type of shunt affects the gastrointestinal system rather than the genitourinary system, and an increased urinary output is not expected. Option 2 is a concern only if other signs that are indicative of a complication are occurring. The infant should not be positioned on the side of the shunt, because this will cause pressure on the shunt, as well as skin breakdown.

The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for further teaching? a. "It is best if I avoid tight clothing and lumpy bedclothes." b. "I should watch for headache, congestion, and flushed skin." c. "Signs/symptoms I should watch for include fever and chest pain." d. "I need to pay close attention to how frequently my bowels move."

the answer is c. Autonomic hyperreflexia generally occurs in a client with a spinal cord injury after the period of spinal shock resolves. It occurs with injuries above T6 and cervical injuries. Signs/symptoms of autonomic hyperreflexia include headache, congestion, flushed skin above the level of injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition.

The nurse is teaching a group of nursing students about the complications and types of cholecystitis, the nurse knows that additional teaching is needed when the student states what? a. Cholecystitis can affect the liver. b. Cholecystitis can affect the pancreas. c. Cholecystitis is only caused by stones in the gallbladder. d. Chronic Cholecystitis occurs d/t repeated episodes of cystic duct obstruction and inflammation.

the answer is c. Cholecystitis can be caused by stones in the gallbladder (calculous/cholelithiasis) OR by obstruction or biliary stasis (acalculous).

The nurse is preparing to ambulate a client with a diagnosis of Parkinson's disease who has recently been prescribed levodopa. Which information is most important for the nurse to assess before ambulating the client? a. The client's history of falls b. Assistive devices used by the client c. The client's postural (orthostatic) vital signs d. The degree of intention tremors exhibited by the client

the answer is c. Clients diagnosed with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa, which can also cause postural hypotension. Although knowledge of the client's risk for falls and the client's use of assistive devices are helpful, it is not the most important piece of assessment data, based on the wording of this question. Clients with Parkinson's disease generally have resting, not intention, tremors.

Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful at this time? a. Have the client sip liquids from a straw. b. Position the client with the bed at a 30-degree angle. c. Offer thickened or solid foods from the unaffected side of the mouth. d. Feed the client a soft diet from a spoon into the cheek on the left side of the mouth.

the answer is c. Following a stroke, it is easiest for clients with dysphagia (difficulty swallowing) to swallow solid foods; the nurse should introduce foods on the unaffected side and verify that the client has swallowed the food and is not retaining it in the cheek. Liquid foods are difficult to swallow, and the nurse can instruct the client and family to offer thickened liquids. The client with facial paralysis will have difficulty sipping using a straw. The nurse can raise the head of the bed to 90 degrees, or instruct the client to sit up, if possible, while eating to prevent choking and aspiration.

The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse would take which action? a. Tell the parents that this may indicate spina bifida. b. Recognize that this is normal in the neonate and continue with the bath. c. Arrange to notify the primary health care provider of this physical finding. d. Assess for other associated anomalies, and carefully document all findings.

the answer is c. In this instance, the tuft of hair may be indicative of a spinal anomaly, and the primary health care provider should be notified of the finding. It is inappropriate to discuss abnormal findings with the parents because this role is the responsibility of the primary health care provider if an anomaly is suspected or diagnosed. The nurse should take the priority intervention of notifying the primary health care provider before documenting in the chart.

The nurse prepares to admit a newborn with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant? a. Monitoring the temperature b. Monitoring the blood pressure. c. Inspecting the anterior fontanel for bulging d. Monitoring the specific gravity of the urine

the answer is c. Increased intracranial pressure is a complication that is associated with spina bifida. A sign of increased intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and the closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain the moisture of the sac and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed during the newborn stage of development.

The nurse teaches a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure for cholecystitis. The nurse determines that the client has a need for further teaching if the client makes which statement? a. "An anesthetic throat spray will be used." b. "A signed informed consent is necessary." c. "Medication will be given orally for sedation." d. "It is important to lie still during the procedure."

the answer is c. Intravenous sedation (not oral) is given to relax the client, and an anesthetic throat spray is used to help keep the client from gagging as the endoscope is passed. The client has to sign an informed consent form. The client also needs to lie still for ERCP, which takes about an hour to perform.

A client admitted to the nursing unit with a closed head injury 6 hours ago has begun to vomit and reports being dizzy and having a headache. Based on these data, which is the most important nursing action? a. Administering a prescribed antiemetic b. Having the client rate the headache pain on a scale of 1 to 10 c. Notifying the primary health care provider of the client's condition d. Reminding the client to use the call bell when needing help to the bathroom

the answer is c. The client with a closed head injury is at risk of developing increased intracranial pressure (ICP). Increased ICP is evidenced by signs and symptoms such as headache, dizziness, confusion, weakness, and vomiting. Because of the implications of the client's manifestations, the most important nursing action is to notify the primary health care provider. Although the other nursing actions are not inappropriate, none of them address the critical issue of the potential of the client developing ICP.

The patient complaining of discomfort and pain post laparoscopic cholecystectomy should do all of the following except what? a. Ambulates to relieve the discomfort. b. Uses a splint on the incision in order to deep breathe. c. Stays on bedrest for 8-12 weeks. d. Report severe abdominal pain, vomiting, and diarrhea to the doctor.

the answer is c. The patient who has done laparoscopic surgery to remove the gallbladder is usually inflated with 2-3 liters of air/ carbon dioxide "free air". The patient should GET UP AND WALK!! to relieve the discomfort. The patient should also use a splint on the side of the incision to help them deep breathe and use the incentive spirometer. The patient should report any severe pain, vomiting, and diarrhea to the doctor as it may be a sign of post-cholecystectomy syndrome (PCS). The patient will not remain on bed rest for 8-12 weeks.

The nurse observes a client during a seizure and notes that the client's entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure would the nurse document that the client had experienced? a. Partial seizure b. Absence seizure c. Tonic-clonic seizure d. Complex partial seizure

the answer is c. Tonic-clonic seizures are characterized by body rigidity (tonic phase) followed by rhythmic jerky contraction and relaxation of all body muscles, especially those of the extremities (clonic phase). Absence seizures are characterized by a sudden lapse of consciousness for approximately 2 to 10 seconds and a blank facial expression. There are two types of complex partial seizures: complex partial seizures with automatisms and partial seizures evolving into generalized seizures. Complex partial seizures with automatisms include purposeless repetitive activities such as lip smacking, chewing, or patting the body. Partial seizures evolving into a generalized seizure begin locally and then spread through the body.

The nurse caring for a client diagnosed with acute pancreatitis would give which client problem priority? a. Compromised skin integrity due to pruritus b. Inability to tolerate activity due to debilitation c. Acute pain related to inflammation and enzyme leakage d. Inadequate fluid volume from blood and gastrointestinal losses

the answer is c. When caring for a client diagnosed with acute pancreatitis, abdominal pain is the priority and is the most prominent symptom of acute pancreatitis. The main focus of nursing care is aimed at reducing discomfort and pain by the use of measures that decrease gastrointestinal tract activity, thereby decreasing pancreatic stimulation. The other problems are also appropriate and related to a client with acute pancreatitis, but they are not the priority related to pain control.

Part 4 Today: 0915 The healthcare provider has ordered t-PA to be administered at 0.9 mg/ kg over 60 minutes. The client's blood glucose level is 109 mg/dL (6.05 mmol); CT scan results indicate that no hemorrhagic stroke was evident. The client verbalizes consent for treatment. The nurse is determining if the client has any contraindications to receiving tPA medication. Which finding(s) would be a contraindication to the administration of tPA? Select all that apply. a. The symptoms began less than 3 hours ago. b. The client is experiencing disabling stroke symptoms. c. The blood pressure is lower than 185/110 mm Hg. d. The client currently uses anticoagulant medications. e. The client had a gastrointestinal bleed 2 weeks ago. f. The client is younger than 85 years of age. g. The client takes metformin for diabetes.

the answer is d, e. When/ how should tPa be given: - - ischemic strokes - IV on a programmable pump. (DO NOT GIVE IV PUSH) - 3 to 4.5 hours after onset of symptoms. - 90 mg over 60 minutes including a 10% bolus dose in the first minute OR 0.9mg/kg over 60 minutes with a 10% bolus dose in the first minute. - BP should be maintained below 185/110 but diastolic should not be below 90mmHg. Contraindications for tPa:- - over 80 yrs - on anticoagulants - history of bleeding/hemorrhage. - active bleeding - hemorrhagic stroke - high NIHSS score - Uncontrolled HTN - TBI < 3 months

Bromocriptine is an antiparkinsonian prolactin inhibitor. Frequent side effects include hypotension, dizziness, light-headedness, nausea, and confusion. Adverse effects include visual or auditory hallucinations. a. nausea b. confusion c. hypotension d. auditory hallucinations

the answer is d. Bromocriptine is an antiparkinsonian prolactin inhibitor. Frequent side effects include hypotension, dizziness, light-headedness, nausea, and confusion. Adverse effects include visual or auditory hallucinations.

A client newly diagnosed with Parkinson's disease is prescribed entacapone. The nurse is reviewing the client's medical record. What finding warrants primary health care provider notification immediately? a. The client is experiencing hallucinations. b. The client is experiencing an increase in tremors. c. The client is currently taking levodopa/carbidopa. d. The client is currently taking a monoamine oxidase inhibitor.

the answer is d. Entacapone acts by decreasing the effects of Parkinson's disease. The client with Parkinson's disease, particularly if the client is taking medication for this disease, may experience hallucinations and an increase in tremors. Entacapone is commonly given concurrently with levodopa/carbidopa. This medication is contraindicated for use if given within 14 days of administration of a monoamine oxidase inhibitor.

The nurse is reviewing the doctor's orders for a patient with cholecystitis. Which order should the nurse question? a. Ketorolac b. Antibiotics c. Ursodiol d. Morphine

the answer is d. NSAIDA like ketorolac is usually given for pain in these patients. An antibiotic may be prescribed for infection. Ursodiol is a medication used to dissolve bile acids/stones. Morphine, however, can increase spasms and pain in patients with cholecystitis.

The nurse who has been closely monitoring a child who has been exhibiting decorticate (flexor) posturing after sustaining severe head trauma notes that the child suddenly exhibits decerebrate (extensor) posturing. The nurse interprets that this change in the child's posturing indicates what? a. An insignificant finding b. An improvement in condition c. Decreasing intracranial pressure d. Deteriorating neurological function

the answer is d. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. It is a sign that death is imminent.

Amantadine hydrochloride 100 mg orally twice daily has been prescribed for a client diagnosed with Parkinson's disease. After the home care nurse provides medication instructions, which statement by the client indicates that there is a need for further teaching? a. "I should see improvement in my condition in about 7 days." b. "I can get this medication in syrup form if I have difficulty swallowing." c. "I can empty the capsules into food or fluid to make swallowing easier." d. "I'll take this medication early in the morning and just before I go to bed."

the answer is d. Amantadine hydrochloride is administered twice a day, but the last dose should not be administered near bedtime because it may cause insomnia in some clients. All the remaining options are correct statements.

A client with a diagnosis of subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions. To promote safety, the nurse would ensure that which intervention is provided to the client? a. Liquid diet b. Enemas as needed c. Help with ambulation d. Daily stool softeners

the answer is d. Aneurysm precautions include a variety of measures designed to decrease stimuli that could increase the client's intracranial pressure. Stool softeners should be provided, but enemas should be avoided. Straining at stool is contraindicated because it increases intracranial pressure. Other measures to decrease stimuli include instituting dim lighting and reducing environmental noise and stimuli. The remaining options are not related to minimizing stimulation.

The nurse is assisting a client diagnosed with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which entree item? a. Tomato soup b. Fresh fruit plate c. Vegetable lasagna d. Ground beef patty

the answer is d. Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, milk, peanut butter, and gelatin. The food items in options 1, 2, and 3 are acceptable to eat.

The nurse is monitoring a child who sustained a severe head injury in a motor vehicle crash. On assessment, the nurse notes that the child's apical heart rate has decreased significantly and notes a widening pulse pressure. What is the nurse's best action? a. Obtain orthostatic blood pressure measurements. b. Plan to reassess the client on next hourly rounds. c. Document that these findings are normal and expected. d. Notify the primary health care provider of increasing intracranial pressure (ICP).

the answer is d. Cushing's triad is a late sign of increased ICP and consists of an increased systolic blood pressure with widening pulse pressure, bradycardia, and a change in the respiratory rate and pattern. Cushing's response is usually apparent just before or when the brain stem herniates. The primary health care provider should be notified. The remaining options provide inappropriate actions for this scenario.

The nurse has given parenteral pain medication to a client experiencing an acute episode of cholecystitis. Thirty minutes later, the nurse determines whether the client obtained relief from the pain that had originated in which location? a. Lower quadrant radiating to the back b. Lower quadrant radiating to the umbilicus c. Upper quadrant radiating to the left scapula and shoulder d. Upper quadrant radiating to the right scapula and shoulder

the answer is d. During an acute episode of cholecystitis, the client experiences severe right upper quadrant pain that radiates to the right scapula and shoulder. This is governed by the pattern of dermatomes in the body. The nurse who has administered pain medication determines whether this type of pain has been relieved. The other locations are incorrect for pain related to cholecystitis.

The emergency department nurse is assessing a client who suffered a spinal cord injury (SCI). Assessment reveals a heart rate of 50 beats/min, dry skin, temperature of 100.1 degrees Fahrenheit, and blood pressure of 90/40 mm Hg. What is the nurse's best action? a. Administer antipyretic medication. b. Obtain a prescription for an antihypertensive. c. Explain to the client that the findings are normal for this injury. d. Inform the primary health care provider of suspected shock.

the answer is d. Neurogenic shock usually occurs within 30 minutes of a spinal cord injury at the fifth thoracic vertebra or above, and can last up to 6 weeks. Clinical manifestations associated with neurogenic shock include bradycardia, hypotension, an inability to regulate temperature, hypothermia, and dry skin. The provider should be notified of suspected neurogenic shock to ensure prompt treatment and management of this condition.

The nurse is conducting a health screening on a client with a family history of hypertension. Which assessment finding would alert the nurse to the need for further teaching related to stroke (brain attack) prevention? a. Eats high-fiber grain cereal with skim milk for breakfast b. Has a blood pressure of 118/78 mm Hg and has lost 10 pounds recently c. Uses condoms for pregnancy and disease prevention and jogs 2 miles daily d. Uses oral contraceptives for pregnancy prevention and works as a manager of a busy medical-surgical unit

the answer is d. Oral contraceptive use is discouraged in some clients because of the adverse effect of clot formation. The use of oral contraceptives, obesity, hypertension, hypercholesterolemia, and smoking are all modifiable risk factors for stroke. Low-fat diet and stress-reduction methods are encouraged and identified in options 1 and 3. In option 2, the client has a normal blood pressure and has lost weight.

A client diagnosed with Parkinson's disease has begun therapy with levodopa. The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for what period of time? a. 1-week b. 24 hours c. 5 to 7 days d. 2 to 3 weeks

the answer is d. Parkinson's disease is a degenerative illness caused by the depletion of dopamine. Signs and symptoms of Parkinson's disease usually begin to resolve within 2 to 3 weeks after starting therapy, although in some clients marked improvement may not be seen for up to 6 months. Clients must understand this concept to aid in their compliance with medication therapy. NOTE: Levodopa taken with a monoamine oxidase inhibitor antidepressant can cause a hypertensive crisis.

An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety. a. Covering the back dressing with a binder b. Placing the infant in a head-down position c. Strapping the infant in a baby seat sitting up d. Elevating the head with the infant in the prone position

the answer is d. Rationale:Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. Care of the operative site is carried out under the direction of the surgeon and includes close observation for signs of leakage of cerebrospinal fluid. The prone position is maintained after surgical closure to decrease the pressure on the surgical site on the back; however, many neurosurgeons allow side-lying or partial side-lying position unless it aggravates a coexisting hip dysplasia or permits undesirable hip flexion. This offers an opportunity for position changes, which reduces the risk of pressure sores and facilitates feeding. Elevating the head will decrease the chance of cerebrospinal fluid collecting in the cranial cavity. If permitted, the infant can be held upright against the body with care taken to avoid pressure on the operative site. Binders and a baby seat should not be used because of the pressure they would exert on the surgical site.

The nurse is caring for a client with a diagnosis of a C-6 spinal cord injury during the spinal shock phase. Which action would the nurse implement when preparing the client to sit in a chair? a. Apply knee splints to stabilize the joints during transfer. b. Teach the client to lock the knees during the pivoting stage of the transfer. c. Administer a vasodilator in order to improve circulation of the lower limbs. d. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes.

the answer is d. Spinal shock is a sudden depression of reflex activity in the spinal cord that occurs below the level of injury (areflexia). It is often accompanied by vasodilation in the lower limbs, which results in a fall in blood pressure upon rising. The client can have dizziness and feel faint. The nurse should provide for a gradual progression in head elevation while monitoring the blood pressure. The use of splints would impair the transfer. Clients with cervical cord injuries cannot lock their knees. A vasodilator would exacerbate the problem.

The nurse would place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)? a. In modified left lateral recumbent position b. In reverse Trendelenburg c. With the head elevated on a small, flat pillow d. With the head of the bed elevated at least 30 degrees

the answer is d. The client with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. The head of the bed is elevated to at least 30 degrees or as recommended by the primary health care provider. Therefore, options 1, 2, and 3 are incorrect since they contradict appropriate care.

The nurse is providing care to the diagnosed with stroke who has received medication therapy with tissue plasminogen activator. Which item would the nurse have available for use as part of standard nursing care for this client? a. Flashlight b. Pulse oximeter c. Suction equipment d. Occult blood test strips

the answer is d. Tissue plasminogen activator is a thrombolytic medication that is used to dissolve thrombi or emboli caused by thrombus. A frequent and potentially adverse effect of therapy is bleeding. The nurse monitors for signs of bleeding in clients receiving this therapy. Equipment needed by the nurse would include occult blood test strips to monitor for occult blood in the urine, stool, or nasogastric drainage. A flashlight may be used for pupil assessment as part of the neurological exam in the client who is neurologically impaired. Pulse oximeter and suction equipment would be needed if the client had evidence of respiratory problems.

A client diagnosed with epilepsy has a prescription for valproic acid 250 mg once daily. To maximize the client's safety, which time is best for the nurse to schedule administration of the medication? a. With lunch b. With breakfast c. Before breakfast d. At bedtime with a snack

the answer is d. Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side and adverse effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. Otherwise, it may be given after meals to avoid gastrointestinal upset.

The nurse is caring for a client with a diagnosis of Parkinson's disease who is taking benztropine mesylate daily. When assessing the client, what would the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication? a. Pupil response b. Prothrombin time c. Skin temperature d. Intake and output

the answer is d. it is an anticholinergic medication. IT DRYS YOU UP. "can't pee, can't poop".

A client has begun medication therapy with pancrelipase. The nurse would educate the client to expect which occurrence from this medication? a. Relieve of heartburn. b. Eliminate of abdominal pain. c. Help regulating blood glucose. d. Decrease in the amount of fat in the stools

the answer is d. when in doubt break down the word. Pancre (relating to the pancreas)- lipase (the breakdown of fats or lipids). Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. It does not regulate blood glucose; this is a function of insulin, a hormone produced in the beta cells of the pancreas.

A nurse is assessing a patient who is suspected of having a CVA. The nurse knows that all of these are signs of a right-sided stroke except? a. impulsive behavior b. rapid movement c. impaired judgement d. right-sided weakness

the answer is d. In Right sided strokes the patient will present with visual/spatial awareness deficits and proprioception deficits. It will also affect the opposite side of the body.

All are signs of cholecystitis except? SATA a. Murphy's sign b. Blumberg's sign c. Jaundice d. Biliary colic e. green stools f. clear white urine

the answer is e, and f. Cholecystitis causes stools to be CLAY COLORED, and urine to be DARK. Murphys sign is pain on inspiration after palpating the RUQ. The Blumberg's sign is rebound tenderness. Other signs of cholecystitis include RUQ pain that may radiate to the right shoulder and scapula (biliary colic), jaundice, steatorrhea, increase HR and increase TEMP, dehydration, low appetite d/t pain, anorexia, nausea, vomiting, abdominal fullness.

Carbidopa/Levodopa should be taken with full meals? true or false?

the answer is false. the drug should be taken on an empty stomach with a full glass of water to enhance absorption.