Z- NUR 180: Module 2 Exam

Which client would the nurse identify as being most at risk for experiencing a CVA 1. A 55-y.o. African American male 2. an 84 yo Japanese female 3. a 67 yo caucasian female 4. a 39 yo pregnant female

Answer: 1 Rationale: African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups

The nurse is assessing the client diagnosed with CHF. Which lab data would indicate that the client is in severe CHF. 1. Elevated B type natriuretic peptide (BNP) 2. Elevated Creatine kinase 3. A positive D-dimer 4. A positive ventilation/perfusion scan

Answer: 1 Rationale: BNP is a specific diagnostic test. Levels higher than normal indicate CHF, with the higher the number the more severe the CHF

The nurse is caring for a client diagnosed with rule out peptic ulcer disease. which test confirms the diagnosis? 1. Esophagogastroduodenoscopy 2. MRI 3. Occult blood test 4. Gastric acid stimulation

Answer: 1 Rationale: The esphagogastroduodenoscopy (EGD) is an invasive diagnostic test which visualizes the esophagus, stomach, and duodenum to accurately diagnose an ulcer and evaluate the effectiveness of the client's treatment

The Client is admitted to the telemetry unit diagnosed with acute exacerbation of CHF. Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet 2. Thick white sputum and crackles that clear with cough 3. The client sleeping with no pillow and eupnea 4. Radial pulse rate of 90 and capillary refill time less than 3 seconds

Answer: 1 Rationale: the client with CHF would exhibit tachycardia, dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status

The client with CAD asks the nurse " Why do I get chest pain" which statement would be the most appropriate by the nurse? 1. Chest pain is caused by decreased oxygen to heart muscle 2. there is ischemia to the myocardium as a result of hypoxemia 3. the heart muscle is unable to pump effectively to perfuse the body 4. chest pain occurs when the lungs cannot adequately oxygenate the blood

Answer: 1 Rationale: this is a correct statement presented in laymans terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain

The nurse is preparing to administer a beta blocker to the client diagnosed with CAD. Which assessment data would cause the nurse to question administering the medication? 1. Bp of 110/70 2. Apical pulse of 56 3. Complaint of headache 4. Potassium level 4.5 mEq/L

Answer: 2 Rationale: A beta blocker decreases sympathetic stimulation of the heart, thereby decreasing the heart rate. An apical rate of 56 is lower than normal heart rate and should make the nurse question administering the med because it will further decrease the heart rate

The nurse is developing a nursing care plan for a client diagnosed with CHF. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge 2. Have an audible S1 and S2 with no S3 heard by end of shift 3. Turn, cough, and deep breathe every 2 hours 4. have a pulse ox reading of 98% by day 2 of care

Answer: 2 Rationale: Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening

The health care provider has ordered an angiotensin converting enzyme inhibitor for the client diagnosed with CHF. Which discharge instructions should the nurse include? 1. instruct client to take a cough suppressant if a cough develops 2. teach the client how to prevent orthostatic hypotension 3. encourage the client to eat bananas to increase potassium levels 4. explain the importance of taking medication with food

Answer: 2 Rationale: Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored

The client diagnosed with CHF is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. check the client for peripheral edema and make sure the client takes a diuretic early in the day 2. monitor the client's potassium level and assess the client's intake of bananas and orange juice 3. determine if the client has gained weight and instruct the client to keep the legs elevated 4. instruct the client to ambulate frequently and perform calf muscle stretching

Answer: 2 Rationale: the most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. perform passive ROM 2. assess the client's neurovascular status 3. keep the client in high fowlers position 4. assess the gag reflex prior to feeding patient

Answer: 2 Rationale: the nurse must make sure that blood is circulating to the right leg so the client should be assessed for pulses, paresthesia, coldness, and pallor

The nurse is developing a discharge teaching plan for the client diagnosed with CHF. Which interventions should be included in the plan? Select all that apply 1. Notify health care provider of a weight gain of more than 1 pound in a week 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside 3. Instruct client to remove the saltshaker from the dinner table 4. Encourage client to monitor urine output for change in color to become dark 5. Discuss the importance of taking loop diuretics at bedtime

Answer: 2,3 Rationale: The client should not take digoxin if the radial pulse is less than 60. The client should be on a low sodium diet to prevent water retention

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen 2. Discuss the precipitating factors that caused the symptoms 3. Schedule for a STAT CT scan of the head 4. Notify the speech pathologist for an emergency consult.

Answer: 3 Rationale: a CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If CVA is diagnosed a CT scan can determine if its hemorrhagic or ischemic accident and guide treatment

The nurse is assessing the client diagnosed with CHF. Which signs/symptoms would indicate that the medical treatment has been effective? 1. the clients peripheral pitting edema has gone from 3+ to 4+ 2. the client is able to take the radial pulse effectively 3. The client is able to perform ADLs without dyspnea 4. The client has minimal JVD

Answer: 3 Rationale: Being able to perform ADLs without shortness of breath would indicate the client's condition is improving. The client's heart is more effective pump and can oxygenate the body better with out increasing fluid in the lungs

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced nurse? 1. the client diagnosed with CHF who is being discharged in the morning 2. the client who is having frequent incontinent liquid BMs and vomiting 3. the client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62 4. The client who is complaining of chest pain with inspiration and nonproductive cough.

Answer: 3 Rationale: This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client

The nurse is planning care for a client experiencing agnosia secondary to CVA. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration 2. position the client in a semi fowler's position when sleeping 3. place a suction set up at the client's bedside during meals 4. Refer client to an occupational therapist for evaluation

Answer: 4 Rationale: A collaborative intervention is an intervention in which another health care discipline- in this case, OT

The nurse enters the room of a client diagnosed with CHF. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the clients forehead 2. obtain a pulse ox reading 3. take the clients vital signs 4. assist the client to a sitting position

Answer: 4 Rationale: The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse ox and then sponge the clients forehead

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with CHF. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. measure I &O 2. provide 2 g sodium diet 3. weight client daily 4. plan for frequent rest periods

Answer: 4 Rationale: scheduling activities and rest periods allows the client to participate in his or her own care and assesses the desired outcome

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette 2. Transport the client to the ICU via stretcher 3. Provide client going home discharge teaching instructions 4. Help position the client who is having a portable X-ray done

Answer: 4 Rationale: the UAP can assist the X-ray tech in positioning the client for the portable X-ray. this does not require judgment

What are we looking for on the CBC with Gastroenteritis

Are both hematocrit and hemoglobin low enough they need a transfusion? Are their white blood cells elevated and showing they have an infection

Diagnostic testing for GERD

Barium swallow, EGD, 24 hr ambulatory pH monitoring, esophageal manometry

Blood tests for Gastroenteritis

CBC, Chem 7

Bacterial causes of gastroenteritis

Campylobacter bacterium, E. Coli enteritis, salmonella, shigellosis, staphylococcus, Yersinia, Parasites

Diagnostic procedures for PUD

EGD (esophagogastroduodenoscpy)

GERD stands for

Gastroesophageal Reflux Disease

PUD Risk factors

H. pylori infection, NSAID drugs, Corticosteroid usage, Severe stress, Hypersecretory states, Type O blood, Excess alcohol ingestion, Chronic pulmonary or kidney disease, Zollinger-ellison syndrome

Laboratory tests for PUD

H.pylori testing, Urea breath testing, IgG serologic testing, Stool sample, Hct, Hgb

Acid Controlling medications for PUD

H2 receptor antagonists, tagamet, pepcid, zantac, axid, PPI

Common NSAIDs

Ibuprofen, Naproxen, Tolectin, Indomethacin, feldene, clinoril, mobic, daypro, toradol, celebrex

Gastroenteritis tends to spread quickly through what areas of living?

LTC, dorms, homes, prisons, and cruise ships

Symptoms of Gastroenteritis

Loss of appetite, bloating, nausea, vomiting, diarrhea, abdominal pain and cramps, bloody stool possible, pus in stools possible, lethargy, fever and weakness

If a patient with gastroenteritis presents with the following lab values which F&E imbalance do they have and why? pH: 7.28 CO2: 43 HCO3: 20 PaO2: 88 SaO2: 96

Metabolic Acidosis rationale: its caused by the diarrhea since the patient is loosing all the electrolytes and fluids rapidly

Treatment for gastroenteritis

NPO, IV hydration, oral hydration, antibiotics, anti nausea medication, pain medication, resume diet when able

Viral causes of gastroenteritis

Norovirus, rotavirus, astrovirus, and adenovirus

Clinical manifestations of PUD

Pain is the first symptom usually seen, feelings of emptiness along with pyrosis and eructions

PPI meds

Prilosec (omeprazole), Prevacid (lansoprazole), Protonix (pantoprazole) Nexium (esomeprazole), Aciphex (rabeprazole)

peptic ulcer

a break in the mucous lining of GI tract exposed to acid-pepsin secretions, including the esophagus, stomach, and duodenum

Peptic Ulcer Disease (PUD)

a break in the mucous lining of the GI tract where it comes in contact with gastric juices

What is GERD

a disease in which stomach contents flow back up into the esophagus

What do gastric juices contain?

acid, pepsin, and bile which are all corrosive substances

Cycloprotective agents; Carafate

acts locally to form a barrier over the ulcerated area, protects from further erosion; does nothing to neutralize or decrease acid secretion

Gastroenteritis definition

an infection or inflammation of the digestive tract, particularly the stomach and intestines

Intractability

an ulcer that refuses to respond to treatment

The nurse on the telemetry unit has just received the am shift report. which client should the nurse assess first? 1. the client diagnosed with MI who has audible S3 heart sounds 2. The client diagnosed with CHF who has 4+ sacral pitting edema 3. The client diagnosed with pneumonia who has a pulse ox reading of 94% 4. The client with chronic renal failure who has an elevated creatinine level

answer: 1 Rationale: an S3 heart sound indicated left ventricular failure, and the nurse must assess this client first because it is an emergency situation

Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? 1. Auscultate the client's bowels in all four quadrants 2. palpate the abdominal area for tenderness 3. percuss the abdominal borders to identify organs 4 Assess the tender area progressing to nontender

answer: 1 Rationale: auscultation should be used prior to palpation or percussion when assessing the abdomen. manipulation of the abdomen can alter bowel sounds and give false information

The client diagnosed with Atrial Fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication 2. a betta blocker medication 3. an anti-hyperuricemic medication 4. a thrombolytic medication

answer: 1 Rationale: the nurse would anticipate an oral anticoagulant, warfarin, to prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. the thrombi can become embolic and may case a TIA or CVA

The client diagnosed with a right sided CVA is admitted to the rehab unit. Which interventions should be included in the nursing care plan? Select all that Apply 1. Position the client to prevent shoulder adduction 2. Turn and reposition the client every shift 3. encourage the client to move the affected side 4. Perform quadricep exercises 3x a day 5. Instruct the client to hold the fingers in a fist

answer: 1, 3 Rationale: Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible

The nurse is assessing a client experiencing motor loss as a result of left sided CVA. Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia 2. Paralysis of the right side of the body and ataxia 3. Homonymous hemianopsia and diplopia 4. Impulsive behavior and hostility toward family.

answer: 2 Rationale: The most common motor dysfunction of a CNA is paralysis of one side of the body, hemiplegia; in this case with left sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications 2 use of NSAIDS 3. any known allergies to drugs and environment 4. medical histories of at least three generations

answer: 2 Rationale: Use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach which is protective mechanism to prevent damage from hydrochloric acid

The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply 1. perform a complete pain assessment 2. Assess the client's vital signs frequently 3. Administer a PPI intravenously 4. obtain permission and administer blood products 5. monitor intake of a soft, bland diet

answer: 3,4 Rationale: this is a collaborative intervention the nurse should implement. it requires an order from the HCP 4) administering blood products is collaborative, requiring an order from the HCP

The male client is diagnosed with CAD and is prescribed sublingual nitro. Which statement indicates the client needs more teaching? 1. I should keep the tablets in the dark colored bottle they come in 2. if the tablets do not burn under my tongue they are not effective 3. i should keep the bottle with me in my pockets at all times 4. if my chest pain is not gone with one tablet, i will go the ER

answer: 4 Rationale: the client should take one tablet every five minutes and if no relief occurs after the third table, have someone drive him to the emergency department or call 911

Which assessment data support to the nurse the client's diagnosis of gastric ulcer? 1. presence of blood in the client's stool for the past month 2. reports of a burning sensation moving like a wave 3. sharp pain in the upper abdomen after eating a heavy meal 4. complaints of epigastric pain 30-60 minutes after ingesting food

answer: 4. Rationale: in a client diagnosed with a gastric ulcer, pain usually occurs 30-60 minutes after eating, but not at night. In contrast, a client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs 1-3 hours after a meal

Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. alteration in bowel elimination patterns 2. knowledge deficit in the causes of ulcers 3. inability to cope with changing family roles 4. potential for alteration in gastric emptying

answer: 4. rationale: potential for alteration in gastric emptying is caused by edema or scarring associated with an ulcer, which may cause a feeling of fullness, vomiting of undigested food, or abdominal distention

Drug causes of gastroenteritis

antibiotics can cause gastroenteritis in susceptible people and can irritate the digestive tract

Pyloric Obstruction

area distal to pyloric sphincter becomes scarred and stenosed from spasm, edema, scar tissue

Nursing interventions for PUD

avoid alcohol consumption, smoking cessation, manage stress, avoid NSAIDs, take medications, notify cpp if any signs of bleeding is noted, don't crush or chew tablets, change diet- refer to a dietition

PPI (protein pump inhibitors)

block both gastrin stimulated and basal acid secretion. used for long term treatment of hypersecretory conditions and for short term treatment of PUD

How do NSAIDS exert topical injury?

by crossing the lipid membrane of gastric epithelial cells, damaging the cells themselves

Greatest complication of Gastroenteritis

dehydration. The risk for dehydration increases as symptoms are prolonged. Dehydration should be suspected if a dry mouth,, increased or excessive thirst, or scanty urination is experienced

PUD pt education

discuss smoking cessation and stress management, educate on foods to avoid that cause excessive HCL production, medication regime, educate on the importance of med compliance, Don't crush, chew, or break SR tablets

What is the most frequent site of PUD

duodenal site

Parasitic causes of Gastroenteritis

entamoeba, histolytica, giardia lamblia, cryptosporidum

Nursing interventions for Gastroenteritis

establish rapport with pt, check vital signs, assess bowel sounds, assess pain, assess neurostatus, assess what OTC treatments they have done, assess for any edema, NPO until normal diet can be resumed, Medicate as ordered

Ulcerogenic substances besides NSAIDS

excessive alcohol, caffeine, ASA, aminophylline, and steroids

Patient education of gastroenteritis

handwashing, keep cold foods cold, hot foods hot, uses paper towels instead of cloth towels when drying hands, cook food throughly, keep bathrooms clean, be aware of traveling alerts, vaccines

Symptoms of GERD

heartburn, dysphagia, regurgitation, chest pain, pain after eating, belching, night time cough, early morning sore throat

Complications of PUD

hemorrhage, perforation, pyloric obstruction, intractability

What do blood cultures show in terms of bacteria?

how long it takes to grow, and what antibiotics it responds to and is resistant to.

Where do duodenal ulcers usually develop

in the proximal portion of the duodenum

Causes of GERD

increased gastric volume, transient relaxation of the lower esophageal sphincter, an incompetent lower esophageal sphincter, increased pressure in the stomach, hiatal hernia, positioning that allows gastric contents to remain close to gastroesophageal junction

Another name for Gastroenteritis

intestinal flu

Diagnosis of gastroenteritis

it is important to establish the cause as different types of gastroenteritis respond to different treatments.

Chemical causes of gastroenteritis

lead poisoning, food poisoning

Diagnostic methods for Gastroenteritis

medical history, physical examination, blood tests, stool tests

PUD nursing interventions

monitor for orthostatic changes in vital signs and tachycardia as these findings are suggestive of GI bleed, administer saline lavage via NG tube if ordered, Administer meds as ordered, decrease environmental stress, encourage rest periods

s/s of pyloric obstruction

nausea, vomiting, constipation, epigastric fullness, anorexia, weight loss

COX-1 Enzyme

necessary to maintain the integrity of gastric mucosa

Risk factors of GERD

obesity, excessive alcohol consumption, smoking, hiatal hernia, pregnancy

Treatment of perforation

only treatment is surgery

how might the pain of perforation be referred to

pain may be referred to right shoulder due to irritation of phrenic nerve in the diaphragm

Pain of PUD

pain typically described as gnawing, burning, aching, or hunger like and is experienced in epigastric region sometimes radiating to the back and is relieved by eating with a classic pain, food, relief pattern

chemical food poisoning

poisoning occurs after ingesting poisonous species such as shell fish or mushrooms

Use of Cycloprotective agents is contraindicated in

pregnancy

Common causes of PUD

presence of H.pylori or C. pylori, the use of apirin and NSAIDS/Steroids, gastric hyperactivity as in Zollinger-Ellison Syndrome, smoking, Type O blood, Alcohol abuse

What is one goal of gastroenteritis care

prevent dehydration and manage diarrhea

Antacid Therapy

remain the mainstay of symptomatic treatment, want to inactivate pepsin and do this by keeping pH of gastric secretions at 3.5 or higher

COX-2 Enzyme

responds to inflammatory stimulation

Perforation

rupture, as in the penetration of ulcer through mucosal wall

S/S of perforation

sudden severe upper abdominal pain, vomiting, fainting, shock/death if left untreated

Treatment of intractability

surgery may be needed- typically last choice for treatment, vagotomy, pyloraplasty, bilroth I or bilroth II procedures

When to seek prompt treatment for Gastroenteritis

symptoms lasting longer than a week, fever greater than 102F, blood in stool or vomitus, severe abdominal swelling and pain

How does gastroenteritis spread

the infection is highly contagious illness that spreads through close contact with the people who are infected, or through contaminated food or water

What does a nurse need to know in terms of giving broad spectrum antibiotics?

they can cause kidney problems

How do NSAIDS contribute to PUD

though both systemic and topical mechanisms of injury. NSAIDs interrupt prostaglandin synthesis by disrupting the action of the two COX enzymes

Treatment of hemorrhage

treat hypovolemia, iced saline lavage, endoscopic procedures to coagulate bleeders with lasers, heat probes, injection of epinephrine, partial gastrectomy may be needed

Treatment of pyloric obstruction

treat with NG tube, surgery may be needed

H.Pylori

unique to colonizing in the stomach and decreases cells ability to produce mucous

Hemorrhage

upper GI bleeding is most common complication, 30-40% mortality rate, large upper GI bleed-hematemesis, coffee ground emesis

Cycloprotective agents; Cytotec

used specifically to prevent NSAID induced PUD in those at high risk or in those with a history of same; used when person taking NSAIDs; replaces gastric prostaglandins depleted by NSAID therapy

Barium Swallow

used to see any pathological abnormalities to evaluate the esophagus, stomach, and upper small intestine

Prognosis of gastroenteritis

usually resolved within 2-3 days and there are no long term effects. if dehydration occurs recovery is extended by a few days