Adult Health 2 - Exam 1

Based on the 5 level system, how would you assign levels to patients?

*ESI 1* - Requires immediate life-saving intervention (apneic, pulseless, resp. distress, O2 <90, AMS change, unresponsive. *ESI 2* - Physician needs to see patient quickly, but not immediately life threatening. (chest pain, signs of stroke, ectopic pregnancy, immunocompromised with fever, suicidal/homicidal) *ESI 3* - 2 or more resources (complaint that needs eval., labs, ecg, x-rays, iv, im, speciality consult) *ESI 4* - 1 resource (sore throat & fever = throat culture, UTI = urine culture) *ESI 5* - No resources needed (poison ivy, ear infection, out of BP meds)

________: period of hyper coagulability (the hemorrhagic phase). FDP further enhances bleeding, bleed out.

*Fibrinolysis*

What are the 3 function of the liver?

1. *Glycogen Metabolism*: glucose converted to glycogen, stored in hepatocytes, & released to maintain blood glucose 2. *Ammonia Conversion*: ammonia (byproduct of gluconeogenesis is converted to urea in the liver to be excreted. 3. *Protein Metabolism*: includes almost all plasma proteins (blood clotting factors made in the liver; Vit. K required, albumin & globulins made by the liver to maintain osmotic pressure.

ACE Inhibitors relax blood vessels and decrease blood volume which dec. BP and oxygen demand. Name 4 ACE inhibitor drugs.

1. Captopril 2. Enalapril (Vasotec) 3. Fosinopril 4. Lisinopril (Prinivil, Zestril)

What are the 7 warning signs of cancer?

1. Change in bowel/bladder habits 2. Sore that does not heal 3. Unusual bleeding or discharge 4. Thickening or lump 5. Indigestion or difficulty swallowing 6. Obvious change in wart/mole 7. Nagging cough/hoarseness

Name the 4 types of Polyps?

1. Hyperplastic 2. Adenomatous 3. Sessile 4. Pedunculated

Explain the RAS (Renin Angiotensin System)

1. Motor vehicle accident. BP & Fluid drops 2. Kidneys produce renin 3. Renin is released from the kidneys. 4. Renin acts on angiotensinogen to form angiotensin 1. 5. ACE (angiotensin-converting enzyme) releases from lungs 6. ACE acts on angiotensin 1 to form angiotensin 2 7. Angiotensin 2 acts on the adrenal glands to stimulate release of aldosterone 8. Aldosterone acts on kidneys to stimulate reabsorption of salt & water. 9. Angiotensin 2 acts on blood vessels stimulating vasoconstriction.

When classifying tumors, what 3 things are identified?

1. Tissue or Origin 2. Anatomic Site 3. Behavior of the tumor (benign/malignant)

If a child (1 day old-3 month)'s rectal temp is > 100.4 F, they should receive ESI level ____?

2

If a child between (3 months & 3 years) rectal temp. is > 102.2 F & patient has incomplete immunizations or no obvious sources of fever, they should be assigned ESI level ___?

2

If a child between (3 months & 3 years) rectal temp. is >102.2 F & patient has complete immunizations & obvious source of fever, they should be assigned ESI level ____?

3

The CRAMS System rates 5 characteristics from 0-2. 2 being normal, and 0 being absent. What score is considered a major trauma?

< or = 8

The nurse is caring for a patient who reports diffuse abdominal pain and recent weight loss. Which personal/social history findings suggest the patient is at increased risk for colorectal cancer (CRC)? Select all that apply. A. 10-year history of diabetes B. Drinks at least 2 beers per day C. 35-year history of cigarette smoking D. Consumes chicken and fish a few times a week E. A history of gastroesophageal reflux disease (GERD)

A. 10-year history of diabetes B. Drinks at least 2 beers per day C. 35-year history of cigarette smoking

A male client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, & fatigue. Suspecting gallbladder dz, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing dx may be appropriate for this client? A. Anticipatory grieving B. Impaired swallowing C. Disturbed body image D. Chronic low self-esteem

A. Anticipatory grieving few live more than 1 yr after dx

The nurse is caring for a patient with colorectal cancer (CRC). Which assessment findings indicate the possibility of metastases? Select all that apply. A. Ascites B. Dry mouth C. Lower back pain D. Elevated bilirubin level E. Elevated hemoglobin level

A. Ascites C. Lower back pain D. Elevated bilirubin level

Which of the following is NOT a duty of the Flow Facilitator? A. The discharging of patients. B. Quick triage of incoming ambulance patients. C. Patient placement from triage and EMS. D. Quick evaluation of placement of already triaged patients. E. Evaluation of acuities regarding already placed patients and workload for the staff.

A. The discharging of patients.

For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care? A. Administer aspirin if the temp. exceeds 102 F B. Inspect skin for petechiae once every shift C. Provide frequent rest periods D. Place client in strict isolation

B. Inspect skin for petechiae once every shift

Nurse Amy is speaking to a group of women about early detection of breast cancer. The avg age of women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women: A. perform breast self-exams annually B. have a mammogram annually C. have a hormonal receptor assay annually D. have a physician conduct a clinical exam every 2 years.

B. have a mammogram annually

What is cancer?

a group of diseases characterized by uncontrolled and unregulated growth of cells.

What features of cancer cells distinguish them from normal cells (select all that apply)? a. Cells lack contact inhibition. b. Oncogenes maintain normal cell expression. c. Cells return to a previous undifferentiated state. d. Proliferation occurs when there is a need for more cells. e. New proteins characteristic of embryonic stage emerge on cell membrane.

a. Cells lack contact inhibition. c. Cells return to a previous undifferentiated state. e. New proteins characteristic of embryonic stage emerge on cell membrane.

The most common type of colorectal cancer is an ____________________.

adenocarcinoma

The spleen sends unconjugated bilirubin bound to __________ to the liver.

albumin

Unconjugated bilirubin needs to be bound to _________ to travel through bloodstream.

albumin (Bc it is fat soluble)

The liver makes _________ & ________ to maintain osmotic pressure and keep fluids intravascular. When these two are low, edema & ascites are present.

albumin & globulins

A characteristic manifestation of hepatic encephalopathy is ___________ (flapping tremors). This may take several forms, with the most common involving the arms and hands. When asked to hold the arms and hands stretched out, the patient is unable to hold this position and performs a series of rapid flexion and extension movements of the hands.

asterixis

__________: well differentiated tumors. Usually encapsulated. Rare recurrence

benign neoplasms

A patient with platelets <20,000 will _____________.

bleed

In abruptio placentae, the process of DIC begins with __________. & then massive thromboplastin from placenta.

bleeding

DIC is an alteration in what?

blood clotting mechanism: *abnormal acceleration of the coagulation cascade*, resulting in thrombosis. Hemorrhage occurs simultaneously due to depleted clotting factors.

Nurse Brian is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable? a. 24 hours b. 2 to 4 days c. 7 to 14 days d. 21 to 28 days

c. 7 to 14 days

Nurse April is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by: A. breast self-exam B. mammography c. fine needle aspiration d. chest x-ray

c. fine needle aspiration

What is the most common CIS?

carcinoma of the cervix, diagnosed with a Pap smear. Good prognosis

DIC is a paradoxical ______________________ of clotting & bleeding

clinical presentation

In sepsis, the process of DIC begins with __________.

coagulation

Trends in the incidence and death rates of cancer include the fact that a. lung cancer is the most common type of cancer in men. b. a higher percentage of women than men have lung cancer. c. breast cancer is the leading cause of cancer deaths in women. d. African Americans have a higher death rate from cancer than whites.

d. African Americans have a higher death rate from cancer than whites.

Hepatic Portal Vein Hypertension results in increased blood flow causing dilation & enlargement of the plexus veins of the esophagus & produces ____________.

esophageal varices

In men with cirrhosis, _______________ (benign growth of the glandular tissue of the male breast), loss of axillary and pubic hair, testicular atrophy, and impotence with loss of libido may occur because of increased estrogen levels.

gynecomastia

DIC is a Paradoxical Clinical Presentation through clotting & __________________.

hemorrhage

Liver cirrhosis and right heart failure may both display _________________.

high blood pressure

Canadian Triage System Level 1 patients are seen __________. & 2 & 3 are seen in a timely manner.

immediately

The FDP & D-Dimer products from fibrin breakdown are _______________ in DIC patients.

increased

______________: well differentiated to undifferentiated tumors. Capable of metastasizing. Possible recurrence. Rarely encapsulated. Cells are abnormal.

malignant neoplasm

Colorectal Cancer is more common in ___________. -Individuals of African American ethnicity have the highest mortality rate -Risk increases with age -Incidence is increasing for those under the age of 50, who consume high-fat, low-fiber diets

men.

The coagulation problems result from the liver's inability to produce ______________ and other factors essential for blood clotting. Manifestations of coagulation problems (bleeding tendencies) include epistaxis, purpura, petechiae, easy bruising, gingival bleeding, and heavy menstrual bleeding.

prothrombin

If DIC occurs in the brain, this can cause?

stroke

Oncology DIC is usually related to ___________ or __________.

the disease process or treatment of the cancer (chemo, radiation, sepsis)

What is the TNM classification system?

tumor size & invasiveness (*T*) presence of abnormal spread to lymph nodes (*N*) metastasis to distant organs (*M*)

A 35-yr-old client with ovarian cancer is prescribed hydroxyurea (Hydrea), an antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with: A. cell division or mitosis during the M phase of the cell cycle B. normal cellular processes during the S phase of the cell cycle C. the chemical structure of DNA & chemical binding b/w DNA molecules (cell-cycle-nonspecific) D. 1 or more stages of RNA synthesis, DNA, or both (cell-cycle-nonspecific)

B. normal cellular processes during the S phase of the cell cycle

When caring for a male client dx with a brain tumor of the parietal lobe, the nurse expects to assess: A. short term memory impairment B. tactile agnosia C. seizures D. contralateral homonymous hemianopia

B. tactile agnosia inability to identify objects by touch

A 35-yr old client has been receiving chemo to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)? A. white, cottage cheese patches on tongue B. yellow tooth discoloration C. red, open sores on oral mucosa D. rust-colored sputum

C. red, open sores on oral mucosa

________________: refers to a neoplasm whose cells are localized & show no tendency to invade or metastasize to other tissues

Carcinoma in situ (CIS)

____________: originate from embryonal ectoderm (skin & glands) and endoderm (mucous membranes in respiratory tract, GI, & GU.)

Carcinomas

What is the difference between assessing an infant, child, or adult when assigning a triage level?

Children can be up-triaged if not up to date on immunizations, looks flaccid, or fever >100.4 F

_____________: develops over a period of months. Maybe subclinical. Eventually evolves into an acute DIC pattern.

Chronic DIC

__________: end stage of liver disease

Cirrhosis

A female client is receiving methotrexate (mexate), 12 g/m2 IV, to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells? A. probenecid (Benemid) B. Cytarabine (ara-C, cytosine arabinoside) C. Thioguanine (6-thioguanine, 6-TG) D. Leucovorin (citrovorum factor or folinic acid)

D. Leucovorin (citrovorum factor or folinic acid) (protects normal cells)

Which intervention is appropriate for the nurse caring for a male client in severe pain receiving continuous IV morphine? A. Assist with naloxone challenge test before therapy begins B. Discontinue drug immediately if signs of dependence appear C. Changing the administration route to PO if the client can tolerate fluids D. Obtain baseline VS before administering 1st dose.

D. Obtain baseline VS before administering 1st dose.

The nurse is interviewing a male client about his past med hx. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? A. Duodenal ulcers B. Hemorrhoids C. Weight Gain D. Polyps

D. Polyps

What are the most common sites for developing cancer?

Men - Prostate, Lung Women - Breast, Lung

What is the term for dark urine?

Urobilinogen

If DIC occurs in the heart, this can cause?

MI (myocardial infarction)

What levels increase during DIC?

Thromboplastin, Thrombin, Fibrin FDP & D-Dimer

_____________: brief period of hyper-coagulability. Coagulation cascade with widespread fibrin formation, microthrombi deposited, fibrin causes tissue ischemia, hypoxia, necrosis, leads to multi-organ dysfunction.

Thrombosis

How is DIC treated?

Treat cause, provide supportive management, support organ functions, stop abnormal coagulation & control bleeding by replacing depleted blood & clotting components, Meds used

A person with a T3N2M1 stage has a poorer prognosis than a patient with a T1N0M0. True or False?

True

The risk of cancer increases with polyp size. True or False?

True

Tumor cell genes prevent cells from going through the cell cycle. Examples are ________, ________ & ___________.

*BRCA1, BRCA2*. Increase person's risk of breast & ovarian cancer *APC* increase risk of colorectal cancer *p53* many cancers like bladder, breast, colorectal, liver, lung, ovarian

What are the 5 stages of cancer?

-Stage 0: cancer in situ -Stage I: tumor limited to the tissue of origin; localized tumor growth -Stage II: limited local spread -Stage III: extensive local and regional spread -Stage IV: metastasis

What are the modifiers added in the Canadian Triage System & why were the changes made?

*a) Pediatric Fever* -Children 3-18 months with fever >38.5 C/101.3 F & looks unwell = level 2 ->38.5 C/101.3 F & looks well = level 3 -Newborns to 3 months old with 101.3 or higher remain a level 2. *b) Frailty Modifiers* -used to identify patients who are more prone to deterioration with long wait times & up-triage them to a level 3 so they don't get missed. (wheelchair bound, homeless, cognitive impairment, over 80, weakness/signs of cachexia) *c) Other Modifiers* -chest, pain, non cardiac features, ripping/tearing, pain is considered level 2 to avoid missing aortic dissection. -ECG is completed on all chest pain cardiac features, & physician review in 15 mins to avoid missing anything. -Stable patients with extremity weakness/symptoms of CVA, level 2, activate stroke team, direct to CT

Colorectal Cancer has a subtle, insidious onset, and the patient is asymptomatic until the disease is advanced. What are the symptoms of colorectal cancer?

-Fatigue -Weight loss -Iron-deficiency anemia -Rectal bleeding -Abdominal pain -Changes in bowel habits

What are the 5 grades of cancer?

-Grade I: Cells differ slightly from normal cells (mild dysplasia) and are well differentiated (low grade). -Grade II: Cells are more abnormal (moderate dysplasia) and moderately differentiated (intermediate grade). -Grade III: Cells are very abnormal (severe dysplasia) and poorly differentiated (high grade). -Grade IV: Cells are immature and primitive (anaplasia) and undifferentiated; cell of origin is difficult to determine (high grade). -Grade X: Grade cannot be assessed.

What are the lab findings for DIC? Platelets, FDP, Fibrinogen, D-Dimer

-Platelets will *decrease* < (150-400/mL) -FDP will *increase* > 10 mg/mL [>40mg/mL is critical] -Fibrinogen will *decrease* < 300 mg/dL -D-Dimer will *increase* > 3000-4000 mcg/L

Canadian Triage System Geriatric Concerns Include...

-Resp. rate >27/min identify as critically ill -BP <110 = hypotension -Subtle temp chances may indicate hypothermia or serious infection -Atypical presentations of common dzs. -Early recognition of cognitive changes -Falls common -Adverse Drug Events

For a female client with newly diagnosed cancer, the nurse formulates a nursing dx of anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client? A. Client verbalizes feelings of anxiety B. Client doesn't guess at prognosis C. Client uses any effective method to reduce tension D. Client stops seeking information

A. Client verbalizes feelings of anxiety

What ESI level would a patient who is deemed a "P" on the AVPU scale? A. ESI 1 B. ESI 2 C. ESI 3 D. ESI 4 E. ESI 5

A. ESI 1

Why are vital signs not utilized to determine ESI levels 4 or 5 in non-pediatric patients? A. It is a variable that is not constant and unreliable even under the best conditions. B. Vital signs are time consuming. C. Vital signs can change the patient's complaint. D. Vital signs can be manipulated by the patient. E. Vital signs are not required by the ER MD.

A. It is a variable that is not constant and unreliable even under the best conditions.

A female client with cancer is being evaluated for possible metastatic. Which of the following is one of the most common metastasis sites for cancer cells? A. Liver B. Colon C. Reproductive Tract D. White Blood Cells

A. Liver

How often should a patient be reassessed after the initial triage assessment? A. Minimum of every 2 hours for ESI 3 or lower and as often as determined by the triage nurse. B. Minimum of every 1 hour for ESI 5. C. Minimum of every 7 hours for all levels. D. As determined strictly by the triage nurse. E. We do not reassess patients in this ER

A. Minimum of every 2 hours for ESI 3 or lower and as often as determined by the triage nurse.

What should a male client over the age 52 do to help ensure early identification of prostate cancer? A. have a digital rectal exam & PSA test done yearly B. have a transrectal ultrasound every 5 yrs C. perform monthly testicular self-exams, especially after 50 D. Have a complete blood count, BUN, & creatinine levels checked yearly

A. have a digital rectal exam & PSA test done yearly

Jeoniva with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately? A. vision changes B. hearing loss C. headache D. anorexia

A. vision changes

Nurse Lucy is providing breast cancer education to a community facility. The American Cancer Society recommends that women get mammograms: A. yearly after age 40 B. after the birth of the 1st child and every 2 yrs after C. after the first menstrual period & annually thereafter D. every 3 years between ages 20-40 & annually thereafter.

A. yearly after age 40

If DIC occurs in the kidneys, this can cause?

AKI (Acute Kidney injury)

____________: develops rapidly or over a period of hours. Presents with sudden bleeding from multiple sites. Treated as medical emergency.

Acute DIC

What is the most common type of colorectal cancer?

Adenocarcinoma

Hypertension can cause edema due to angiotensin 2 stimulating __________________.

Aldosterone

The common bile duct opens in the duodenum at the _______________________ which is controlled by the sphincter of Odi.

Ampulla of Vater

What is DIC (Disseminated Intravascular Coagulation)?

An acquired bleeding disorder. It is *not* a disease but an event that can accompany many dz processes.

What is a side effect of ACE Inhibitor drugs?

Angio edema

The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for? A. Actinic B. Asymmetry C. Arcus D. Assessment

B. Asymmetry

A 10-day old infant is brought to the Emergency Department in triage to which the mother states she measured a fever of 101.9 F at home. The current temperature of the patient in the triage department is 99.0 F rectally. The patient is appropriate for age, sleeping but arousable, skin pink and dry, and the mucous membranes are moist. What ESI level are you going to assign to this patient? A. ESI level 1 B. ESI level 2 C. ESI level 3 D. ESI level 4 E. ESI level 5

B. ESI level 2 ??? rectal temp is < 100.4 F

What information MUST be documented on the patient triage record for all pediatric patients? A. Height, weight, temperature, pulse rate, respiratory rate, and oxygen saturation. B. Height, weight, pulse rate, respiratory rate, oxygen saturation, and components of the pediatric triangle. C. Height, weight, pulse, temperature, respiratory rate only

B. Height, weight, pulse rate, respiratory rate, oxygen saturation, and components of the pediatric triangle.

During chemo, an oncology client has a nursing dx of impaired oral mucosa membrane related to decreased nutrition & immunosuppression secondary to the cytotoxic effects of chemo. Which nursing intervention is most likely to dec. pain of stomatitis? A. Discontinue chemo B. Hydrogen peroxide & water to rinse mouth C. Monitoring client's platelets/leukocytes D. Checking for signs/symptoms of stomatitis

B. Hydrogen peroxide & water to rinse mouth

A male client is in isolation after internal radioactive implant to treat cancer. 2 hours later, the nurse discovers the implant in bed linens. What should the nurse do first? A. Stand as far away from the implant as possible & call for help B. Pick up the implant with long-handled forceps & place it in a lead-lined container C. Leave the room & notify radiation therapy dept immediately D. Put the implant back in place using forceps & a shield for self protection, & call for help

B. Pick up the implant with long-handled forceps & place it in a lead-lined container

Which of the following patients are NOT considered ESI level 2 patients? A. Suicidal ideation. B. Rash with no shortness of breath or stridor. C. Dialysis patient after fistula placement that same day and having arm swelling. D. Chest pain radiating to the left arm and into the back. E. Witnessed syncopal episode.

B. Rash with no shortness of breath or stridor.

A 34-yr-old female is requesting info about mammograms & breast cancer. She isn't considered high risk. What should the nurse tell this client? A. She should have had a baseline mammogram by 30 B. She should eat a low fat diet to dec risk C. She should perform self exams during 1st 5 days of menstrual cycle D. When she begins yearly mammograms, breast self exams will no longer be necessary

B. She should eat a low fat diet to dec risk baseline between 30 & 40

What is a major issue as it relates to "frequent flyers" to the Emergency Department? A. The tendency to anger the staff for consuming their time. B. The possibility that a future visit may turn out to be an emergency need. C. The increased amount of cost to the system. D. The need to provide specialty consultation such as behavioral health.

B. The possibility that a future visit may turn out to be an emergency need.

A person should be considered for a higher acuity rating if the patient presents how soon after their previous visit for the same complaint that is not resolved? A. Within three days. B. Within 24 hours. C. Within 36 hours. D. Within 2 days. E. Within one week.

B. Within 24 hours.

What question should a triage nurse ask themselves when deciding if a patient meets level 2 criteria? A. How many resources will this patient need? B. Would I give this patient my last available bed? C. Is this patient dying? D. What would my peers decide when in the same situation?

B. Would I give this patient my last available bed?

A female client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect: A. hair loss B. stomatitis C. fatigue D. vomiting

C. fatigue

A female client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include: A. Dec. serum creatinine level B. Hypocalcemia C. Bence Jones protein in the urine D. Low serum protein level

C. Bence Jones protein in the urine

What ESI level should be considered for a 2 year-old child who presents with a measured temperature of 103.0 F, who is not current on their vacinations, and has no obvious cause for the fever? A. ESI 1 B. ESI 2 C. ESI 3 D. ESI 4 E. ESI 5

C. ESI 3 ???

What is the danger zone pulse rate for a patient in the 3-8 year-old range? A. Greater than 120/min. B. Greater than 130/min. C. Greater than 140/min D. Greater than 150/min. E. Greater than 160/min.

C. Greater than 140/min

A male client with a nagging cough makes an appointment to see the physician after reading that his symptom is 1 out of 7 warning signs of cancer. What is another warning sign of cancer? A. Persistent nausea B. Rash C. Indigestion D. Chronic ache/pain

C. Indigestion or difficulty swallowing.

A male client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing dx of risk for injury. Which "related-to" phrase should the nurse add to complete the nursing dx statement? A. Related to visual field deficits B. Related to difficulty swallowing C. Related to impaired balance D. Related to psychomotor seizures

C. Related to impaired balance

Nurse April is teaching a group of women to perform breast self-exams. The nurse should explain that the purpose of performing the exam is to discover: A. cancerous lumps B. areas of thickness/fullness C. changes from previous self-exams D. fibrocystic masses

C. changes from previous self-exams

____________ arise from the mucosal surface of the colon and project into the lumen and can be found anywhere in the colon, but most often found in the rectosigmoid area.

Colonic polyps

What is the third leading cause of cancer-related deaths & the third most common cancer

Colorectal Cancer

A male client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? A. Keep the stoma uncovered B. Keep the stoma dry C. Have a family member perform stoma care initially until you get use to the procedure D. Keep the stoma moist

D. Keep the stoma moist

A focused Emergency Severity Index, Version 4 triage assessment should take how many minutes to complete and assign an acuity level? A. 9-10 minutes. B. 6-8 minutes. C. 4-5 minutes. D. 2-3 minutes. E. Less than 1 minute.

D. 2-3 minutes.

According to the patient flow system of the Emergency Department, what is the accepted door to exam time for a level 4 patient? A. Immediate. B. 10 minutes. C. 30 minutes. D. 60 minutes. E. 120 minutes.

D. 60 minutes.

A female client has an abnormal result on a Papanicolaou test. After admitting, she read his chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide? A. Presence of completely undifferentiated tumor cells that don't resemble cells fo the tissues of their origin B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ. C. Replacement of one type of fully differentiated cells by another in tissues where the second type normally isn't found. D. Alteration in the size, shape, organization of differentiated cells

D. Alteration in the size, shape, organization of differentiated cells

A female client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a F&E imbalance induced by chemotherapy? A. Urine Output of 400 mL in 8 hours B. Serum K+ level of 3.6 mEq/L C. BP of 120/64 to 130/72 mmhg D. Dry oral mucous membranes & cracked lips

D. Dry oral mucous membranes & cracked lips Low Urine output = <40mL/hr

A client, age 41, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client's hx for risk factors for this dz. Which history finding is a risk factor for cervical cancer? A. Onset of sporadic sexual activity at 17 yrs B. Spontaneous abortion at 19 yrs C. Pregnancy complicated with eclampsia at 27 yrs. D. HPV infection at 32 yrs

D. HPV infection at 32 yrs

What are the three criteria that a presenting patient must meet (at least one of the three) in order to make the case an ESI level 2? A. Severe pain, abnormal vital signs, intoxication B. Abnormal vital signs, acute mental status changes, severe pain. C. High risk situation, abnormal vital signs, severe pain. D. High risk situation, acute mental status changes, severe pain. E. Abnormal vital signs, severe pain, lethargic.

D. High risk situation, acute mental status changes, severe pain.

The nurse is reviewing the medical record of a recently admitted patient with colorectal cancer (CRC). According to the Tumor, Nodes, Metastasis (TNM) system, which finding indicates the patient has a poor prognosis? A. TisN0M0 B. T1N1M0 C. T2N1M0 D. T3N2M1

D. T3N2M1

The nurse is preparing a female client for magnetic resonance imaging (MRI) to confirm or rule out spinal cord lesions. During the MRI scan, which of the following would pose a threat to this client? A. The client lies still B. The client asks questions C. The client hears thumping sounds D. The client wears a watch & wedding band

D. The client wears a watch & wedding band

When someone has liver cirrhosis, what do you expect their urine to look like?

Darker urine due to less enzyme (urobilinogen)

DIC Fibrinogen level ___________

Decreased

DIC Platelets level __________

Decreased

An expecting mother has a Rh- blood type, and has not had D antigen. Her baby is born with Rh+ blood type & D antigen. The 2nd pregnancy comes and antibodies attack the babies D antigen. The baby will die, have severe jaundice, or hydrops fetalis. This is why we do what?

Do blood typing for prevention, D antidote antiglobin, Rhogam within 72 hours of birth.

What is the determining temperature that would determine ESI 2 for a 27 day-old patient with a fever? A. 99.5 F B. 100.3 F C. 101.0 F D. 101.5 F E. 100.4 F

E. 100.4 F

What is the correct response to a mother presenting to your triage window with a small child in her arms that appears: dusky with discolored nail beds, listless, and retractions? A. Grab the child from mom and run immediately to a room. B. Call the Flow Facilitator and attempt room placement. C. Call the ER physician to request orders. D. Shake the child to attempt to arouse the child. E. Immediately push the "code" button on the wall and administer high flow oxygen via a large volume device while in the triage room.

E. Immediately push the "code" button on the wall and administer high flow oxygen via a large volume device while in the triage room.

An example of an ESI level 1 patient is: A. Chest pain with stable vital signs. B. Right flank pain with significant guarding. C. Child with barking cough and mild respiratory stridor but appropriate. D. Elderly female with history of dementia with new mental changes. E. Overdose patient with a respiratory rate of 6

E. Overdose patient with a respiratory rate of 6

How often should the ESI algorithm be manipulated or changed to better the patient flow of the ER? A. Every year. B. Every six months. C. Every 2 years. D. Every 5 years. E. The algorithm should never be changed or manipulated.

E. The algorithm should never be changed or manipulated.

What are the number of levels for each triage system?

ESI - Emergency Severity Index 5 levels

What are the most common signs of DIC bleeding?

Ecchymosis, petechiae, purpura Oozing blood, frank blood Cool, mottled extremities Dyspnea, Chest pain if pleura/pericardium Hematuria

What are the two most commonly used triage systems in the USA?

Emergency Severity Index (ESI) & CRAMS (Circulation, Respiration, Abdomen, Motor, Speech)

____________: are a common and dangerous complication of alcoholic cirrhosis & bleeding. Medical emergency.

Esophageal Varices

________________ are a complex of tortuous, enlarged veins at the lower end of the esophagus. They are the most life-threatening complication of cirrhosis.

Esophageal varices

Trauma, Infections, OB complications, Malignancies are considered ____________ pathways of DIC

Extrinsic (endothelial)

When someone has a gall stone, what do you expect stool to look like?

Light stool, conjugated bilirubin can't pass

As a nurse, what should be done to manage ascites?

Limit sodium intake to 2g/day Assess & monitor F&E balance Albumin infusion may be used to maintain intravascular volume Spironalactone Aldactone may be given. (K sparing). Lasix (furosemide) may be used with.

What is the name for breath that is fruity, musty?

Fetor Hepaticus

A patient with liver cirrhosis should receive what kind of infusion?

Fresh Frozen Plasma to replace fibrinogen that is made in the liver.

An oncology patient has bleeding through the IV site, gums, etc. The patient needs what kind of infusion? Why?

Fresh Frozen Plasma. Doesn't need full blood with more platelets because it will trigger process.

An anemic patient will need what kind of infusion so they don't go into heart failure?

Full Blood (need platelets so they don't go into heart failure)

Angiotensin Converting Enzyme Inhibitors are a class of meds used to treat _______ & ________.

HBP & HF

_____________: results in increased breakdown of RBC's (blood transfusion reaction)

Hemolytic Jaundice

Most common cause of liver cirrhosis in the US is ____________ & ________________.

Hep C & Alcohol induced liver disease

____________ may be used to treat DIC in cancer or sepsis patients.

Heparin

________________ is a neuropsychiatric manifestation of liver disease. Includes the neurotoxic effects of ammonia, abnormal neurotransmission, astrocyte swelling, and inflammatory cytokines. A major source of ammonia is the bacterial and enzymatic deamination of amino acids in the intestines. The ammonia that results from this deamination process normally goes to the liver via the portal circulation and is converted to urea, which is then excreted by the kidneys. Ammonia crosses BBB & produces neurologic toxic manifestations.

Hepatic encephalopathy

____________: livers altered ability to take up bilirubin from blood, conjugate, or excrete it. (Hepatitis, Cirrhosis)

Hepatocellular Jaundice

Hepatic Encephalopathy can cause ________ the hand held upward (dorsiflexed) immediately falls forward & back to dorsiflexed

Liver Flap / Asterixis

A patient with colorectal cancer (CRC) asks the nurse about the common sites of metastasis. Which response by the nurse is most appropriate?

Liver shares blood flow

_____________: originate from the hematopoietic system.

Lymphoma & Leukemias

DIC D-Dimer level __________

Increased

DIC FDP level ________

Increased

Ascites occurs due to what 3 reasons?

Increased capillary pressure & the obstruction of the venous flow through the liver. The liver can't metabolize aldosterone so there is an increase in sodium & water retention by the kidneys. Decrease synthesis of albumin by the liver

Infectious Vasculitis, Vascular Disorders, Intravascular Hemolysis/Transfusion Rxn, Snakebite, pancreatitis, liver dz are ______________ pathways of DIC

Intrinsic (blood vessels)

_____________: decreased ability to conjugate and excrete bilirubin into the small intestine

Jaundice

Late manifestations or liver cirrhosis result from liver failure and portal hypertension. What things develop gradually?

Jaundice (inc. bilirubin) Peripheral edema (inc. ADH aldosterone) Ascites (decrease plasma proteins) Skin lesions (inc. bile salts cause itching), hematologic disorders, endocrine disturbance, peripheral neuropathies. Light stools (dec. bile) Bleeding (dec. vit K) Dark Urine (inc. urobilinogen) Hypertension caused by enlarged portal vein (caput Medusae)

What are the physical assessments of cirrhosis?

Jaundice, Hepatomegaly, Ascites, Pleural Effusion, Spider angiomas/S nevi, Asterixis/Liver flap (ammonia high), personality/behavior changes

Why are stools pale/grey?

Lack of bilirubin

34 year old obese female c/o generalized abd pain rated 6/10 for past 2 days •Last BM 3 days ago •Recent back surgery •Allergy: peanuts •No daily meds •What ESI level would you assign?

Level 3 Vital signs... -T 98.1 F, HR 92, RR 20, BP 132/78,SpO2 99% Don't change level. -More than 2 resources needed, Lab, X-ray, CT, IV Fluids

9 yo presents to the ED with her mother •She slipped on the ice and injured her right arm •Forearm is obviously deformed- CMS intact •No other injuries, NKDA, No daily meds, No PMH •What ESI level would you assign?

Level 3 Vital signs... •BP 100/68, HR 124, RR 32, SpO2 99% VS match pain, need x-ray & pain meds. If they do moderate sedation for reduction, level will be 2.

"My baby has had diarrhea since yesterday. The whole family has this GI stuff that is going around." •15 month old with decreased appetite,low-grade temps at home, numerousliquid stools •Sitting on mom's lap quietly, fusses alittle with getting her ID bracelet on,dry lips •NKDA, No PMH, No Daily meds •What ESI level would you assign?

Level 3 until vital signs display... -T 100.4 F, HR 178, RR 48, BP 78/50 -Tachycardic, Tachypenic Change to level 2

"My doctor told me I am 6 weeks pregnant and now I think I am having a miscarriage" She is a healthy looking 28 year old female "I started spotting this morning and now I am cramping". NKDA •Meds: prenatal vitamins •What ESI level would you assign?

Level 3 until vital signs display... -T 98 F, HR 112, RR 22 BP 90/60 -Tachycardia, tachypneic, hypotensive = Change level to 2

32 year old male present with c/o HTN •He ran out of his meds 3 days ago •Denies headache, chest pain or other signs of HTN •What level ESI would you assign this patient?

Level 5

Hepatic Encephalopathy is frequently a terminal complication due to liver damage causing blood to enter systemic circulation without liver detoxification. Main toxin is __________ though others have been identified. Patients breath is fruity, musty (Fetor Hepaticus. Patient may have a tremor.

NH3 , Ammonium

An oncology patient's veins have phlebitis. Many of the cancer meds are vasoirritants. The lab results sow FDP & D-Dimer elevated. Do you replace the IV immediately?

No, check to see if it is really phlebitis. Check latency with blood return, see what kind of fluids the patient is on. Ask the doctor if patient can get a porticath, picc line, etc.

____________: impeded outflow of bile through liver & duct system (cholelithiasis, cancer)

Obstructive Jaundice

___________: tumor inducing genes

Oncogenes

____________: red area that blanches with pressure. Located on palm of hands.

Palmar Erythema

___________________ is a common finding in alcoholic cirrhosis and is probably due to a dietary deficiency of thiamine, folic acid, and cobalamin. The neuropathy usually results in sensory and motor symptoms, but sensory symptoms may predominate.

Peripheral neuropathy

______________________ is characterized by increased venous pressure in the portal circulation, splenomegaly, large collateral veins, ascites, and gastric and esophageal varices.

Portal hypertension

What levels decrease during DIC?

Prothrombin and Fibrinogen are decreased bc they are depleted and used up. Platelets also decrease.

Thrombocytopenia, leukopenia, and anemia are thought to be caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension). The enlarged spleen results in increased removal of __________ from circulation.

RBC

What are the options for managing cancer?

Radiation, Chemotherapy, Surgical Removal,

___________: originate from embryonal mesoderm (connective tissue, muscle, bone, fat)

Sarcoma

What is the name for the tube that controls esophageal varies?

Sengstaken Blakemore tube

What is the tube name to control ruptured esophageal varices?

Sengstaken-Blakemore Tube

What are the causes of lung cancer?

Smoking Pollution, radiation (radon), asbestos, coal dust, nickel, uranium, chromium, formaldehyde, arsenic

How do you treat esophageal varices?

Soft diet Treat nausea to prevent force

___________________: small, dilated blood vessels with bright red center points and branches. Occur in nose, cheeks, neck, shoulders.

Spider Angiomas (Telangiectasia, Spider Nevi)

What is the pathophysiology of DIC?

Systemic activation of the coagulation system simultaneously leads to thrombus formation (compromising blood supply to organs) & exhaustion of platelets & coagulation factors (hemorrhage)

What is the staging system for colorectal cancer?

TNM (Tumor, Node Involvement, Metastasis) Highest stage is T4N2M1

Irritants can damage a vein, but won't cause tissue damage if infiltrated. ____________ can cause severe local tissue breakdown and necrosis if infiltrated.

Vesicant

What are the signs & symptoms of cirrhosis?

Weakness, fatigue, weight loss, anorexia, nausea, diarrhea (glucose can't be produced) Ab pain, sterility, loss of libido, impotence, hematemesis, urine dark (urobilinogen), stools pale/grey (lack of bilirubin)