exam 3
A patient with a history of alcoholism is admitted to the ICU with hemorrhage from esophageal varices. Admission VS are BP 84/58 mm Hg, HR 105, and RR 32 breaths/min. The nurse recognizes the onset of systemic inflammatory response syndrome (SIRS) upon finding a.pulmonary edema. b.cardiac dysrhythmias. c.absent bowel sounds. d.decreasing blood pressure.
Answer: A Rationale: The respiratory system is often the first system to show signs of dysfunction in systemic inflammatory response syndrome. Increases in capillary permeability facilitate movement of fluid from the pulmonary vasculature into pulmonary interstitial spaces. The fluid then moves to the alveoli, causing alveolar edema and pulmonary edema.
A patient with a head injury has an arterial BP of 92/50 mm Hg, MAP 64 mm Hg, and ICP of 18 mm Hg. The nurse uses the assessments to calculate the cerebral perfusion pressure (CPP). How should the nurse interpret the results? 64-18 = 46 (low; cell death/ischemia) a.The CPP is so low that brain death is imminent. b.The CPP is low, and the BP should be increased. c.The CPP is high, and the ICP should be reduced. d.The CPP is adequate for normal cerebral blood flow.
Answer: B Rationale: The cerebral perfusion pressure (CPP) is the pressure needed to ensure blood flow to the brain. CPP is equal to the MAP minus the ICP (CPP = MAP - ICP). MAP = DBP + 1/3 (SBP-DBP) = 50 + 1/3 (92-50) = 64 mm HgCPP = MAP - ICP = 46 mm HgNormal CPP is 60 to 100 mm Hg. CPP <50 mm Hg is associated with ischemia and neuronal death. A CPP <30 mm Hg results in ischemia and is incompatible with life. It is critical to maintain MAP when ICP is elevated. A patient with a head injury may require a higher blood pressure, increasing MAP and CPP, to increase perfusion to the brain and prevent further tissue damage. ICP also needs to be decreased (normal is 5-15)
A patient admitted to the hospital from a long-term care facility appears to be in the late stage of shock with systemic inflammatory response syndrome (SIRS). Which order implemented by the nurse has the highest priority? a.Insert an indwelling urinary catheter. b.Insert two large-bore intravenous catheters. c.Administer 0.9% normal saline at 100 mL/hr. d.Administer 100% oxygen by non-rebreather mask.
Answer: D Rationale: A patient in the irreversible stage of shock (late stage) will demonstrate profound hypotension and hypoxemia. If the condition progresses to systemic inflammatory response syndrome, the patient may experience profound hypoxemia. Oxygenation is a priority and should be initiated first with a 100% oxygen delivery method such as a non-rebreather mask.
The nurse is caring for a critically ill patient. The nurse suspects that the patient has progressed beyond the compensatory stage of shock if what occurs? a.Increased blood glucose levels b.Increased serum sodium levels c.Increased serum calcium levels d.Increased serum potassium levels
Answer: D Rationale: Hyperkalemia occurs in the progressive phase of shock when cellular death liberates intracellular potassium. Hyperkalemia will also occur in acute kidney injury and in the presence of acidosis.
The nurse is caring for a patient in septic shock. Which hemodynamic change would the nurse expect? a.Increased ejection fraction. b.Increased mean arterial pressure. c.Decreased central venous pressure. d.Decreased systemic vascular resistance.
Answer: D Rationale: Patients in septic shock will have a decreased systemic vascular resistance, decreased ejection fraction, and decreased mean arterial pressure. Decreased central venous pressure (preload) is expected in hypovolemic or obstructive shock.
When assessing a patient in shock, the nurse recognizes that the hemodynamics of shock include a.normal cardiac output in cardiogenic shock. b.increase in central venous pressure in hypovolemic shock. c.increase in systemic vascular resistance in all types of shock. d.variations in cardiac output and decreased systemic vascular resistance in septic shock.
Answer: D Rationale: Septic shock has three major pathophysiologic effects: vasodilation, maldistribution of blood flow, and myocardial depression. Patients may be normovolemic, but because of acute vasodilation, relative hypovolemia and hypotension may occur. The ejection fraction is decreased for the first few days after the initial insult. Because of a decreased ejection fraction, the ventricles will dilate to maintain stroke volume. The ejection fraction typically improves and ventricular dilation resolves over 7 to 10 days. Persistence of a high CO and a low SVR beyond 24 hours is an ominous finding and is often associated with increased development of hypotension and MODS. Systemic vascular resistance (SVR) increases in cardiogenic and hypovolemic shock; SVR decreases in neurogenic, anaphylactic, and septic shock. Cardiac output decreases in cardiogenic shock. Central venous pressure decreases in hypovolemic shock.
The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed? a.Prone with the head turned to the right side b.High-Fowler's position with the legs elevated - flexion of hip increase ICP c.Supine position with the head on two pillows d.Side-lying with the head elevated 30 degrees
Answer: D Rationale: To prevent increased intracranial pressure, the nurse should maintain the patient in the head-up position (no more than 30 degrees). Head elevation over 30 degrees may decrease cerebral perfusion pressure. Extreme neck flexion (head on two pillows) and hip flexion (high-Fowlers position) should be avoided. Head should remain midline. c is incorrect because lying flat and head/neck flexed increases ICP
What is icteric urine (S/S of chronic pancreatitis)?
Dark colored urine (urine with bilirubin)
For someone who has a history of acute pancreatitis, do they still have to have a low fat/high carb/high protein diet? Or is it just during the acute infection?
Definitely during the acute infection they will need to eat small, frequent high carb meals. If it is just a one time issue (maybe due to gallstones) and their pancreas heals, they may be able to resume their regular diet. For patient with chronic pancreatitis, they will likely need to eat 5-6 small, frequent high carb and meals and take pancreatic enzymes for life.
Why are liver enzyme levels increased in acute pancreatitis?
If a gallstone (one of the most common causes of pancreatitis) is blocking the bile duct that can cause the bile to back up and cause the elevation of liver enzymes
How do respiratory complications occur from acute pancreatitis? I.e. pulmonary edema, ARDS, penumonia, etc.?
It's not some much related to the pancreatitis itself as much as the body becoming weak from infection, taxing the immune system, the patient not eating, etc., not drinking, and possibly being bedbound all leading to in extreme cases sepsis, ARDS, and pneumonia.
Why are antispasmodics used for drug therapy? Do antispasmodics prevent the pancreas and gallbladder from contracting and secreting fluids/enzymes?
Pancreatic pain is extremely intense. By helping to relax the smooth muscles in conjunction with opioids, it help to relieve the pressure and pain in the abdomen.
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? a) gallstone b) hypolipidemia c) COPD d) diabetes mellitus
a) gallstone Gallstones are one of the leading reasons for pancreatitis. Hyper (not hypo) lipidemia can be a risk factor. DM and COPD are not causes of pancreatitis.
what is the #1 cause of death for a patient with Acute Kidney injury (AKI)? a) infection b) hypertension c) acute tubular necrosis d) decreased release of renin
a) infection
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? a) Decreased WBC b) Increased serum amylase c) Decreased serum lipase d) Increased serum calcium
b) Increased serum amylase patients with acute pancreatitis have elevated amylase and lipase. Often their WBC is elevated and their calcium level is decreased.
what is the best food option for my patient with kidney disease? a) orange juice b) apple slices c) potatoes d) dark leafy green vegetables
b) apple slices avoid foods high in potassium
if the patient is in the diuretic phase of AKIs, what is the most important electrolyte imbalance for the nurse to monitor? a)hyperkalemia and hyponatremia b) hyponatremia and hypokalemia c) dehydration d) hyperkalemia and hypernatremia
b) hyponatremia and hypokalemia importance of PHASE Oliguric phase - hyperkalemia & hyponatremia (retaining water and decreased urine production) Diuretic phase - lots of urine production à decrease in electrolytes
The nurse explains to a patient with an episode of acute pancreatitis that the most effective means of relieving pain by suppressing pancreatic secretions is the use of: a. Antibiotics. b. NPO status. c. Antispasmodics. d. Proton pump inhibitors.
b. NPO status - prevents stimulation of pancreatic enzymes think: Which of these methods suppress pancreatic secretions?
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention? a) Auscultate the client's lungs b) Assist the client to a side lying position c) Provide oral hygiene d) Withhold oral fluid and food
d) Withhold oral fluid and food If rewording the question, it is really asking "What is a priority for patients who have pancreatitis?" Priorities for pancreatitis include pain mgmt. and keeping patient NPO as oral foods an fluids stimulate those digestive enzymes which then can cause worsening of pancreatitis.
