final exam block 3
treatment of HHNS
-rehydration FIRST -insulin administration (check potassium) -monitor fluid volume and electrolyte status
The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? Abdominal tightness Absence of peristalsis Abdominal distention Increased abdominal girth
Absence of peristalsis
In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter? -Acetylcholine -Epinephrine -Norepinephrine -Dopamine
Acetylcholine
The nurse is caring for a client with external bleeding. What is the nurse's priority intervention? Pressure point control Application of a tourniquet Direct pressure Elevation of the extremity
Direct pressure
Nursing management of the client with a urinary tract infection should include: Discouraging caffeine intake Teaching the client to douche daily Instructing the client to limit fluid intake Administering morphine sulfate
Discouraging caffeine intake
Which instruction would be included in a teaching plan for a client diagnosed with a urinary tract infection? Use tub baths as opposed to showers. Drink liberal amount of fluids. Drink coffee or tea to increase diuresis. Void every 4 to 6 hours.
Drink liberal amount of fluids.
The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action? Assess facial weakness 5 minutes after injection. Ensure atropine is readily available. Administer edrophonium chloride per orders. Document the results.
Ensure atropine is readily available.
A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? Adult Failure to Thrive Imbalanced Nutrition: More than body requirements Sedentary Lifestyle Excess Fluid Volume
Excess Fluid Volume
treatment of DKA
Fluids, insulin, and aggressive replacement of electrolytes (e.g., K+) slowly lower glucose check potassium before administering insulin
When assessing a client with anemia, which assessment is essential? Health history, including menstrual history in women Family history Age and gender Lifestyle assessments, such as exercise routines
Health history, including menstrual history in women
Causes of respiratory acidosis
Hypoventilation, parasympathetic drug, re-breathing
A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? Limit foods high in fiber due to the risk for diarrhea. Increase the intake of vitamin E to enhance absorption. Iron will cause the stools to darken in color. Take the iron with dairy products to enhance absorption.
Iron will cause the stools to darken in color.
A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) "It is a hereditary disease." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." "It can be caused by ingestion of strong acids." "It is probably your nerves."
It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin.
The nurse is caring for a patient with Parkinson's disease and is preparing to administer medication. What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's? Requip Levodopa Symmetrel Permax
Levodopa
What is an Addisonian crisis?
Life threatening emergency caused by insufficient adrenocorticol hormones or a sudden sharp decrease in these hormones. can be caused by an increase in stressors as well
The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following? -Medications must be taken on time. -Medications can be taken whenever convenient. -Medications are best taken while the client is in a reclining position. -There is no conflict with the disorder and dental work.
Medications must be taken on time.
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? Esomeprazole (Nexium) Metoclopramide (Reglan) Famotidine (Pepcid) Nizatidine (Axid)
Metoclopramide (Reglan)
A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit? Moon face Hypotension Weight loss Pale thick skin
Moon face
When preparing teaching plan for a client with an endocrine disorder, the nurse includes information about hormone regulation. Which of the following would the nurse include? The gland becomes enlarged leading to a deficiency of the hormone. The gland slows hormone secretion when the hormone level decreases. Hormone secretion occurs as a straight-line continuous process. Most disorders result from over- or underproduction of the hormone.
Most disorders result from over- or underproduction of the hormone.
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? -Parkinson disease -Huntington disease -Creutzfeldt-Jakob disease -Multiple sclerosis
Multiple sclerosis
Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. Pain Fatigue Spasticity Aphasia Depression Numbness
Pain Fatigue Spasticity Depression Numbness
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe? -Ptosis and diplopia -Muscle weakness and hyporeflexia of the lower extremities -Difficulty with urination -Facial distortion and pain
Ptosis and diplopia
Which of the following is the first-line therapy for myasthenia gravis (MG)? Pyridostigmine bromide (Mestinon) Deltasone (Prednisone) Azathioprine (Imuran) Lioresal (Baclofen)
Pyridostigmine bromide (Mestinon)
A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? Strategies for avoiding irritating foods and beverages Techniques for positioning correctly to promote gastric healing Safe technique for self-suctioning Strategies for maintaining an alkaline gastric environment
Strategies for avoiding irritating foods and beverages
A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? Streptococcal infection Menarche Hypersensitivity to an immunization Psychosocial stress
Streptococcal infection
A client was diagnosed with pernicious anemia. Which vitamin cannot be absorbed without an intrinsic factor? Vitamin A Vitamin B12 Vitamin C Vitamin D
Vitamin B12
The nurse is caring for a client with chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? Vitamin B12 Vitamin C Vitamin E Vitamin A
Vitamin B12
A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem? Vitamin B12 deficiency Folic acid deficiency Vitamin A deficiency Vitamin C deficiency
Vitamin B12 deficiency
what do you give to treat metabolic acidosis
bicarbonate
How does Kayexalate work?
binds to potassium and exits the body through stool
priority nursing assessment for nephrotic syndrome
daily weights and extremity size
A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: thick, coarse skin. deposits of adipose tissue in the trunk and dorsocervical area. hypotension. weight gain in arms and legs.
deposits of adipose tissue in the trunk and dorsocervical area.
treatment for diabetes insepidous
desmopressin (vasopressin)
A nurse is reviewing lab results for a client with an intestinal obstruction, and infection is suspected. What would be an expected finding? leukopenia; metabolic acidosis; elevated sodium, potassium, and chloride leukocytosis; metabolic alkalosis; elevated sodium, potassium, and chloride leukopenia, decreased hematocrit; low sodium, potassium, and chloride leukocytosis; elevated hematocrit; low sodium, potassium, and chloride SUBMIT ANSWER
leukocytosis; elevated hematocrit; low sodium, potassium, and chloride
GFR in chronic kidney disease
lower than 60% for three months
a patient presents with a GI bleed with nausea and vomiting. The ER nurse has already placed a NG tube. what is the patient most at risk for? respiratory alkalosis respiratory acidosis metabolic alkalosis metabolic acidosis
metabolic alkalosis
what is a substance or chemical that destroys kidney tissue called?
nephrotoxic
patient education with desmopressin (vasopressin)
notify physician if you get a major headache because it can cause severely low sodium ("death by headache")
first sign of acute renal failure
oliguria (400 ml or less in 24 hours)
early sign of hyperkalemia
palpatations
how do you determine the patency of dialysis
palpation of a thrill or auscultation of a bruit
distinctive sign of nephrotic syndrome
peripheral edema
common and serious complication of peritoneal dialysis
peritonitis
two major signs of hypocalemia
positive trousseus and chvosteks signs
Causes of metabolic alkalosis
severe vomiting, excessive GI suctioning, diuretics
A client is admitted to the hospital with an exacerbation of chronic gastritis. When assessing the client's nutritional status, the nurse should expect to find what type of deficiency? vitamin B12 vitamin C vitamin A vitamin B6
vitamin B12
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: a decreased serum phosphate level secondary to kidney failure. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. metabolic alkalosis secondary to retention of hydrogen ions. an increased serum calcium level secondary to kidney failure.
water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? -Apply an eye patch to the right eye. -Exercise the right eye twice a day. -Administer eye drops as needed. -Place needed items on the right side.
Apply an eye patch to the right eye.
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia? Implementing neutropenic precautions Eliminating direct contact with others who are infectious Monitoring temperature at least once per shift Applying prolonged pressure to needle sites or other sources of external bleeding
Applying prolonged pressure to needle sites or other sources of external bleeding
When describing the functions of the kidney to a client, which of the following would the nurse include? Regulation of white blood cell production Synthesis of vitamin K Control of water balance Secretion of enzymes
Control of water balance
A nursing student asks the nurse why older adults are at risk for renal disease. The best response by the nurse is: "The glomerular filtration rate decreases as we age." "Contractility of the bladder wall increases with age." "Urethral hypertrophy occurs following menopause." "Hypoplasia of the prostate occurs in older men."
"The glomerular filtration rate decreases as we age."
causes of HHNS
#1 - illness or infection. (UTI, PN, sepsis)
Normal HCO3 range
22-26 mEq/L
Which of the following hormones controls secretion of adrenal androgens? Calcitonin Parathormone Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH)
Adrenocorticotropic hormone (ACTH)
What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? Weigh daily. Limit the fluid intake at night. Come to the clinic for IV fluid therapy daily. Consume adequate amounts of fluid.
Consume adequate amounts of fluid.
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? Distended jugular veins Crackles in the lung fields Dark, concentrated urine Cool and pale skin
Dark, concentrated urine
During hemodialysis, toxins and wastes in the blood are removed by which of the following? Filtration Ultrafiltration Osmosis Diffusion
Diffusion
SIADH treatment
Fluid restriction, IV hypertonic saline, conivaptan/tolvaptan, demeclocycline
A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Gastritis Peptic ulcer with melena Diverticulitis with perforation Gastroesophageal reflux disease
Gastroesophageal reflux disease
The nurse is caring for a client with diabetes who developed hypoglycemia. What can the nurse administer to the client to raise the blood sugar level? Cortisone Glucagon Estrogen Insulin
Glucagon
what should you monitor in a post op patient relating to fluid volume changes?
I+O, base lung sounds, LOC, skin turgor
treatment for addisonian crisis
IV push steroids (prednisone) normal saline or dextrose for dehydration caused by the crisis
Postrenal causes of AKI
Obstruction of urine flow: BPH, stones, tumors (uterolithiasis)
While assessing a client, the nurse will recognize what as the most obvious sign of anemia? Flow murmurs Jaundice Tachycardia Pallor
Pallor
A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level? Alopecia Dermatitis Urticaria Petechiae
Petechiae
Based on her knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator? Serum glucose pH and HCO3 Blood pressure Urine protein
Serum glucose
A client has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the client knows to do what action? Slowly taper down the dose of prednisone, as prescribed. Take the drug concurrent with levothyroxine. Take each dose of prednisone with a dose of calcium chloride. Gradually replace the prednisone with an over-the-counter (OTC) alternative.
Slowly taper down the dose of prednisone, as prescribed.
What is total incontinence?
The loss of urine with no warning sign
what is stress incontinence?
The loss or leaking of urine during exercise, sneezing, laughing, coughing, or when lifting something heavy.
A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: Trousseau's sign. Homans' sign. Hegar's sign. Goodell's sign.
Trousseau's sign.
two major risks for end stage renal disease
diabetes and uncontrolled hypertension
difference between cushings disease and syndrome
disease is usually caused by a tumor and can not be corrected syndrome can be corrected and can be caused by steriod usage
in a patient with glomerulonephritis, what would you expect their blood pressure to look like?
high
what drug is used to treat hyperkalemia?
sodium polystyrene sulfonate (Kayexelate) insulin can also lower potassium
A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching? "Taking a nap after meals, when possible." "Sleeping flat without pillows is beneficial." "Eating two large meals a day, instead of three." "Eliminating bothersome foods will help."
"Eliminating bothersome foods will help."
What is glomerulonephritis precipitated by?
streptococcal infection
The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia? "I have difficulty breathing when walking 30 feet." "I have an increase in my appetite." "I feel hot all of the time." "I have a difficult time falling asleep at night."
"I have difficulty breathing when walking 30 feet."
When fluid intake is normal, the specific gravity of urine should be 1.000. less than 1.010. greater than 1.025. 1.010 to 1.025.
1.010 to 1.025.
if a patient has oliguria and low creatinine clearance, what is going on in their system?
abnormal function of glomerular filtration
major prerenal cause of acute kidney injury
cardiac failure or GI bleed
nursing diagnosis for nephrotic syndrome
excess fluid volume related to generalized edema
Which nerve is implicated in the Chvostek's sign? Optic Spinal accessory Facial Hypoglossal
facial
renal cause of AKI
glomerulonephritis
Addisons disease s/s
"ADD steroids" -low BP -low weight -low temperature -low hair -low mood/energy -low NA -low glucose HIGH pigmentation HIGH potassium
treatment for addisons diease
"ADD" steroids "-sone"
s/s of diabetes insipidus
"dry inside," high sodium osmolality, low BP, dry skin, diluted urine, high urine output, low specific gravity, hypernatremia, extreme thirst
A client has a decreased secretion of erythropoietin from the kidneys due to end-stage kidney disease. What outcome will the decrease in erythropoietin have? Anemia from the decrease in maturation of red blood cells Increase in blood sugar levels due to alteration in insulin levels Decrease in blood sugar levels due to alteration in insulin levels Development of male sex characteristics
Anemia from the decrease in maturation of red blood cells
The nurse is caring for a client with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply. Auscultate the client's apical heart rate for dysrhythmias. Assess the client's BP. Assess the client's orientation and judgment. Percuss for pain in the right lower abdominal quadrant. Assess for the presence of peripheral edema.
Assess for the presence of peripheral edema. Assess the client's BP.
The nurse instructs the client with gastroesophageal reflux disease (GERD) regarding dietary measures. Which action by the client demonstrates that the client has understood the recommended dietary changes? Eliminating spicy foods. Avoiding chocolate and coffee. Eliminating cucumbers and other foods with seeds. Avoiding steamed foods.
Avoiding chocolate and coffee.
The patient diagnosed with thrombocytopenia is at risk for which of the following adverse effects: Bleeding Headache Diminished reflexes Stomatitis
Bleeding
An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? Administering sodium bicarbonate intravenously Reversing acidosis by administering insulin Fluid and electrolyte replacement Administration of antihypertensive medications
Fluid and electrolyte replacement
A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes Chronic obstructive pulmonary disease (COPD) Respiratory failure (RF) Congestive heart failure (CHF) Gastroesophageal reflux disease (GERD)
GERD
When assessing a client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Lifestyle assessments, such as exercise routines Age and gender Menstrual history Health history, such as bleeding, fatigue, or fainting
Health history, such as bleeding, fatigue, or fainting
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? Liver enzyme Intrinsic factor Hydrochloric acid Histamine
Intrinsic factor
cushings disease treatment
control causes surgical removal of ACTH secreting tumor
UTI prevention
drink at least 2 to 3 liters of fluid every day, get enough sleep, rest, and nutrition daily, clean perineum from front to back, avoid irritating substances (bubble bath, nylon underwear, scented toilet tissue), wear loose-fitting cotton underwear, empty bladder before and after intercourse, if you experience burning when you urinate, if you have to urinate frequently, or if you find it difficult to begin urinating, notify physician right away
dyspepsia
indigestion
Cushings disease s/s
"Big, round, and hairy" -big GP -big glucose and sodium -big belly (trunkal obesity) -big face (moon face) -big buffalo hump -big hair (hairtruism) -big stretch marks -big infections/risk for fractures
A patient is scheduled for a test with contrast to determine kidney function. What statement made by the patient should the nurse inform the physician about prior to testing? "I don't like needles." "I am allergic to shrimp." "I take medication to help me sleep at night." "I have had a test similar to this one in the past."
"I am allergic to shrimp."
A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching? "I will see my ophthalmologist regularly for a check-up." "I will eat lots of chicken and dairy products." "I may stop taking this medication when I feel better." "I will avoid friends and family members who are sick."
"I may stop taking this medication when I feel better."
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? "I'll eat three large meals every day without any food restrictions." "I'll eat frequent, small, bland meals that are high in fiber." "I'll lie down immediately after a meal." "I'll gradually increase the amount of heavy lifting I do."
"I'll eat frequent, small, bland meals that are high in fiber."
A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." "Instead of eating three meals a day, try eating smaller amounts more often." "Many clients obtain relief by taking over-the-counter antacids 30 minutes before eating." "Drinking beverages after your meal, rather than with your meal, may bring some relief."
"Instead of eating three meals a day, try eating smaller amounts more often."
A client with chronic renal failure comes to the clinic for a visit. During the visit, he complains of pruritus. Which suggestion by the nurse would be most appropriate? "Liberally apply alcohol to the areas of your skin where you itch the most." "When you shower, use really warm water and an antibacterial soap." "Try washing clothes with a strong detergent to ensure that all impurities are gone." "Keep your showers brief, patting your skin dry after showering."
Correct response: "Keep your showers brief, patting your skin dry after showering."
The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom? Azotemia Impaired immunologic response Electrolyte imbalances Diminished erythropoietin production
Diminished erythropoietin production
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Diplopia and ptosis Numbness Patchy blindness Loss of proprioception
Diplopia and ptosis
Causes of metabolic acidosis
DKA, severe diarrhea, renal failure, shock
The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth? Do not combine iron with other prescribed or over-the-counter medications Avoid taking iron simultaneously with an antacid Dilute liquid preparations of iron with juice and drink with a straw Take iron with or immediately after meals
Dilute liquid preparations of iron with juice and drink with a straw
Cancer of the esophagus is most often diagnosed by which of the following? X-ray Fluoroscopy Esophagogastroduodenoscopy (EGD) with biopsy and brushings Barium swallow
Esophagogastroduodenoscopy (EGD) with biopsy and brushings
A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal? -Establish a timed voiding schedule. -Avoid foods that change the pH of urine. -Perform intermittent catheterization q6h. -Administer anticholinergic drugs as prescribed.
Establish a timed voiding schedule.
A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? Sedentary Lifestyle Excess Fluid Volume Adult Failure to Thrive Imbalanced Nutrition: More than body requirements
Excess Fluid Volume
A client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The priority nursing diagnosis for a client with this condition is what? Risk for peripheral neurovascular dysfunction Excess fluid volume Ineffective airway clearance Hypothermia
Excess fluid volume
Which is a clinical manifestation of diabetes insipidus? Excessive activities Excessive thirst Low urine output Weight gain
Excessive thirst
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? Assess for dehydration. Teach client behaviors that decrease urination. Limit sodium and water intake. Give medications that promote fluid retention.
Limit sodium and water intake.
The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? -MS is a progressive demyelinating disease of the nervous system. -MS usually occurs more frequently in men. -MS typically has an acute onset. -MS is sometimes caused by a bacterial infection.
MS is a progressive demyelinating disease of the nervous system.
Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? -Involvement with diversion activities -Enhancement of the immune system -Establishing balanced nutrition -Maintaining a safe environment
Maintaining a safe environment
Erythropoietin growth factor increases production of which of the following? Red blood cells Platelets White blood cells Plasma
Red blood cells
The nurse advises the patient who has just been diagnosed with acute gastritis to: Take an emetic to rid the stomach of the irritating products. Refrain from food until the GI symptoms subside. Restrict food and fluids for 12 hours. Restrict all food for 72 hours to rest the stomach.
Refrain from food until the GI symptoms subside.
A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has? -Benign -Primary progressive -Relapsing-remitting (RR) -Disabling
Relapsing-remitting (RR)
A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has had not ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? Facilitate a referral to the wound-ostomy-continence (WOC) nurse. Contact the physician and obtain a swab of the stoma for culture. Encourage the client to mobilize in order to enhance motility. Report signs and symptoms of obstruction to the health care provider.
Report signs and symptoms of obstruction to the health care provider.
A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? Risk for Infection Related to Possible Rupture of Appendix Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake Chronic Pain Related to Appendicitis Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake
Risk for Infection Related to Possible Rupture of Appendix
The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth? Use a straw or place a spoon at the back of the mouth to take the liquid supplement. Do not combine iron with other prescribed or over-the-counter medications. Take iron with or immediately after meals. Avoid taking iron simultaneously with an antacid.
Use a straw or place a spoon at the back of the mouth to take the liquid supplement.
The nurse is teaching a client with recurrent urinary tract infections (UTIs) ways to decrease risk for additional UTIs. The nurse includes which information? Increase intake of coffee, tea, and colas. Void every 5 hours during the day. Void immediately after sexual intercourse. Take tub baths instead of showers.
Void immediately after sexual intercourse.
first nursing priority/assessment for patient with renal calculi
assess severity and location of pain
patient education if they are prescribed pyridium
their urine may be reddish-orange and may cause staining to their clothes
why is renal failure associated with anemia?
there will be a decreased production of erythropoietin by the kidneys
if your patient have hyperphosphatemia, what will their calcium levels look like?
they will have hypocalcemia (they are inverse of eachother)
what supplies does the nurse need in order to do a creatinine clearance test?
this will be a 24 hour urine test, so they will need a large container
A client has been diagnosed with pernicious anemia. During client education, the nurse emphasizes the importance of lifelong intramuscular administration of: vitamin B12. vitamin A. vitamin C. folic acid.
vitamin B12.
Normal PaCO2 range
35-45 mm Hg
normal pH levels
7.35-7.45
During a health history, a client explains that he was just diagnosed with Parkinson's disease and wants to know what to expect. What should the nurse include during client teaching? -Abnormal body movements such as tremors may occur at rest along with asymmetry of movement. -Eventually there will be paralysis of the extremities on one side of the body. -Whole-body convulsive movements will occur as the disease progresses. -Over time, the client's eyesight will diminish, especially at night.
Abnormal body movements such as tremors may occur at rest along with asymmetry of movement.
main cause of death in patients with chronic kidney disease
cardiovascular disease
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? -Avoid hot temperatures. -Avoid physical activity. -Take moderate amounts of alcohol. -Avoid analgesic medication.
Avoid hot temperatures.
A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? -Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes -Flexor spasm, clonus, and negative Babinski reflex -Blurred vision, intention tremor, and urinary hesitancy -Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Blurred vision, intention tremor, and urinary hesitancy
The clinic nurse is preparing a plan of care for a client with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? Teach the client to perform pelvic floor muscle exercises. Prepare the client for an anterior vaginal repair procedure. Provide medication teaching related to pseudoephedrine sulfate. Provide information on periurethral bulking.
Teach the client to perform pelvic floor muscle exercises.
signs and symptoms of pylonephritis
flank pain on affected side with costovertebral angle tenderness, fever, N/V, nocturia
dietary restrictions for chronic renal failure patient
fluid, protein, potassium, and sodium restrictions
what would the specific gravity be like in a dehydrated patient
high
Causes of respiratory alkalosis
hyperventilation (anxiety, PE, fear), mechanical ventilation
what is the most serious risk factor for a patient receiving lasix?
hypokalemia
what is the nurses priority in monitoring for a patient on dialysis
hypotension
What is urge incontinence?
inability to stop urine flow long enough to reach the toilet
A 30 year-old female client has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the client's care? Powerlessness related to disease progression Disturbed body image related to changes in physical appearance Spiritual distress related to changes in cognitive function Decisional conflict related to treatment options
Disturbed body image related to changes in physical appearance
A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point should the nurse include? Notify the physician if urinary urgency, burning, frequency, or difficulty occurs. Wear only nylon underwear to reduce the chance of irritation. Take medication ordered for a UTI until the symptoms subside. Limit fluid intake to reduce the need to urinate.
Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.
A client is scheduled for a diagnostic test to measure blood hormone levels. The nurse expects that this test will determine which of the following? The concentration of a substance in plasma Details about the size of the organ and its location The client's blood sugar level The functioning of endocrine glands
The functioning of endocrine glands
flow of peritoneal dialysis
inflow, dwell, and drain
most accurate way to determine fluid balance
weight
DKA s/s
*sudden* hyperglycemia more than 300 fruity breath kussmaul breathing ketones present metabolic acidosis polyuria, polydipsia dehydrated N/V, abdominal pain
main causes of DKA
-Decreased or missed insulin dose -Illness or infection -Undiagnosed and untreated diabetes
patient education for addisons disease
-signs and symptoms of steroid deficiency -carry emergency kit -need for lifelong hormone replacement and medical supervision -notify doctor if they have an increase in stressors, as they may need to increase the dose -diet high in protein, carbs and sodium -medication is not a cure
Which of the following measurable urine output recorded indicates the patient is maintaining adequate fluid intake and balance? A patient with a minimal urine output of 50 mL/hour A patient with a minimal urine output of 10 mL/hour A patient with a minimal urine output of 20 ml/hour A patient with a minimal urine output of 30ml/hour
A patient with a minimal urine output of 50 mL/hour
GFR in end stage renal disease
less than 15%
A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has? peptic ulcer disease appendicitis ulcerative colitis diverticulitis
peptic ulcer disease
patient education about urinary incontinence to the geriatric population
urinary incontinence is not considered normal with aging
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide? Observe the gums for bleeding after the client brushes teeth. Observe stools for blood. Observe the sputum for signs of blood. Observe client for facial droop.
Observe stools for blood.
A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? -Arrange for the client to receive a low residue diet. -Position the client upright during feeding. -Suction the client following each meal. -Withhold liquids until the client has finished eating.
Position the client upright during feeding.
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? Chloride Sodium Potassium CO2
Potassium
Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus? Odynophagia Dysphagia Pyrosis Dyspepsia
Pyrosis
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? Left lower quadrant Right upper quadrant Left upper quadrant Right lower quadrant
Right lower quadrant
interventions for kidney stones
increase fluids, strain urine to keep stones (test composition and measure amount that has come out)
what should you monitor for in a patient in the diuresis phase of acute kidney injury?
monitor for dehydration
A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with: gastroenteritis. complete bowel obstruction. paralytic ileus. Crohn's disease.
paralytic ileus.
The most accurate indicator of fluid loss or gain in an acutely ill client is: pulse rate. weight. edema. blood pressure.
weight.
A young female client has pale nailbeds. Her hemoglobin count is 10.2 gm/dL and her hematocrit count is 30%. She reports fatigue and states, "I'm tired all the time." The client also reports excessive menstrual flow. The nurse assesses further and determines the client's diet is balanced and provides adequate calories. The client is prescribed supplemental iron therapy. The highest nursing diagnosis is Altered tissue perfusion related to diminished oxygen-carrying capacity of the blood Fatigue related to diminished oxygen-carrying capacity of the blood Altered nutrition: less than body requirements, related to inadequate intake of nutrients Deficient knowledge related to new information with no previous experience
Altered tissue perfusion related to diminished oxygen-carrying capacity of the blood
The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? Taking multivitamins as prescribed and eating organic foods whenever possible Performing 15 minutes of physical activity at least three times per week Avoid taking aspirin to treat pain or fever Maintaining a healthy body weight
Avoid taking aspirin to treat pain or fever
A client is having chronic pain from arthritis. What type of hormone is released in response to the stress of this pain that suppresses inflammation and helps the body withstand stress? Estrogen Glucocorticoids Mineralocorticoids Testosterone
Glucocorticoids
HHNS s/s
Gradual Onset • Hypotension • Profound Dehydration - impairment of brain thirst centers, patient may lose 15-25% body fluid • Tachycardia • Neuro - Altered LOC, seizures, hemiparesis, myoclonic jerking, mimic stroke
A young mother with a 2 year old and a 6 month old is experiencing fatigue related to anemia. The client states that she is having difficulty performing the activities needed for her job, family, and home. With what task is it most appropriate for the nurse to assist the client? Prioritizing and balancing activities and rest. Finding a babysitter to take care of her children. Obtaining assistance from someone to help with cleaning in the home. Requesting a leave of absence from her job.
Prioritizing and balancing activities and rest.
if a patient is on diuretics what is important to assess daily?
weight
The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. " "It is normal to be a little confused following surgery, and it is safe not to urinate at night." "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup."
"Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids."
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? -"You will have a steady and gradual decline in function." -"Your type of MS is the least common, making it difficult to manage." -"You must avoid stress and extreme fatigue, because these can trigger a relapse." -"You should take your medications only during times of relapse."
"You must avoid stress and extreme fatigue, because these can trigger a relapse."
SIADH s/s
"soaked" Stops Urination Sticky and thick urine (high specific gravity) Soaked/swollen inside (low liquidy labs- hyponatremia, hypoosmolality) Sodium low (headache early sign**) Seizures Severely high BP Stop all fluids, give salt, diuretics
Which of the following is the most accurate indicator of fluid loss or gain? Urine output Body temperature Caloric intake Weight
Weight
A nurse is reviewing the laboratory order for a client suspected of having an endocrine disorder. The lab slip includes obtaining cortisol levels. What is being tested? thyroid function parathyroid function adrenal function thymus function
adrenal function
A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond? "Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery." "Your small intestine will adapt over time to the absence of your appendix." "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this."
"Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery."
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? -"Avoid taking daytime naps." -"Avoid hot baths and showers." -"Limit your fruit and vegetable intake." -"Restrict fluid intake to 1,500 ml/day."
"Avoid hot baths and showers."
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? -A disorder in which the body has too many immunoglobulins -A disorder in which histocompatible cells attack the immunoglobulins -A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" -A disorder in which the body does not have enough immunoglobulins
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems? Gastric cancer Gastric ulcer Acute gastritis Duodenal ulcer
Acute gastritis
A nurse caring for a client with small-bowel obstruction should plan to implement which nursing intervention first? Preparing to insert a nasogastric (NG) tube Administering I.V. fluids Obtaining a blood sample for laboratory studies Administering pain medication
Administering I.V. fluids
Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply. -Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. -Elevate the upper body on pillows. -Elevate the head of the bed on 6- to 8-inch blocks. -Avoid beer, especially in the evening. -Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid.
Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows.
The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Avoid eating or drinking 2 hours before bedtime Wear tight-fitting clothing Elevate the foot of the bed on 6- to 8-inch blocks Eat a low-carbohydrate diet
Avoid eating or drinking 2 hours before bedtime
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test? -Cyclosporine (Sandimmune) -Edrophonium (Tensilon) -Immunoglobulin G (Iveegam EN) -Azathioprine (Imuran)
Edrophonium (Tensilon)
The nurse is caring for a client who is hospitalized with an exacerbation of MS. To ensure the client's safety, what nursing action should be performed? -Ensure that suction apparatus is set up at the bedside. -Pad the client's bed rails. -Maintain bed rest whenever possible. -Provide several small meals each day.
Ensure that suction apparatus is set up at the bedside.
A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? Esophageal or pyloric obstruction related to scarring Chronic referred pain in the lower abdomen Gastric hyperacidity related to excessive gastrin secretion Uncontrolled proliferation of H. pylori
Esophageal or pyloric obstruction related to scarring
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? Gastroesophageal reflux disease Esophageal tumor Hiatal hernia Gastritis
Esophageal tumor
A client admitted with nephrotic syndrome is being cared for on the medical unit. When writing this client's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? Constipation related to immobility Hyperthermia related to the inflammatory process Excess fluid volume related to generalized edema Risk for injury related to altered thought processes
Excess fluid volume related to generalized edema
A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about? Gastric slowing Peptic ulcer disease Nausea Extrapyramidal
Extrapyramidal
A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? Impaired Skin Integrity Related to Bowel Obstruction Ineffective Tissue Perfusion Related to Bowel Ischemia Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption Anxiety Related to Bowel Obstruction and Subsequent Hospitalization
Ineffective Tissue Perfusion Related to Bowel Ischemia
Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply. Rabeprazole (AcipHex) Famotidine (Pepcid) Nizatidine (Axid) Lansoprazole (Prevacid) Esomeprazole (Nexium)
Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium)
A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? Lansoprazole Omeprazole Calcium carbonate Metoclopramide
Metoclopramide
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. The appendix may develop gangrene and rupture, especially in a middle-aged client. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? Pancreatitis Peptic ulcer Cholecystitis Appendicitis
Pancreatitis
Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? Acute pancreatitis Gastritis Peritonitis Gastroesophageal reflux
Peritonitis
A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering: IV dextrose 50% Sorbitol sodium polystyrene sulfonate (Kayexalate) Calcium supplements
sodium polystyrene sulfonate (Kayexalate)
A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? Takes over-the-counter antacids frequently throughout the day. Smokes one pack of cigarettes daily. Reports a history of social drinking on a weekly basis. Consumes one or more protein drinks daily.
Smokes one pack of cigarettes daily.
A child is brought into the clinic with symptoms of edema and dark brown rusty urine. Which nursing assessment finding would best assist in determining the cause of this problem? Red blood cells in the urine Sore throat 2 weeks ago Protein elevation in the urine Elevation of blood pressure
Sore throat 2 weeks ago
A client who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the client's condition is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? Sudden thirst, unrelieved by oral fluid administration Diaphoresis and sudden onset of abdominal pain Tachycardia, hypotension, and tachypnea Tarry, foul-smelling stools
Tachycardia, hypotension, and tachypnea
A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? -The muscles will become fatigued and the patient will not be able to chew food or swallow pills. -There should not be a problem, since the medication was only delayed by about 2 hours. -The patient will go into cardiac arrest. -The patient will require a double dose prior to lunch.
The muscles will become fatigued and the patient will not be able to chew food or swallow pills.
The nurse is caring for a client who describes changes in his voiding patterns. The client states, "I feel the urge to empty my bladder several times an hour and when the urge hits me I have to get to the restroom quickly. But when I empty my bladder, there doesn't seem to be much urine flow." What would the nurse expect this client's physical assessment to reveal? Urine retention Dehydration Hematuria Kidney injury
Urine retention
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: -a positive edrophonium (Tensilon) test. -Kernig's sign. -a positive sweat chloride test. -Brudzinski's sign.
a positive edrophonium (Tensilon) test.
What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply. abdominal distention sudden, sustained abdominal pain sudden drop in body temperature intermittent, severe pain
sudden, sustained abdominal pain abdominal distention
A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: hypotension. thick, coarse skin. deposits of adipose tissue in the trunk and dorsocervical area. weight gain in arms and legs.
deposits of adipose tissue in the trunk and dorsocervical area.
A nurse is providing education to a client with GERD. The client asks what measures can be taken independently to help reduce the symptoms. Which interventions would the nurse recommend? Select all that apply. sleeping in a supine position ensuring intake of food and fluids 2 to 3 hours before bedtime maintaining an upright position following meals avoiding foods that intensify symptoms
maintaining an upright position following meals avoiding foods that intensify symptoms
Which client requires immediate nursing intervention? The client who: presents with ribbonlike stools. presents with a rigid, board-like abdomen. complains of anorexia and periumbilical pain. complains of epigastric pain after eating.
presents with a rigid, board-like abdomen.
