med surg post assess

A nurse is caring for a 76-year-old client post-hip arthroplasty. What are three (3) complications the nurse should assess for?​

1. Dislocation can occur. To avoid dislocation, use an elevated seating and a raised toilet seat, use straight chairs with arms, and use an abduction pillow or regular pillow if prescribed, between legs while in bed and with turning. Externally rotate the toes and avoid greater than 90 degree flexion. 2. Infection can occur. Monitor for signs of infection and use aseptic techniques during dressing changes. 3. Venous Thromboembolism: Monitor for manifestations of pulmonary embolism. Also follow venous thromboembolism prophylaxis.

A nurse finds a client on the floor actively having a seizure. What should the nurse do to keep the client safe?

1. Position the client to provide patent airway. Turn the client on side to decrease risk of aspiration. For safety reasons, if you need to hold the patient's head on your lap and move furniture or other things that are too close to the client, do so or have someone else do so. 3. Be prepared to suction oral secretions and loosen restrictive clothing 5. Do not attempt to restrain the patient. 6. Do not attempt to open jaw or insert airway during seizure activity because this can cause further damage. Additionally, do not use padded tongue blades 8. Document onset and duration and findings (LOC, apnea, cyanosis, motor activity, incontinence) prior to, during, and following the seizure.

​A client with Parkinson's disease has been prescribed selegiline. What is the medication classification of selegiline and what dietary instructions should the nurse provide to a client who is taking medication?

Selegiline is a MAO inhibitor that works by slowing the breakdown of certain neurotransmitters such as dopamine, norepinephrine, and serotonin. The client should avoid foods high in tyramine when using these medications because they can cause hypertensive crisis.

A nurse is caring for a client who has experienced a mild traumatic brain injury. Describe the manifestations of increased intracranial pressure the nurse should be alert for.

Some manifestations of increased ICP are: Severe headache Nausea and vomiting Altered Level of consciousness, restlessness, irritability Dilated, pinpoint, or non-reactive pupils Cranial Nerve dysfunction Alteration in breathing patterns (Cheyne-stokes resp, hyperventilation, apnea) Deterioration in motor function Abnormal posture: Decerebrate, Decorticate Cushing's Triad, manifested by: Severe HTN, A widened pulse pressure, and bradycardia and Seizures.

The nurse is assessing a client with a left-sided stroke. What clinical manifestations can the nurse anticipate?

The left cerebral hemisphere is responsible for language, math skills, and analytic thinking. Further, some manifestations of a Left sided stoke include: -Expressive or receptive aphasia -Agnosia, or an inability to recognize familiar objects -Alexia, or difficulty reading -Agraphia, or difficulty writing -Right sided hemiplegia, also known as paralysis, or hemiparesis, also known as weakness -Slow behavior -Depression, anger, or easily frustrated -Visual changes such as hemianopsia , which is loss of a visual field in one or in both eyes.

​A nurse is caring for a client with a history of migraines with auras. What are the stages of this type of migraine?

There are 4 stages. The aura stage develops over minutes to an hour to include neuro findings such as: Numbness & tingling of mouth, lips, face, or hands and acute confusion. Additionally, visual disturbances like light flashes or bright spots can occur. 2nd stage: In this stage, a severe, incapacitating, throbbing Headache occurs, that intensifies over several hours and is accompanied by nausea, vomiting, drowsiness, and vertigo. 3rd stage: The third stage lasts 4-72 hrs. Here, the headache becomes dull. The recovery stage is characterized by pain and aura subsiding. Muscle aches/contraction of head and neck muscles are common. Physical activity worsens pain and often the patient is sleeping during this phase.

​A client is prescribed timolol for the treatment of glaucoma. The client asks the nurse, "Why was I asked about my cardiac history for eye drops?" How should the nurse respond?

Timolol is a Beta Blocker. It is a first-line drug therapy for glaucoma, and decrease IOP by reducing aqueous humor production. However, It can also potentiate effects of oral beta-blockers. Because It can cause bradycardia and hypotension, it should be used cautiously in patients with a cardiac history.

​A hospitalized client with a sealed radioactive implant asks the nurse, "can my family visit me?" What education should the nurse provide regarding visitors?

With a sealed radioactive implant, the patient should be placed in a private room. The nurse should wear dosimeter film badge. Regarding visitors, they should be limited to 30 minute visits and maintain distance of 6ft. Additionally, visitors who are pregnant or under 16yrs should not be allowed to visit the patient.

A nurse has just received report on four (4) clients. How can the nurse use the prioritization principle ""Acute over Chronic"" to help decide which client to assess first? Provide an example

Regardless of the scenario, the nurse should always prioritize acute over chronic conditions. The nurse should use assessment techniques to be able to recognize manifestations that are expected with chronic conditions, versus maifestations that indicate an acute problem that should be addressed immedicately. For example, Patient one has Diabetes and insulin Due at 9:00 Patient 2 had a recent thyroidectomy and reports tingling around his mount Patient 3 has COPD and reports shortness of breath Patient 4 is post-surgery and is reporting pain at the incision site While we would narrow it down to patient 2 or 3, we know that COPD is a chronic condition that causes shortness of breath, and thus is not a priorty when circumoral paresthesia is being reported post-thyroidectomy. Thus, the nurse should assess Patient 2 first.

A nurse is caring for a client who has had a below the knee amputation of his right leg due to traumatic injury. Discuss (3) potential postoperative complications that can develop and the nursing interventions to address the complication.

Some post-operative complications that can occur include Infection: The nurse should monitor for signs and symptoms of infection by monitoring the drainage color, odor, and amount. Heat at the residual limb can indicate infection as well. The nurse should also administer antibiotics and perform dressing changes as prescribed. Flexion Contractures: The nurse should have the client lie prone for 20-30 minutes several times a day to help prevent hip flexion contractures. The nurse should also discourage prolonged sitting. Education of the patient should include practicing exercises that will prevent contractures and stand using good posture with the residual limb in extension. Hypovolemia: Nurses should assess for bleeding. Nurses should also monitor vital signs frequently (every 15 minutes for the first hour). If this complication occurs, rapid lfuid replacement is needed and oxygen as ordered. Medications may also be given to improve hemodynamic parameters.