medsurg exam 4
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
"I will receive parenteral vitamin B12 therapy for the rest of my life."
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide concerning cast care?
"Keep your right leg elevated above heart level."
A client with osteoarthritis tells the nurse they are concerned that the disease will prevent them from doing their chores. Which suggestion should the nurse offer?
"Pace yourself and rest frequently, especially after activities."
A client has a 10-year history of rheumatoid arthritis and is concerned now that the client's child is experiencing some morning stiffness and pain. What would be the most appropriate response by the nurse?
"There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated."
A client with the beta-thalassemia trait plans to marry a person of Italian ancestry who also has the trait. Which client statement indicates understanding of the teaching provided by the nurse?
"We'll need more genetic counseling in the future."
Folic acid deficiency - normal level -treatrment
- 3-25 - replacement therapy foods with lots of folic acid
Anemia: Gerontologic Considerations
- Common in older adults - S/S may go unrecognized or mistaken for normal aging process -nutritional deficiencies
Goals and therapy for anemia
- blood transfusion -drug thx -volume replacement -diet/lifestyle changes -oxygen -prevent injuries
Carcinogens
- detoxified by protective enzymes most of the time, failure of protective mechanisms allows them to enter cell nucleus and alter dna
Lysis of a clot -antithrombins -fibrolysis
- interfere w thrombin -dissolution of fibrin clot
Vascular response to injury
- local vasoconstriction, gives times for platelet and clotting factors to be triggered
Fibromyalgia criteria
- pain on 11 of 18 tenderpoints with palpation -widespread pain for at least 3 mos
T score -osteopenia -osteoporosis
-1 to -2.5 -2.5 AND lower
Blood cells -make up how much of blood -RBC function -leukocyte function -platelet function
-45% -oxygen transport -infeciton -coagulation
RA CM -what joints affected
-Fatigue, anorexia, weight loss, generalized stiffness, insidious,inactivity, Morning stiffness 60 minutes to several hours or longer -Often affects small joints, Larger joints and cervical spine may be involved
Sickle Cell anemia -definition -predominant in -Sickle cell crisis -cm -complications
-Group of inherited, autosomal recessive disorders -African americans -painful, vasoocclusive, tissue necrosis. life threatening shock -pain, pallor, jaundice -infection, compromised spleen, pneumonia, aplastic crisis (shut down rbc production)
Lymph system -function -lymphedema
-Protein and fat from the GI tract and certain hormones are returned to circulatory system Returns excess interstitial fluid to blood to prevent or reduce edema -•Too much interstitial fluid or reduced absorption leads to lymphedema.
Aplastic anemia (aquired) -definiton -cm caused by -cm -treatment
-Results from exposure to ionizing radiation, chemical agents, viral and bacterial infections -Symptoms caused by suppression of any or all bone marrow elements •Fatigue, dyspnea, Cardiovascular and cerebral responses, Neutropenia -treat causative agent, supportive care
Osteoporosis -definition -cm
-bone reabsorption exceeds bone deposition -back pain, spontaneous feactures, loss of height, kyphosis
rheumatoid arthritis -definiton -spells -men or women
-chronic, systemic inflammation of synovial joints -periods of remission and exacerbation -three times as many women as men
Platelets -function -regulated by
-clotting -thrombopoietin
Pancytopenia -definition
-decrease in all blood cell types
FUnctions of spleen -filtration -immunologic
-filtration removes old rbcs, returns iron to bone marrow for reuse, filters bacteria -contains lymphocytes and stores rbc/ platelets
Lymphocytes Monocytes
-humorat immune, B and T cells -phagocytic at site of injury, turn into macrophages
Erythopoiesis -stim by -controlled by
-hypoxia -erythpoietin kidney
Neutrophils
-increase d/t bacterial infection, phagocytosis, inflammatory response mature- seg immature-band
Osteomyelitis -patho - acute cm -chronic cm -treatment -nursing management
-indirect (young boys, blunt trauma, other system infection) or direct entry of pathogen into bone -infection of less than one month, pain unrelieved with rest, REEDA, systemic manifestations -infection longer than one month, failure to respond to antibiotic treatment, less systemic cm, avascular d/t granulation of scare tissue, cant be penetrated by antibiotics -aggresive prolonged iv antibiotics for acute(CVAD port) 4-6 wk, chronic tx: surgery, extended antibiotics, antibiotic bead chains, sntibiotic irrigation -dressing change, pain management, observation CDIFF, mobilization, peak trough
RA -corticosteroids -NSAID and salicylates
-injections or low dose oral for short time -antiinflamatoru, 2-3 wks for effectiveness
Two pathways of clotting
-intrinsic: collagen extrinsic: tissue thromboplastin released from injured site
Fibromyalgia Nursing Management
-limit intake sugar, caffeine, alcohol -supplements -relaxation and counseling
Immune Thrombocytopenic Purpura (ITP) -is it common -what is it -onet -when treatment intiated -spleen
-most common aquired, abnormal destruction of platelets, autoimmune, chrinic in adults, gradual onset -platelets below 30,000 intiate corticosteroids -enlarged spleen destroys platlets
Granulocytes Agranulocytes
-neutrophils, eosinophils, basophils -lymphocytes, monocytes
Thrombocytopenia -CM -diagnostic -what to avoid
-often asymptomatic, gums and hang nail bleeding, petechiae, purpura, ecchymoses, prolonged bleeding after procedure, hemmorrhage -decreased platelet count, below 50,000 hemorrhage at below 20,000 -aspirin
Cobalamin Deficiency -cause -gastro CM -Neuro CM -treatment
-pernicious anemia -Sore tongue, anorexia, N/V & abdominal pain -Weakness, paresthesias of feet & hands, ↓ vibratory and position senses, ataxia, muscle weakness, and impaired thought processes -Parenteral or intranasal administration of cobalamin
Heparin-induced thrombocytopenia (HIT) -cause -how long after heparin thx -complications -tx
-pos feedback loop resulting in clots -5-10 days after heparin therapy started -arterial thrombosis, DVT, PE -stop all heparin, start direct thrombin inhibitor start coumadin
Osteoarthritis - definition -cause -risk factors -prevention -cm
-progressive noninflammatory disorder of synovial joints -loss of auricular cartilage and formation of osteophytes -Age, Decreased estrogen at menopause, Obesity, Anterior cruciate ligament injury,frequent kneeling and stooping -regular excersize -joint pain worsening with joint use, morning stiffness resolving in 30 min
Cancer Education
-public education to modify behaviors and encouragement of health promoting behaviors -screenings, self examination, evoid carcinogens
Thrombocytopenia -involves -2 types -examples of acquired
-reduction of platelets in abnormal homeostasis resulting in prolonged and spontaneous bleeding -inherited, acquired -ITP, TTP, HIT
iron deficiency anemia -is it common? -causes -where is it absorbed -where is most blood lost -cm -goal -drug thx -common side effect -when is iron given PNT
-the most common form of anemia -inadequate intake or malabsorption of iron or blood loss, or pregnancy - duodenum -GI and GU systems -pallor, glossitis, cheilitis -treat underlying disease/ increase intake to replace iron -Best absorbed as ferrous sulfate in an acidic environment -black stools -malabsorption, oral iron intolerance, need for iron beyond normal limits, poor patient compliance, in hospital
Thrombotic Thrombocytopenic Purpura (TTP) -is it common -associated w -caused by -emergency? -tx
-very uncommon -aggregation of platelets forming into microthrombi -plasma enzyme deficiency, can be idiopathic -yes, bleeding and clotting occur at same time -treat underlying cause first, plasmapheresis to reverse platelet consumption, other immunosuppressants like rituximab may be used, splenectomy
Fibromyalgia -what is it -other cm -patho -what kind of pain -diagnosis
-widespread nonarticular musculoskeletal pain -other cm may be nonrestorative sleep, morning stiffness, IBS< anxiety -abnormal central processsing nociceptive pain input -vague pain -difficult to establish definitive diagnosis, rule out other disorders
platelet transfusion -when indicated
-•Indicated for platelet count < 10,000/μL or if bleeding is anticipated before a procedure
RA Stage 1 Stage 2 Stage 3 Stage 4
1: no joint destruction 2:destruction in joint cartilage 3:extensive cartilage loss with possible deformity 4: loss of function, subq nodules
The nurse is preparing to administer 500 mL of whole blood to a client. The blood is to be infused over 4 hours. The infusion tubing delivers 10 gtt/mL. How many drops of blood per minute must the nurse infuse to complete the infusion in 4 hours? Record your answer using a whole number.
21
Plasma -how much in blood -what is serum
55% of blood -plasma minus clotting factors
The nurse is collaborating with the healthcare provider to develop a care plan to help control chronic pain in a client with cancer who is receiving hospice home care. Which plan would be most appropriate for managing the client's pain?
Administer analgesics on a regular basis, with the administration of additional analgesics for breakthrough pain.
Acute low back pain avoid
BLT bending, lifting, twisting
Folic acid vs cobalamin defeciencies
CM are similar, but no neuro cm in folic acid deficiency
viral carcinogens
Eptein BArr- burkitt HIV- kaposi Hep B -hepaticellular HPV- Squamous cell
Deformity of joints in OA
Heberdens nodes, bouchards nodes
A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse in the operating room do?
Initiate a time-out.
Acquired Hemolytic AnemiaDestruction from Antibodies
Isoimmune- blood onor reactions, autoimmune
A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?
It will get better and worse again.
nursing skill after diagnosis of cancer
LISTENING
A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurological symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period?
Logroll the client from side to side.
Degenerative disc disease
Loss of elasticity, flexibility, and shock-absorbing capabilities
The nurse is developing a care plan for a client who has leukemia. What instructions should the nurse include in the plan? Select all that apply.
Monitor temperature and report elevation. Recognize signs and symptoms of infection. Avoid crowds. Maintain integrity of skin and mucous membranes.
Macrophages
Monocytes that have migrated into tissue •When damage, infection, or even injury triggers a response, the monocytes leave their primary location and travel through the blood stream to enter other tissues and organs in the body
Protooncogenes
Mutations that alter their expression can activate them to function as oncogenes
A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
Essential role of nurses with cancer
PREVENTION IS KEY
lymphnodes function
Primary function is filtration of pathogens and foreign particles carried by lymph fluid
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
Providing a solution of viscous lidocaine for use as a mouth rinse
Risk factors of lower back pain
SMOKING, obesity, decreased muscle, stress, pregnancy, posture, hx of fractures
A nurse is caring for a client who complains of lower back pain. Which instruction should the nurse give to the client to prevent back injury?
Stand close to the object you're lifting."
A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?
Stop the transfusion, infuse normal saline solution, and call the physician.
A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate?
Take a warm tub bath or shower before exercising. This may help with your discomfort."
A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
Use the smallest needle possible for injections
A client received treatment with cytotoxic medications 24 hours ago. Which precautions are necessary when caring for the client?
Wear personal protective equipment when handling blood, body fluids, and feces
The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia?
a client with digoxin toxicity
drug therapy for OA
acetaminophen, topical agent, otc cream, NSAIDS, corticosteroid injections
Platelet plug formation activated by
activated by exposure to interstitial collagen
A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include
administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.
Osteoporosis risk factors
advance age, female, low body weight, white or asian, smoker, sedentary, low estrogen, low vit d, increase alcohol
Health promotion in OA
alteration of risk factors (lose weight, reduce enviornemental hazards) and physical fitness programs
What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture?
assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation
Patho of RA
autoimmune, genetic and envioirnmental triggers, IgG, antibodies develop
Rest and Joint protection in OA
balance rest and activity, rest with acute exacerbation, decrease joint stress, avoid prolonged standinf, kneeling, squatiing, assistive devices, weight reduction is critical
Progression of cancer metastasis
begins with rapid growth of primary tumor, •Tumor cells can detach and invade surrounding tissues
RA and BRMs
biologics or immunotherapy, used when dmards arent working as well -Bind with TNF, inhibits inflamation, monitor infection and avoid live vaccines
Drug thx osteoporosis
biophosphates, given with full glass of water 30 min before meal, sat upright for 30 min
Hematopoeisis
blood cell production in bone marrow, rbc, wbc, and platelets
How cancer is classified
by site of orgin, histology, extent of disease (stage)
Supplemental calcium
calcium carbonate taken w meals, calcium citrate
Tenosunovitis
carpal tunnel like symptoms and fine motor difficulty Walking disability, safety
Cancer- defect in cellilar proliferation
cells have no regard for cellular boundaries
Majority of megaloblastic anemias result from deficiency in:
cobalamin (vit b 12) and folic acid
WHat does thrombin do
converts fibrogen to fibrin
A client with aplastic anemia is instructed to eat foods rich in iron. The nurse should instruct the client to include which food in the diet to increase iron intake?
dark green leafy vegetables
causes of anemia
deficient number of rbc, amount of hemoglobin, and volume of pakced rbcs (hematocrit)
SEID diagnosis
diagnosis of exclusion, to rule out other possibilities
SEID v fibromyalgia
difficult to distinguish
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?
dyspnea, tachycardia, and pallor
Decreased platelet production
ex: leukemia pancytopenia, chemo suppresses bone marrow -will resolve with pt is supported through treatment
A client takes prednisone, as ordered, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as
fluid retention, weight gain
The family of an older adult with terminal cancer asks about having hospice services. What should the nurse tell the family?
focuses on supportive care for the client and family
Acquired Hemolytic AnemiaMicroangiopathic Destruction
fragmentation of the cells as they try to pass by abnormal arterial or venous microcirculation, excessive platelet aggregation
RA without treatment
functional impairment in 20 yrs, need for joint reconstruciton, experience loss of independence
Excersize for RA
gentle ROM, aquatic excersize
A male client comes to the clinic with complaints of pain in his great toe. The client reports that the pain is worse at night. Assessment reveals tophi. The nurse suspects the client has
gouty arthritis
A nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (Canadian Cancer Society) guidelines, the nurse should recommend that the women
have a mammogram annually
Lifestyle changes to prevent cancer
healthy weight, rest, cope with stress, examination, balanced diet, limit alcohol, exercise
A client has been diagnosed with osteoporosis after a bone density test and is asking what has caused it. Discussion of risk factors would include:
heavy smoking, sedentary lifestyle, and high intake of carbonated drinks
Eosinophils
histamine, allergic reaction, parasites, large in lungs and GI
A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?
igE
Neutrophil left shift
increase in bands, baby neutrophils, meaning acute infection
Acquired Hemolytic AnemiaInfectious Agents & Toxins
infectious agents invade RBC, release hemolytic substances generate antibody reaction
Thalassemia
inherited defect in ability to produce hemoglobin
A female client is at risk for developing osteoporosis. Which action will reduce the client's risk?
initiating weight-bearing exercise routines
Development of cancer: 1st stage
initiation -mutation of cells genetic structure
A client with cancer is receiving radiation therapy and develops thrombocytopenia. What is the priority nursing goal to prevent which effect of thrombocytopenia for this client?
injury related to the decreased platelet count
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?
intrinsic factor
What is required for cobalamin absorption
intrinsic factor
The client asks the nurse to explain what it means that Hodgkin's disease is diagnosed at stage 1A. What should the nurse explain about the involvement of the disease?
involvement of a single lymph node
A nurse is caring for a client who recently underwent a total hip replacement. The nurse should:
limit hip flexion of the client's hip when he sits
Vertebral disc surgery nursing management
log rolling, spinal precautions
A multidisciplinary oncology team of health care providers, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply.
low rbc, wbc, platelet
Why osteoporosis is more common in women than in men?
lower calcium levels, less bone mass, bone reabsorption after menopause increases, pregnancy/nbreastfeeding
The teaching plan for the client with rheumatoid arthritis includes rest promotion. What position of the involved joints should the nurse tell the client to avoid when at rest?
maintaining the joints in a flexed position
banign v malignant
malignant invade and metastasize
Interprofessional care of OA
manage pain, prevent disability, maintain function of joint, nondrug intervents in adjunct to drug therapy
cauda equina
medical emergency -incontinence -severe low back pain
Spinal stenosis
narrowing of spinal canal
lumbar radiculopathy
nerve pain in the lower back caused by muscle spasms or by nerve root irritation from the compression of vertebral disks such as a herniated disk SCIATICA
radiculopathy
nerve root becomes pinched or damaged
Radicular pain
nerve root pain
Does stage of cancer change once established?
no
Clinical staging of cancer via
none and liver scans, ultrasonography, ct, mri, pet scan
Prevention of RA
not possible at this time
Spinal surgery post op
observe for Cerebral spinal fluid, glucose pos Assess neuro signs and GI function-- notify if incontinent
A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of
organ meats.
cervical disc disease
pain radiated to arms and hands
Myofascial Pain syndrome -what is it -treatment
pain within connective tissue of skeletal muscle -physical therapy, topical patches, injections, massage, acupuncture, ultrasound
CM of anemia
pallor, jaundice, pruitis, tachycardia, fatigue
Basophils
phagocytosis
Acquired Hemolytic AnemiaMacroangiopathic Destruction
physical destruction of RBCs
A nurse is interviewing a client about their past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
polyps
SEID
profound fatigue, malaise, unrefreshing sleep
A client asks the nurse what PSA is. The nurse should reply that it stands for
prostate-specific antigen, which is used to screen for prostate cancer.
2 types of genes that can be affected by mutation in cancer
protooncogenes promoting growth, tumor suppressing genes suppressing growth
A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to
provide oral and I.V. fluid
osteoporosis prevention
regular weight bearing exercise, vit d and calcium
Fibromyalgia interprofessional care
requires high level of pt motivation
Things to do when having lower back pain
side lying position with knees and hips bent sleep on back with a lift under knees and legs prevent lower back strain use lumbar roll or pillow for sitting exercise in morning, carry items close to body, local heat and cold, weight
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to
sit upright, leaning slightly forward.
RA and DMARDS
slow progression, decrease joint erosiion, therapeutic effects take 4-6 wks
Smoking and RA
smoking increases incidence in predisposed
Steroid and Osteoporosis
steroids increase risk of OP
Acquired Hemolytic Anemia management
supportive care until causative agent eliminated
SEID treatment
supportive management activity well balanced diet behavioral therapy
What cells activated in RA
t helper cells (CD4)
A client is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) to manage the pain of rheumatoid arthritis. What information should the nurse give to the client about taking these medications?
take nsaid with food
A client with rheumatoid arthritis tells the nurse that she feels "quite alone" in adjusting to changes in her lifestyle. Which response by the nurse will be most effective?
telling the client about her community's arthritis support group.
A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used
to provide long-term access to central veins.
Cancer definition
uncontrolled growth of cells
Osteoporosis health promotion
weight bearing excersize, quit smoking
When is surgical treatment for intervertebral disc disease indicated
when conservative treatment fails
RA diagnostic studies
§Rheumatoid factor (RF) §ESR and C-reactive protein (CRP) §Antinuclear antibody (ANA)
Chemical carcinogens
•Benzene •Arsenic •Formaldehyde
Acute blood loss CM
•Caused by the body's attempts to maintain adequate blood volume and meet oxygen requirements
Hemolytic anemia -definition -cm -tx focus
•Destruction or hemolysis of RBCs at a rate that exceeds production -same as generalized anemia with enlarged sleep and liver and jaundice -maintaining renal function
Liver
•Functions as a filter •Produces all procoagulants essential to hemostasis and blood coagulation •Stores excess iron
Development of cancer: latent period
•Length of latent period associated with mitotic rate of tissue of origin and environmental factors 1-40 yr
Role of immune system in cancer
•Lymphocytes continually check cell surface antigens and detect and destroy abnormal cells
Sources of calcium
•Milk •Yogurt •Turnip greens •Cottage cheese •Ice cream •Sardines •Spinach
Activities of promotion of cancer
•Obesity •Smoking, alcohol Dietary fat
Reticulocyte
•Reticulocytes mature into RBCs and are a good indication of production rates.
RBC function
•Transport oxygen (O2) from lungs to systemic tissues •Carry carbon dioxide from tissues to the lungs
Radiation in cancer
•Ultraviolet radiation is associated with melanoma and squamous and basal cell carcinoma •Sunlight is main source of UV exposure
VIT D
•Vitamin D necessary for calcium absorption/function; bone formation
Blood values with acute blood loss
•With sudden blood volume loss, values may seem normal or high for 2 to 3 days. •Once the plasma volume is replaced, low RBC concentrations become evident.
