NURS301- Exam 4

Drug Therapy for PE

1. Anticoagulation - Low-Molecular-Weight Heparin (LMWH) - Unfractionated IV Heparin - Warfarin (Coumadin) 2. Fibrinolytic Agents - Tissue Plasminogen Activator (tPA) - Alteplase (Activase)

How many classifications of Strokes are there? (2)

1. Hemorrhagic (bleeding) 2. Ischemic (deficient supply of blood) - Thrombotic - Embolisms

What are the Risk Factors associated with physiological Stress leading to Stress Ulcers?

1. Hypotension & Shock - #1 Risk Factor 2. Trauma - Traumatic Brain Injury (TBI) 3. Coagulopathy (clot formation) - INR > 1.5 - Platelets (plt) <50 - PTT > x2 the normal limits 4. Burns 5. Severe Sepsis - When chemicals get released in the bloodstream to fight off an infection triggered by inflammation 6. Liver, Kidney OR Respiratory Failure - esp. Mechanical Ventilation >48hrs 8. Steroid Use - esp. those of HIGH dosaging 9.GI Bleeding - Is the COMMON cause of Re-Admissions after a lengthy Hospitalization: consider: + PPI's, +H2 blockers + Sucralfate

- QUESTION: Which action would the nurse take first for a patient arriving at the emergency department with headache, nausea, hypertension, and difficulty talking? A. Prepare the patient for a CT scan. B. Place anti-embolism stockings on the patient. C. Place a stat consult for the speech-language pathologist (SLP). D. Prepare to administer recombinant tissue plasminogen activator (tPA).

A. Prepare the patient for a CT scan.

- QUESTION: Which assessment data would indicate to the nurse that the client would be at risk for a Hemorrhagic Stroke? A. Blood glucose level of 480 mg/dl. B. Right-sided carotid bruit. C. Blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma

C. Blood pressure of 220/120 mmHg. - Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the cranium. Why it's not the other ones: A. Blood glucose level of 480 mg/dl. - This glucose level is elevated and could predis- pose the client to ischemic neurological changes due to blood viscosity, but it is not a risk factor for a hemorrhagic stroke. B. Right-sided carotid bruit. - A carotid bruit predisposes the client to an embolic or ischemic stroke but not to a hemorrhagic stroke. D. The presence of bronchogenic carcinoma - Cancer is not a precursor to developing a hemorrhagic stroke.

- QUESTION: Which assessment data indicate that the client recovering from an open cholecystectomy requires pain medication? A. The client's pulse is 65 beats per minute. B. The client has shallow respirations. C. The client's bowel sounds are 20 per minute. D. The client uses a pillow to splint when coughing

B. The client has shallow respirations.

- QUESTION: Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? A. History of side effects experienced from all medications B. Use of non-steroidal anti-inflammatory drugs (NSAIDs) C. Any known allergies to drugs and environmental factors D. Medical histories of at lease 3 generations

B. Use of non-steroidal anti-inflammatory drugs (NSAIDs) - Use of NSAIDs places the client at risk for peptic ulcer and hemorrhage. - NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid.

- QUESTION: An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching? A. "tPA is administered IV." B. "tPA is administered by intra arterial infusion." C. "tPA should be administered within 12 hours of the onset of a stroke." D. "tPA requires BP monitoring during and 24 hours after the treatment."

C. "tPA should be administered within 12 hours of the onset of a stroke."

- QUESTION: In order for, tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered when? A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms

C. 3 hours after the onset of stroke symptoms - tPA dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. - It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!

- QUESTION: You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition: A. TIAs are caused by a temporary decrease in blood flow to the brain. B. TIAs produce signs and symptoms that can last for several weeks to months. C. A TIAs is a warning sign that an impending stroke may occur. D. TIAs don't require medical treatment.

C. A TIAs is a warning sign that an impending stroke may occur. Why it's not the other ones: B. TIAs produce signs and symptoms that can last for several weeks to months. ▪ TIA's produce S&S that can last a few minutes-hours and resolve (NOT over several weeks-months) D. TIAs don't require medical treatment. ▪ They do require medical treatment

- QUESTION: What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability. B. Vasoconstriction. C. Dissolved emboli. D. Prevention of hemorrhage

C. Dissolved emboli. - Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion.

- QUESTION: A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory-perceptual deficits. During the patient's rehabilitation, it is important for the nurse to A. Avoid positioning the patient on the affected side B. Place all objects for care on the patient's unaffected side C. Teach the patient to care consciously for the affected side D. Protect the affected side from injury with pillows and supports

C. Teach the patient to care consciously for the affected side - Unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. - During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

- QUESTION: A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics? A. Management of fluid balance in the home setting B. The need for blood glucose monitoring for the next week C. Signs and symptoms of intra-abdominal complications D. Appropriate use of prescribed pancreatic enzymes

C. Signs and symptoms of intra-abdominal complications - Because of the early discharge following laparoscopic cholecystectomy, the patient needs thorough education in the signs and symptoms of complications Why it's not the other ones: A. Management of fluid balance in the home setting - Fluid balance is not typically a problem in the recovery period after laparoscopic cholecystectomy. B. The need for blood glucose monitoring for the next week - NO NEED D. Appropriate use of prescribed pancreatic enzymes - NO NEED

- QUESTION: Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

C. Slow and possibly fearful performance of tasks

- QUESTION: The nurse is caring for a patient with increased intracranial pressure (ICP). The nurse realizes that some nursing actions are contraindicated with ICP. Which nursing action should be avoided? A. Reposition the patient every two hours. B. Position the patient with the head elevated 30 degrees. C. Suction the airway every two hours per standing orders. D. Provide continuous oxygen as ordered.

C. Suction the airway every two hours per standing orders. - Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Why it's not the other ones: B. Position the patient with the head elevated 30 degrees. - Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) ICP. D. Provide continuous oxygen as ordered. - Keeping the patient properly oxygenated may also help to control ICP.

- QUESTION: The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for complaints of a serious headache. C. Take antihypertensive medication as ordered. D. Drowsiness is normal for the first week after discharge.

C. Take antihypertensive medication as ordered. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a patient being discharged.

- QUESTION: During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

C. Blood pressure - Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. - Blood pressure should be maintained according to physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. - Other vital signs are monitored, but the priority is blood pressure.

Liver Profile: Hepatic Function Panels

1. Albumin (3.5-5.5 g/dL) - A Protein made in the Liver - The measurement of Protein in the Blood - Pre-albumin 2. Total protein (6.0-8.3 g/dL) - Total amount of Protein in the Blood 3. ALP (40-120 u/L) - Alkaline Phosphatase - COMMONLY High in Gallbladder Disease 4. AST (SGOT) (10-40 u/L) - Aspartate Aminotransferase - Is released in response to Liver Disease 5. ALT (SGPT) (7-56 u/L) - Alanine Transaminase - Is released in response to Liver Disease 6. LDH (< 110 mmol/L) - Lactate Dehydrogenase - Can be elevated in: + Muscle Injury + Pancreatitis + Cancer + Liver + Kidney Disease 7. PT (11-13.5 seconds or INR of 0.8-1.1) - A Protein involved in Blood Clotting (synthesized by the Liver) 8. Bilirubin- Direct: <0.3 mg/dL and Total from 0.1-1.2 mg/dL - The measurement of RBC destruction - Conjugated & Unconjugated (COMMONLY High in Gallbladder Disease)

What happens if the Right Cerebral Hemisphere is damaged?

1. Altered Perception of Deficits 2. Unilateral Neglect Syndrome (MORE COMMON in Right) When the pt. CANNOT feel, see, or move affected side - they are UNAWARE of its existence 3. LOSS of Depth Perception Inability to see things in 3 dimensions; ex. how far an object is 4. POOR Impulse Control Difficulty to stop themselves from engaging in certain behaviors 5. Left Extremity Hemiplegia Paralysis of the left side of the body 6. Visual Changes

What other Medications other than Fibrinolytic Therapy- tPA (Reteplase Recombinant) [-ase] can be used for Strokes?

1. Anticoagulants - Warfarin (Coumadin) for Atrial Fibrillation OR Oral Anticoagulants - Apixaban - Rivaroxaban 2. Antiplatelet - Aspirin - Dipyridamole - Clopidogrel 3. Antiepileptic - Phenytoin - Gabapentin

Important Studies of PE

1. Arterial Blood Gases (ABGs) - Low PaO2 in otherwise Unremarkable ABG - Evidence of Tachypnea, Hyperventilation 2. Chest X-Ray - Atelectasis - Pleural Effusion 3. Electrocardiogram - ST Segment and T-Wave Changes 4. Troponin Levels 5. B-Type Natriuretic Peptide (BNP) - Frequently ELEVATED

What causes Chronic Gastritis?

1. Autoimmune diseases 2. Dietary factors 3. Medications: NSAIDs & Aspirin can cause a Chemical injury 4. Alcohol 5. Smoking 6. Chronic Reflux of Pancreatic secretions or Bile

What are Problems and Potential Complications for a pt. with Cholelithiasis?

1. Bleeding 2. GI Symptoms 3. Complications related to Surgery (in general) - Atelectasis The complete or partial collapse of the entire lung or area (lobe) of the lung - Thrombophlebitis The inflammatory process that causes a blood clot to form and block one or more veins, usually in the legs

Diagnostic Procedures for a Stroke

1. CT 2. MRI 3. Lumbar Puncture 4. Glasgow Coma Scale Level of consciousness- LOC

What Therapeutic Procedures are used for Strokes?

1. Carotid Artery Angioplasty (Balloon) with Stenting (tube) - Placed on the side of your Neck (Carotid Artery) 2. Carotid Endarterectomy Surgical procedure that is used to REDUCE the Risk of a Stroke from the REMOVAL of build-up of plaque that causes narrowing of a Carotid Artery (Neck) 3. Extracranial-Intracranial Bypass Surgery that is done to - INCREASE/MAINTAIN Cerebral Blood Flow - or to ALLOW occlusion of a surgically inaccessible Intracranial Aneurysm (an abnormal bulge or ballooning in the wall of a blood vessel)

Risk factors for a Stroke?

1. Cerebral Aneurysm When an Abnormal Bulge or Ballooning in the wall of a Blood Vessel causes bleeding in the Brain 2. Arteriovenous (AV) Malformation When the Arteries and Veins in an Arteriovenous Malformation can RUPTURE, causing bleeding into the brain or spinal cord. 3. Diabetes When your body can't make Insulin or use Insulin correctly, which causes Glucose (sugar) to build up in your blood; overtime HIGH Glucose levels can damage (add pressure) the body's blood vessels increasing the chance of Stroke 4. Hypertension Can cause Blood Clots to FORM in Arteries leading in the brain, leading to Ischemia when blood flow is blocked. 5. Atherosclerosis Occurs when a Blood Clot forms on an Atherosclerotic plaque (fats, cholesterol & other substances in/on walls) within a Blood Vessel in the Brain & BLOCKS Blood Flow to that part of the Brain 6. Hyperlipidemia AKA HIGH Cholesterol from excessive uptake in Diet leading to high levels of Blood Lipids- causing for an increased formation of plaque that NARROWS Blood Vessels 7. Hypercoagulability This state has SLOWING Blood Flow in the veins, especially those of the lower extremities. It can lead to Emboluses or Thrombus formation 8. Atrial Fibrillation INCREASES risk because of the RAPID Heartbeat allows blood to pool in the Heart, which can cause clots to form and travel to the Brain 9. Use of Oral Contraceptives (Birth Control) These INCREASE the risk of Cerebral Venous Thrombosis; esp. those that contain only Estrogen 10. Smoking By INCREASING Blood Pressure and REDUCES Oxygen in the Blood. Also containing toxic chemicals that get deposited on the Lungs or absorbed in the Bloodstream causing damage to Blood Vessels, making them WEAK 11. Cocaine Use It causes DIRECT effects on Cerebral Circulation, including: - an elevated BP - Vasculitis (inflammation of the blood vessels) - and Cerebral Vasospasm

Diagnostic Studies of PE

1. D-Dimer - Elevated with any Clot DEGRADATION - FALSE Negatives with Small PE 2. Spiral (Helical) CT Scan/CT Angiography - MOST Frequently used Diagnostic Test - Requires IV Contrast Media 3. Ventilation-Perfuion (V/Q) Scan 4. Pulmonary Angiography - MOST Sensitive but is INVASIVE 5. Arterial Blood Gases (ABGs)

Risk Factors for Cholelithiasis

1. Diabetes 2. Weight Changes - Including rapid weight loss 3. Estrogen Therapy 4. Native American & Hispanic people

What causes Acute Gastritis?

1. Dietary Indiscretion 2. Medications: NSAID''s and Aspirin that can cause a Chemical Injury 3. Alcohol 4. Bile Reflux 5. Radiation Therapy 6. Ingestion of a STRONG Acid or Alkali that can cause serious complications like Poisoning or Overdose

Clinical Manifestations of PE

1. Dyspnea - MOST COMMON occurring in 85% of cases - Hypoxemia may be observed 2. Tachypnea 3. Cough 4. Chest Pain 5. Hemoptysis 6. Crackles 7. Wheezing 8. Fever 9. Tachycardia 9. Syncope 10. Change in LOC & Hypotension - From Massive Emboli's

Risk Factors associated with Peptic ulcers

1. EXCESSIVE Secretion of Stomach Acid (Traumatic Events) - Zollinger-Edison Syndrome 2. Dietary Factors 3. CHRONIC use of: - NSAID's - Aspirin (ASA) - Alcohol - Smoking 4. and, Familial Tendencies

Diagnostic Testing for Cholelithiasis using...

1. Endoscopic Retrograde Cholangiopancreatography (ERCP) - X-ray and Endoscopy 2. Magnetic Resonance Cholangiopancreatography (MRCP) - Imaging Screening like an MRI 3. Ultrasound

Medical Management of Cholelithiasis

1. Endoscopic Retrograde Cholangiopancreatography (ERCP) - X-ray and Endoscopy can help visualize the Biliary Tree - Removes Stones - Place Stents - Balloon Dilation 2. Dietary Management 3. Medications: - Ursodeoxycholic Acid - Chenodeoxycholic Acid + Outpatients have HIGH Risk of Surgery & the has a LOW Success Rate 4. Laparoscopic Cholecystectomy 5. Percutaneous Drain - DECREASES the Risk of Perforation, Rupture - Requires Local Anesthesia - Can buy time to allow pt. to be treated with Antibiotics and become MORE Stable B4 Surgery 6. Nonsurgical Removal - By Instrumentation - Intracorporeal or Extracorporeal Lithotripsy

S&S Manifestations of Chronic Gastritis

1. Epigastric Discomfort 2. Anorexia 3. Heartburn AFTER Eating 4. Belching (burping) 5. Sour Taste in the Mouth 6. N/V 7. Intolerance to some Foods 8. Malabsorption of B12 Fatigue (Pernicious Anemia) from: - Intrinsic Factor, the protein that helps your intestines absorb the Vitamin located in Stomach & Small intestine (duodenal) - Ethyl Alcohol (EtOH) - Gastric Surgery pts 9. Achlorhydria, Hypochlorhydria or Hyperchlorhydria - Absence/Less or Excessive Hydrochloric Acid

What happens if the Left Cerebral Hemisphere is damaged?

1. Expressive (Broca) & Receptive Aphasia (Wernicke) 2. Agnosia The inability to recognize familiar objects. 3. Alexia Difficulty reading 4. Agraphia Difficulty writing 5. Right Extremity Hemiplegia Paralysis of the right side of the body 6. Slow Cautious Behavior 7. Feelings of Depression & Anger 8. Visual Changes

What are Problems and Potential Complications associated with a pt. who has Peptic Ulcers?

1. Hemorrhages (an abnormal discharge of blood) 2. Perforation Having a Board-like Abdomen in which the pt. experiences SEVERE Pain causing for the pt to: - Double Over (bend forward) - Writher (twisting, squirming movements or contortions of the body) 3. Penetration 4. Pyloric-bacterial Obstruction - Gastric Outlet Obstruction

Assessment of someone with Gastritis

1. History including present S&S 2. Dietary Hx & Dietary associations w symptoms 3. 72-hour Diet Diary 4. S&S of Bleeding? 5. Abdominal Assessment - Shape - Size' - Sounds - Palpation - Percussion (striking w/ hand)

When Bile is not dumped into the small intestine due to the malfunction of the Biliary Tree it can result in what?

1. Jaundice 2. Brownish Urine 3. Pain 4. Bloating 5. Constipation 6. Vomiting 7. Clay-colored stools 8. Seizures 9. Brain Damage 10. Death

What is the DIFFERENCE b/w Gastric and Duodenal/Peptic Ulcers?

1. Location - Gastric: Stomach - Peptic: Duodenum 2. Weight LOSS or GAIN - Gastric: LOSS w/ Emesis - Peptic: GAIN 3. Time of Pain - Gastric: 0.5-1 hr AFTER Meal - Peptic: 2-3 hrs AFTER Meal & pt. can AWAKEN AT NIGHT 4. Eating can either Worsen or Relieve Pain - Gastric: WORSEN - Peptic: Provides RELIEF 5. Age - Gastric: Ages 45-55 - Peptic: Ages 35-45 6. Gastric Acid Levels - Gastric: HYPOchlorhydria - Peptic: HYPERchlorhydria 7. Bleeding - Gastric: + Hemorrhages (an abnormal discharge of blood) + Hematemesis (vomiting blood) - Peptic: + Perforation (hole) + Melena (dark sticky feces containing digested blood) 8. Malignancies - Gastric: OCCASIONAL - Peptic: RARE

What can result because of Erosive Gastritis?

1. Melena - Dark sticky feces containing party digested blood 2. Hematochezia - The vomiting' of blood 3. Hematemesis - Passage of fresh blood per Anus, usually in OR with Stools 4. Bright Red Blood PER Rectum (BRBPR) - Indicates small amounts of blood on toilet paper after wiping or amounts in the toilet bowl after defecation

Nursing Care for someone who has a Stroke?

1. Monitor Vital Signs (VS) - Notify HCP if BP is <180 mm Hg (may be having an Ischemic Stroke) 2. Monitor Temperature Fever can cause an INCREASE in Intracranial Pressure (ICP) leading to Cushing's Triad 3. Oxygen Therapy (Spo2 <92%) 4. Place the pt. on a Cardiac Monitor 5. Monitor pt. for changes of their Level of Consciousness (LOC) 6. Monitor pt. for Hyperglycemia 7. Elevate the HOB to DECREASE Intracranial Pressure (ICP) - AVOID EXTREME Flexion, Extension of Neck & Coughing 8. Institute Seizure Precautions - To protect the patient from injury and to reduce environmental stimuli that may trigger the onset of one. - Includes: Pt. bed in the LOWEST position w/ side rails padded, or if possible, the mattress should be placed on the floor 9. Assist w/ Communication Skills 10. Assist w/ Safe Feeding 11. Preventing Complications of Immobility 12. Teaching pt. to Protect & Care for the AFFECTED Side - Support AFFECTED Side 13. Encourage ROM q2 hours 14. Elevate AFFECTED Extremities to PROMOTE Venous Return 15. Maintaining a SAFE Environment 16. Teach pt. How to Scan if they have LOSS of Vision on 1 side 17. Provide Assistance with ADLs 18. Provide Frequent REST Periods 19. Teach pt. to use UNAFFECTED Side to Exercise AFFECTED Side

S&S of Gastritis

1. N/V 2. Dysphagia (can't swallow) 3. Diarrhea 4. Constipation 5. Changes in Habits 6. Heartburn 7. Dyspepsia (indigestion w/ no obvious cause)

How do we care for a Stroke pt. who is experiencing Unilateral Neglect?

1. Observe AFFECTED Extremities 2. Apply an Arm Sling 3. Dress AFFECTED Side 1st 4. Care for AFFECTED Side 5. Use the UNAFFECTED Side to move AFFECTED Side 6. Look over AFFECTED Side PERIODICALLY.

What can result in Pulmonary Infarction (death of Lung tissue)?

1. Occlusion of a Large or Medium-sized Pulmonary Vessel (>2 mm in diameter) 2. Insufficient Collateral blood flow from the Bronchial Circulation 3. or Preexisting Lung Disease.

Nursing Interventions for a pt. with Cholelithiasis?

1. Place them in a Low Fowler position 2. NG or NPO until Bowel Sounds RETURN - Then incorporated a Soft, Low-Fat, High-Carbohydrate diet 3. Care of the Biliary Drainage System 4. Analgesics- Pain Management 5. Implement Turn, Cough, and Deep Breathing - & Additional Splinting to REDUCE Pain 6. Ambulation 7. Self-Care Education includes: - Activity Restrictions - Incisional Care - Eating Resumption - Follow-Up & Know when to Call

Surgical Therapy for PE

1. Pulmonary Embolectomy for a MASSIVE PE - For Hemodynamically UNSTABLE patients in whom Thrombolytic Therapy is Contraindicated 2. Inferior Vena Cava (IVC) Filter - Prevents migration of Clots in Pulmonary System

Complications of PE

1. Pulmonary Infraction (death of Lung tissue) - Infarction results in Alveolar Necrosis and Hemorrhage. - Occasionally the Necrotic Tissue becomes infected, and an Abscess may develop. - Concomitant Pleural Effusion is frequent. 2. Pulmonary Hypertension - Results from Hypoxemia associated with a Massive or Recurrent Emboli - Right Ventricular Hypertrophy (candidacy for a Ekos Catheter)

Nursing Managements for PE

1. Semi-Fowler's Position 2. Oxygen Therapy 3. Frequent Assessments 4. IV Access 5. Monitor Laboratory Results 6. Emotional Support & Reassurance

Interprofessional Care for a pt. with Stroke?

1. Speech & Language Therapists 2. Occupational Therapists 3. Physical Therapists 4. Social Services (assistance towards a particular group)

What to Assess for a pt. who has a Peptic Ulcer?

1. The SCALE of Pain & METHODS USED to Relieve Pain 2. 72-Hour Diet Diary 3. Lifestyle Habits: - Cigarette Smoking - Alcohol - Caffeine Use 4. Medications - Use of NSAIDs 5. S&S of Anemia or Bleeding 6. Abdominal Assessment - Shape - Size' - Sounds - Palpation - Percussion (striking w/ hand)

Approximately __% of patients with massive PE die within the first hour

10

Hemorrhages (an abnormal discharge of blood externally or internally) have a mortality rate of ___%

10

PT

11 to 13.5 seconds if you're not on blood thinning medicines like Warfarin

How do we care for Dysphagia and Aspirations complications from a Stroke?

1. ASSESS Gag Reflex 2. Let the RN should provide the INITIAL FEEDING 3. Teach pt.s on: - Techniques for Eating - & Sitting UPRIGHT and FLEXING their Head when Swallowing

S&S Manifestations of Acute Gastritis

1. Abdominal Discomfort 2. Headache 3. Lassitude (lack of energy) 4. N/V 5. Hiccupping 6. Signs and symptoms of Bleeding

Nursing Diagnoses of a pt. with Cholelithiasis

1. Acute Pain - NSAIDs and Tylenol - Opioids: Can cause for the Sphincter of Oddi to have spasms, worsening the pain - Demerol is BETTER than Morphine (neurotoxic; not used as much anymore) 2. Impaired Gas Exchange 3. Impaired Skin Integrity 4. Imbalanced Nutrition 5. Deficient Knowledge

- QUESTION: Which assessment data support to the nurse the clients diagnosis of gastric ulcer? A. Presence of blood in the clients stool for the past month. B. Reports of a burning sensation moving like a wave. C. Sharp pain in the upper abdomen after eating a heavy meal. D. Complaints of epigastric pain 30-60 minutes after ingesting food.

D. Complaints of epigastric pain 30-60 minutes after ingesting food. - The client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. In contrast,no client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs 1-3 hours after meals.

- QUESTION: Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? A. Alteration in bowel elimination patterns B. Knowledge deficit in the causes of ulcers C. Inability to cope with changing family roles D. Potential for alteration in gastric emptying

D. Potential for alteration in gastric emptying - Potential for alteration in gastric emptying is caused by edema or scarring associated with an ulcer, which may cause a feeling of "fullness", vomiting of undigested food or abdominal distention

- QUESTION: You're patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected? A. Expressive; Wernicke's area B. Receptive, Broca's area C. Expressive; hippocampus D. Receptive; Wernicke's area

D. Receptive; Wernicke's area

- QUESTION: The client is four (4) hours postoperative open cholecystectomy. Which data would warrant immediate intervention by the nurse? A. Absent bowel sounds in all four (4) quadrants. B. The T-tube with 60 mL of green drainage. C. Urine output of 100 mL in the past three (3) hours. D. Refusal to turn, deep breathe, and cough.

D. Refusal to turn, deep breathe, and cough. - Puts the client at risk for pneumonia. This client needs immediate intervention to pre- vent complications.

- QUESTION: A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patients pain, the nurse should anticipate that it may radiate to what region? A. Left upper chest B. Inguinal region C. Neck or jaw D. Right shoulder

D. Right shoulder - The patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder.

- QUESTION: A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms, and that particular-symptoms that may be exhibited in the elderly patient may include what? A. Fever and pain B. Chills and jaundice C. Nausea and vomiting D. Signs and symptoms of septic shock

D. Signs and symptoms of septic shock - Symptoms of biliary tract disease in the elderly may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, change in mental status, tachycardia, and tachypnea.

- QUESTION: The patient is identified as having modifiable risk factors for stroke. Which of these risk factors will the nurse include in the teaching plan? A. Age B. Gender C. Heredity D. Smoking

D. Smoking

What is the BIGGEST Risk Factor that can lead up to PE?

Deep Vein Thrombosis (DVT)

Alexia

Difficulty reading

FAST Mnemonics as the Warning Signs of a Stroke

F = Facial & Smile Droop A = Arm Drift (1-sided weakness) S = Speech Impairment T = Time to call 911!! & CT Scan IMMEDIATELY

TNF: The most common site for peptic ulcer formation is the Pylorus

False! Duodenum

What factors in Early Treatment can DECREASE the risk of the formation of a Stroke?

Maintaining - Hypertension - Diabetes - and Smoking ... along with having a Healthy Weight & Getting Regular Exercise

Expressive Aphasia (Broca's)

Pts' may eliminate the words "and" and "the" from their language, and speak in short, but meaningful, sentences. They are also able to understand some speech of others

Laparoscopic Cholecystectomy

Surgical removal of the Gallbladder through a very small abdominal incision with the assistance of a Laparoscope

What are nursing considerations we must keep in mind when treating a pt. with Hemorrhages?

Suspect that the Bleeding is ACTIVE so we should always: - HOLD Antihypetensives since an INCREASED BP = INCREASED Bleeding Have IV Access Get Blood Work from the pt! - Determine the Type of Blood and Crossmatching before infusions are given - Monitor Coagulation Studies: PT, PTT - Hematocrit & Hemoglobin (H&H) #

- TNF: The difference between receptive aphasia and expressive aphasia is that in receptive aphasia, the patient cannot understand what you're saying to them, while in expressive aphasia, the patient can receive information, but cannot express themselves.

TRUE

Agonasia

The inability to recognize familiar objects.

How should a pt. modify their intake of Vitamin K while on Warfarin (Coumadin)?

They should maintain a consistent intake

What is the no. 1 Intervention for Gastritis?

To REDUCE ANXIETY within the pt. by: - Using Calm approaches - & Explaining thoroughly of all Procedures and Treatments

Gallbladder

Where Bile is stored and concentrated before it gets released

What are the morality rates associated w/ PE?

- 10% of people die suddenly - More than 30% of people are left untreated - It also has a 5-10% hospital death rates

Nursing Diagnoses of a pt. with Peptic Ulcers

- Acute Pain - Anxiety - Imbalanced Nutrition - Deficient Knowledge

Expected Outcomes for someone with PE

- Adequate Tissue Perfusion and Respiratory Function - Adequate Cardiac Output - Increased Level of Comfort - Prevention of FURTHER Recurrence of PE

Nursing Diagnoses for a pt. with Gastritis?

- Anxiety (we need to reduce this) - Imbalanced Nutrition (avoid irritating foods) - Risk for Fluid Volume Imbalance (teach about having adequate intake of nutrients & fluid balance) - Deficient Knowledge (awareness of dietary management) - Acute Pain (providing relief)

Nonsurgical Removal of Cholelithiasis

- By Instrumentation - Intracorporeal or Extracorporeal Lithotripsy + The procedure to break up stones inside the urinary tract, bile ducts or pancreatic duct with a series of shock waves generated by a machine called a lithotripter. + The shock waves enter the body and are targeted using an X-ray.

Recurrent Pulmonary Embolis' can gradually cause a reduction in the __________ _____ and eventual ___________ ___________

- Capillary Bed - Pulmonary Hypertension

Considerations to PREVENT (prophylaxis) of Stress Ulcers

- Clostridium Difficile (bacteria) - Interstitial Nephritis - Fracture Risk - LOW Mg+ & Ca+ - LONG-TERM Usage of Proton Pump Inhibitors (PPIs) + and H2 Blockers WE NEED TO FEED THE GUT ASAP and STOP when it is no longer indicated

Percutaneous Drain of Cholelithiasis

- DECREASES the Risk of Perforation, Rupture - Requires Local Anesthesia - Can buy time to allow pt. to be treated with Antibiotics and become MORE Stable B4 Surgery - Stopcock can Draw Samples

- TNF: Spatial-perceptual deficits, or difficulty judging distances, is more common in left-brain damage.

- False! It's more common in right-brain damage

What does Hyperbilirubinemia result in?

- Jaundice - Seizures - Brain Damage - Neurologic Dysfunction

What is the Left Cerebral Hemisphere responsible for?

- Language - Mathematics - & Analytic Thinking (think it through)

Treatments for Peptic Ulcers

- Medications (Antibiotics) - Lifestyle Changes - OCCASIONAL Surgeries

Medical Management for Chronic Gastritis?

- Modify Diet - Promote REST - REDUCE Stress - AVOID Alcohol & NSAIDs

PTT (Activated Partial Thromboplastin Time)

- Not on Heparin 30-40 seconds - On heparin aPTT 1.5-2.5 times normal range

The USE of ______ and __ _______ change native pH and INCREASE the Risk of Bacterial Growth and _______-__________ ______________ (___) with Aspiration - particularly in pt's who have ________ ______

- PPIs - H2 Blockers - the Risk of Bacterial Growth - Hospital-Acquired Pneumonia (HAP) with Aspirations - Gastric Tubes

the _________ has the dual function of secreting hormones into blood (___________) and secreting enzymes through ducts (___________)

- Pancreas - Endocrine - Exocrine

Goals of Treatment for PE

- Prevent FURTHER Thrombi - Prevent FURTHER Embolization of the Pulmonary System - Provide Cardiopulmonary Support Supportive Care Variable - Oxygen → Mechanical Ventilation - Pulmonary Toilet - Fluids, Diuretics, Analgesics

Pt. Teaching for PE

- Regarding Long-Term Anticoagulant Therapy - Measures to PREVENT DVT - Importance of Follow-up Exams

Prevention of PE

- Sequential Compression Devices - Early Ambulation - Prophylactic Anticoagulation

What Vital Sign changes are expected with Hemorrhages- an abnormal discharge of blood externally or internally?

- Tachycardia (increased HB/min) - Tachypnea (increased breathing rates) although you might feel sluggish

What is the Right Cerebral Hemisphere responsible for?

- Visual & Spatial Awareness (knowing where your body is in space in relation to objects or other people) - & Proprioception Ex. being able to walk or kick without looking at your feet or being able touch your nose with your eyes closed

What are Risk Factors associated with PE?

1 .Deep Vein Thrombosis (DVT) 2. Immobility or Reduced Mobility 3. Surgery within the last 3 months - Esp. those of the Pelvic and Lower Extremities 4. History of DVT 5. Malignancy 6. Obesity 7. Oral Contraceptives/Hormones - Especially those containing BOTH Progesterone and Estrogen 8. Smoking 9. Heart Failure 10. Pregnancy/Delivery 11. Clotting Disorders 12. Atrial Fibrillation 13. Central Venous Catheters - Cases may be resolved with the removal of the Catheter 14. Fractured Long Bones - LESS COMMON from Fat Emboli

Transient Ischemic Attack (TIA)

A MINOR Stroke- where Neurological function is REGAINED QUICKLY with time but can still be a warning for an IMPENDING Stroke Symptoms include: - Visual disturbances - Diziness - Slurred Speech - Weak Extremity

- QUESTION: Which assessment data indicate to the nurse the client's gastric ulcer has perforated? A. Complaints of sudden, sharp, substernal pain B. Rigid, boardlike abdomen with rebound tenderness C. Frequent, clay-colored, liquid stool D. Complaints of vague abdominal pain in the right upper quadrant

A rigid, boardlike abdomen with rebound tenderness - Is the CLASSIC S&S of Peritonitis, which is a complication of a perforated gastric ulcer

Why would a patient be given Phenytoin Post-Stroke?

A stroke causes damage to the brain tissue that could result in Seizures

How is A-fib & Stroke connected?

A weakened blood vessel may rupture in or near the brain, or diseased arteries may become blocked by a clot or plaque buildup. A-fib occurs because the heart is beating rapidly to compensate and allows blood to pool in the heart. That's when stroke risk increases because it causes clots to form and travel to the brain.

- QUESTION: The nurse evaluates a​ client's understanding of discharge teaching following a laparoscopic cholecystectomy. Which client statement indicates teaching has been​ effective? (Select all that​ apply.) A. ​"I will take my pain medicine on an empty stomach to get the maximum​ benefit." B. "I will be sure to get up and walk every​ hour." C. "I can have some hot chocolate with my​ breakfast." D. ​"I will increase the protein in my diet by drinking whole​ milk."

A, B A. ​"I will take my pain medicine on an empty stomach to get the maximum​ benefit." - Clients should take pain medications with food to diminish irritation to the stomach lining. B. "I will be sure to get up and walk every​ hour." - Clients from a laparoscopic cholecystectomy are often treated in day surgery, but discharge instructions should be similar to those for other clients who have had abdominal surgery. - Therefore, they should be informed to be sure to increase their activity level when they return home. Why it's not the other ones: D. ​"I will increase the protein in my diet by drinking whole​ milk." - The client should follow a diet low in fat and high in​ fat-soluble vitamins.​ - ​Therefore, including hot chocolate and whole milk would not be appropriate food choices.

- QUESTION: A client's stool are light gray in color. The nurse should asses the client for which of the following? Select all that apply. A. Intolerance to fatty foods B. Fever C. Jaundice D. Respiratory distress E. Pain at McBurney's point F. Peptic ulcer disease

A, B, C A. Intolerance to fatty foods B. Fever C. Jaundice - Bile is created in the liver, stored in the gallbladder, and released into the duodenum, giving stool its brown color. - A bile duct obstruction can cause pale-colored stool. Why it's not the other ones: D. Respiratory distress - NOT a Sx E. Pain at McBurney's point - Pain at McBurney's point is associated with appendicitis. F. Peptic ulcer disease - Bleeding ulcers produce black tarry stool.

- QUESTION: A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A. Have the patient refrain from food and fluids after midnight. B. Administer the contrast agent orally 10 to 12 hours before the study. C. Administer the radioactive agent intravenously the evening before the study. D. Encourage the intake of 64 ounces of water 8 hours before the study.

A. Have the patient refrain from food and fluids after midnight. - An ultrasound of the gallbladder is most accurate if the patient fasts overnight, so that the gallbladder is distended. Why it's not the other ones: C. Administer the radioactive agent intravenously the evening before the study. - Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.

- QUESTION: You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as: A. Hemianopia B. Opticopsia C. Alexia D. Dystopic

A. Hemianopia

- QUESTION: The nurse is monitoring a 4 day post-stroke patient. Which of the following will the nurse likely be monitoring? Select all that apply. A. High blood pressure B. Fluid & electrolytes C. Urinary output D. Hypoglycemia

A. High blood pressure B. Fluid & electrolytes C. Urinary output

- QUESTION: Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyperlipidemia C. Alcohol consumption D. Oral contraceptive use

A. Hypertension

- QUESTION: Which issue would the nurse prioritize when planning care for a patient in the acute phase of an ischemic stroke? A. Impaired breathing B. Dysphagia C. Impaired verbal communication D. Muscle atrophy of paralyzed side

A. Impaired breathing

- QUESTION: A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? Select all that apply. A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness

A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception E. Lack of situational awareness

- QUESTION: The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? A. Increase fluid intake to two (2) to three (3) liters a day. B. Eat a low-cholesterol, low-fat diet C. Avoid being around large crowds. D. Receive pneumonia and flu vaccines.

A. Increase fluid intake to two (2) to three (3) liters a day. - Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE. Why it's not the other ones: B. Eat a low-cholesterol, low-fat diet - Pulmonary emboli are not caused by atherosclerosis; therefore, this is not an appropriate discharge instruction for a client with pulmonary embolism. C. Avoid being around large crowds. - Infection does not cause a PE; therefore, this is not an appropriate teaching instruction. D. Receive pneumonia and flu vaccines. - Pneumonia and flu do not cause pulmonary embolism

- QUESTION: A patients abdominal ultrasound indicates Cholelithiasis (gallstones or hardened deposits of digestive fluid that can form in your gallbladder). When the nurse is reviewing the patient's laboratory studies, what finding is most closely associated with this diagnosis? A. Increased bilirubin B. Decreased serum cholesterol C. Increased blood urea nitrogen (BUN) D. Decreased serum alkaline phosphatase level

A. Increased bilirubin - If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. - As a result, bilirubin levels in the blood increase

- QUESTION: The nurse recognizes that the most common type of brain attack (CVA) is related to which of the following? A. Ischemia B. Hemorrhage C. Headache D. Vomiting

A. Ischemia - Found in 80% of cases

- QUESTION: A nurse is using the NIH stroke scale to evaluate a patient. What is true about the NIH stroke scale? SELECT ALL THAT APPLY: A. It evaluates neurological status in stroke patients B. It includes facial palsy, motor of arms or leg limb, and ataxia C. It tests eye opening response, verbal responses, and motor responses and is graded on a scale of 3-15, 3 being the worst and 15 being fully alert D. It must be administered by a physician, OT, or PT. E. A score of 8 or less on the NIH scale indicates coma.

A. It evaluates neurological status in stroke patients B. It includes facial palsy, motor of arms or leg limb, and ataxia

- QUESTION: A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention? A. Laparoscopic cholecystectomy B. Methyl tertiary butyl ether (MTBE) infusion C. Intracorporeal lithotripsy D. Extracorporeal shock wave therapy (ESWL)

A. Laparoscopic cholecystectomy - Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used in the United States. - Cholecystectomy is the preferred treatment.

- QUESTION: A patient has experienced Right-Side Brain Damage. You note the patient is experiencing Neglect Syndrome. What nursing intervention will you include in the patient's plan of care? A. Remind the patient to use and touch both sides of the body daily. B. Offer the patient a soft mechanical diet with honey thick liquids. C. Ask direct questions that require one word responses. D. Offer the bedpan and bedside commode every 2 hours.

A. Remind the patient to use and touch both sides of the body daily. - It is important to watch for neglect syndrome. This tends to happen in right side brain damage. -The patient ignores the left side of the body in this condition. The nurse needs to remind the patient to use and touch both sides of the body daily and that the patient must make a conscious effort to do so.

- QUESTION: A nurse is caring for a client who is 4 hr post-op following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20mL/hr C. T 38.4 D. O2 92%

A. Right shoulder pain

- QUESTION: While assessing a patient who sustained a hemorrhagic stroke, the nurse finds that the patient has decreased gag, cough, and swallowing reflexes. Which complication would the nurse expect in the patient? A. Risk of aspiration B. Unilateral neglect C. Impaired physical mobility D. Decreased intracranial adaptive capacity

A. Risk of aspiration

- QUESTION: The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of the patient's mouth.

A. Safety measures

- QUESTION: During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable? A. Smoking B. Family history C. Advanced age D. Obesity E. Sedentary lifestyle

A. Smoking D. Obesity E. Sedentary lifestyle

- QUESTION: The client is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority? A. Starting a large-bore intravenous (IV) B. Administering intravenous (IV) pain medication C. Preparing equipment for intubation D. Monitoring the client's anxiety level

A. Starting a large-bore intravenous (IV) - A large-bore IV should be placed as requested, so that blood products can be administered.

- QUESTION: The nurse includes which information in the teaching plan about the management of acute ischemic stroke to Mr. Stewart and his family? (Select all that apply.) A. Stroke risk factors B. Need for annual CT scan C. Prevention of aspiration D. Prevention of deep vein thrombosis E. Importance of BP control

A. Stroke risk factors C. Prevention of aspiration D. Prevention of deep vein thrombosis E. Importance of BP control

Pharmacologic Therapy for Chronic Gastritis?

AVOIDING: ‒ Ethyl Alcohol (EtOH) ‒ NSAID's ‒ Aspirin (ASA) USE: ‒ H2 Blockers ‒ Protein Pump Inhibitors (PPI's) ‒ Bismuth Salts

Why would you add additional (+) Blood Pressure medication to a patient's Medical Regimen?

Achieving a lower average BP (HTN) would help PREVENT a Stroke

Emboli

Are mobile clots that generally do not stop moving until they lodge at a narrowed part of the circulatory system.

- QUESTION: A nurse is providing discharge teaching to a client who is post-op following open cholecystectomy with T-tube placement. Which of the following instructions should the nurse include in the teaching ( Select all that apply.) A. Take baths rather than showers B. Clamp T-tube for 1 hr before and after meals C. Keep the drainage system about the level of the abdomen D. Expect to have the T-tube removed 3 days post-op E. Report brown-green drainage to the provider

B, C B. Clamp T-tube for 1 hr before and after meals C. Keep the drainage system about the level of the abdomen

- QUESTION: A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply. A. Administer an antacid hourly until nausea subsides B. Notifying the physician of the client's symptoms. C. Initiating oxygen therapy. D. Reassess the client in an hour.

B, C B. Notifying the physician of the client's symptoms. C. Initiating oxygen therapy. - The appropriate nursing actions currently are for the nurse to monitor the client's vital signs and notify the physician of the client's symptoms.

- QUESTION: A client asks what causes gallstones to form. Which factor should the nurse explain as being present when these stones are​ formed? (Select all that​ apply.) A. Rapid weight gain B. Abnormal bile composition C. Excess cholesterol D. Inflammation of the gallbladder E. Biliary stasis

B, C, D, E B. Abnormal bile composition C. Excess cholesterol D. Inflammation of the gallbladder E. Biliary stasis - Gallstones are formed due to abnormal bile​ composition, an inflammation of the​ gallbladder, biliary​ stasis, and excess cholesterol.

- QUESTION: A nurse is providing a teaching to a patient's spouse about the possibility of thrombolytic therapy for her husband who is is experiencing s/s of a stroke. Which of the following indicates a knowledge deficit by the nurse? SELECT ALL THAT APPLY. A. "The goal of thrombolytic therapy is to lyse & disintegrate the clot and reopen the blood flow." B. "In this procedure, the vessel is opened, the occlusion is manually cleaned out, and the vessel is sewn back up." C. We must first wait for the results of the CT scan or MRI to verify if it is an ischemic stroke or hemorrhagic stroke. tPA can only be used in ischemic stroke patients." D. "tPA must be started within the first 4 hours, ideally within the first 1 hour." E. "It will be important to monitor the patient's vital signs, neuro status, and BP post therapy."

B, D B. "In this procedure, the vessel is opened, the occlusion is manually cleaned out, and the vessel is sewn back up." - This is a Carotid Endartectomy D. "tPA must be started within the first 4 hours, ideally within the first 1 hour." - tPA needs to be administered within the first 3 hours, ideally within the first 1 hour.

- QUESTION: Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.

B, D B. A patient whose blood pressure is 200/110. - Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110 D. A patient who received Heparin 24 hours ago. - If a pt. has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.

- QUESTION: The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply. A. The client has a sore throat. B. The client has a temperature of 100 ° F (37.8 ° C). C. The client appears drowsy following the procedure. D. The client has epigastric pain. E. The client experiences hematemesis.

B, D, E B. The client has a temperature of 100 ° F (37.8 ° C). D. The client has epigastric pain. E. The client experiences hematemesis. - Following a gastroscopy, the nurse should monitor the client for complications, which include perforation and the potential for aspiration. - An elevated temperature, complaints of epigastric pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported promptly. Why it's not the other ones: A. The client has a sore throat. - A sore throat is a common occurrence following a gastroscopy. C. The client appears drowsy following the procedure. - Clients are usually sedated to decrease anxiety and the nurse would anticipate that the client will be drowsy following the procedure.

- QUESTION: A nurse is completing pre-op teaching for a client who is scheduled for a lap chole. Which of the following should be included in the teaching? A. " The scope will be passed through your rectum." B. " You might have shoulder pain after surgery." C. " You will have a Jackson-Pratt drain in place after surgery." D. " You should limit how often you walk for 1 to 2 weeks."

B. " You might have shoulder pain after surgery."

- QUESTION: The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching was effective? A. "I will take my lipid-lowering medicine at the same time each night." B. "I may experience some discomfort when I eat a high-fat meal." C. "I need someone to stay with me for about a week after surgery." D. "I should not splint my incision when I deep breathe and cough."

B. "I may experience some discomfort when I eat a high-fat meal."

- QUESTION: When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply. A. Epigastric pain at night. B. Relief of epigastric pain after eating. C. Vomiting. D. Weight loss. E. Melena (blood in stools)

C, D, E C. Vomiting. - COMMON D. Weight loss. - COMMON E. Melena (blood in stools) - The client may also have blood in the stools (melena) from gastric bleeding. Why its not the other ones: A. Epigastric pain at night. - Clients with a gastric ulcer are most likely to complain of a burning epigastric pain that occurs about 1 hour after eating. B. Relief of epigastric pain after eating. - Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely to complain about pain that occurs during the night and is frequently relieved by eating.

- QUESTION: A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient asks, "What is the most important thing for me to remember?" Which is an appropriate response by the nurse? A. "Know your family history." B. "Keep a list of your medications." C. "Be alert for sudden weakness or numbness." D. "Call 911 if you notice a gradual onset of paralysis or confusion."

C. "Be alert for sudden weakness or numbness." - Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance the key word is sudden. - Family history and past medical history can be indicators for risk, but they are not warning signs of stroke.

- QUESTION: An experienced nurse is teaching a novice nurse about interventions for a patient with a stroke. Which statement by the novice nurse indicates a need for further teaching? A. "I should maintain a calm and relaxing environment." B. "I should refrain from scolding the patient during an emotional outburst." C. "I should refrain from distracting the patient during a sudden emotional outburst." D. "I should educate the patient and the family about emotional outbursts after a stroke."

C. "I should refrain from distracting the patient during a sudden emotional outburst."

- QUESTION: The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A. Denial B. Fear C. Depression D. Disassociation

C. Depression - Depression is a common and serious problem in the patient who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the patient with a loss of independence. The nurse needs to encourage the patient to verbalize feelings to assess the effect of the stroke on self-esteem. Why it's not the other ones: - Denial, fear, and disassociation are not the most common patient response to a change in body image, although each can occur in some patients.

- QUESTION: A nurse in a clinic is reviewing the lab reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. Serum amylase 80 units/L B. WBC 9.000 C. Direct bilirubin 2.1 mg/dL D. Alkaline phosphatase 25 units/L

C. Direct bilirubin 2.1 mg/dL

Perforation (hole) and Penetration (into deeper tissues) S&S when associating w/ Gastric contents

Contents can SPILL into: - Peritoneal Space (the tissue that lines the abdominal wall and pelvic cavity) - & onto OTHER Organs Characterized by having SEVERE Upper Abdominal Pain & a Board-like Abdomen Irritation of the Phrenic Nerve (a nerve that runs from the spinal cord to the diaphragm- helps it contract & relax during breathing) - Can result to Shoulder Pain Sepsis- chemicals getting released in the bloodstream in response to the inflammation cascade needed to fight off Peritonitis (inflammation of the Stomach lining), especially in pt's who have a Gastric Tube

Some Nursing Interventions should be done when a patient is started on Oral Medication after a Stroke.

Crush all the Medications and place it in Pudding OR Ask the pt. to swallow the Medication w/ Water

- QUESTION: The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? A. Monitor the client's arterial blood gases. B. Assess skin color and temperature. C. Check the client for signs of bleeding. D. Keep the client in the Trendelenburg position.

B. Assess skin color and temperature. - These assessment data monitor tissue perfusions, which evaluates for decreased cardiac output. Why it's not the other ones: A. Monitor the client's arterial blood gases. - Arterial blood gases would be included in the client problem "impaired gas exchange." C. Check the client for signs of bleeding. - This would be appropriate for the client problem "high risk for bleeding." D. Keep the client in the Trendelenburg position. - The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing.

- QUESTION: You're assisting a patient who has Right-Side Hemiparesis and Dysphagia with eating. It is very important to: A. Keep the head of bed less than 30'. B. Check for pouching of food in the right cheek. C. Prevent aspiration by thinning the liquids. D. Have the patient extend the neck upward away from the chest while eating.

B. Check for pouching of food in the right cheek. - Because the patient has weakness on the right side and dysphagia the nurse should regularly check for pouching of food in the right cheek. - Pouching of food in the cheek can lead to aspiration or choking. The HOB should be >30', liquids thickened per MD order, and the patient should tuck in the chin to the chest while swallowing.

- QUESTION: A patient has Right-Side Brain Damage from a Stroke. Select all the signs and symptoms that occur with this type of Stroke: A. Right side hemiplegia B. Confusion on date, time, and place C. Aphasia D. Unilateral neglect E. Aware of limitations F. Impulsive G. Short attention span H. Agraphia

B. Confusion on date, time, and place D. Unilateral neglect F. Impulsive G. Short attention span

- QUESTION: After a lumbar puncture, which nursing action should the nurse implement? A. Remind the client not to move legs after the procedure B. Monitor the puncture site for CSF leakage C. Have the client empty his bladder D. Limit the client's fluid intake

B. Monitor the puncture site for CSF leakage - It is most important to monitor for CSF leak and Hematoma formation. Why it's not the other ones: A. Remind the client not to move legs after the procedure - Client is kept flat afterward for 4 to 24 hours but can move the legs. C. Have the client empty his bladder - Client should empty bladder before the procedure; NOT necessary afterward. D. Limit the client's fluid intake - Fluids are increased, NOT limited.

- QUESTION: A client with acute cholecystitis is experiencing jaundice. Which should the nurse consider as the reason for the​ jaundice? A. Viral infection of the gallbladder B. Obstruction of the cystic duct by a gallstone C. Accumulation of bile in the hepatic duct D. Accumulation of fat in the wall of the gallbladder

B. Obstruction of the cystic duct by a gallstone - When acute cholecystitis is accompanied by​ jaundice, partial common duct obstruction is​ likely, which is usually due to stones or inflammation.

- QUESTION: The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? A. Hemiparesis of the client's left arm and apraxia. B. Paralysis of the right side of the body and ataxia. C. Homonymous hemianopsia and diplopia. D. Impulsive behavior and hostility toward family.

B. Paralysis of the right side of the body and ataxia. - The most common motor dysfunction of a CVA is paralysis of one side of the body, HEMIPLEGIA; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement. Why it's not the other ones: A. Hemiparesis of the client's left arm and apraxia. - A left-sided CVA will result in right-sided motor deficits; hemiparesis is weakness of one half of the body, not just the upper extremity. Apraxia, the inability to perform a previously learned task, is a communication loss, not a motor loss. C. Homonymous hemianopsia and diplopia. - Homonymous hemianopsia (loss of half of the visual field of each eye) and diplopia (double vision) are visual field deficits that a client with a CVA may experience, but they are not motor losses. D. Impulsive behavior and hostility toward family. - Personality disorders occur in clients with a right-sided CVA and are cognitive deficits; hostility is an emotional deficit.

- QUESTION: A nurse is caring for a client who has Left-Homonymous Hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body B. Place the bedside table on the right side of her bed C. Orient the client to the food on her plate using the clock method D. Place the wheelchair on the clients left side

B. Place the bedside table on the right side of her bed

- QUESTION: The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? A. Administer oxygen ten (10) L via nasal cannula. B. Place the client in a high Fowler's position. C. Obtain a STAT pulse oximeter reading. D. Auscultate the client's lung sounds.

B. Place the client in a high Fowler's position. - Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. Why it's not the other ones: A. Administer oxygen ten (10) L via nasal cannula. - The client needs oxygen, but the nurse can do something that will help the client before applying oxygen. C. Obtain a STAT pulse oximeter reading. - This is needed, but it is not the first intervention. D. Auscultate the client's lung sounds. - Assessing the client is indicated, but it is not the first intervention in this situation.

- QUESTION: Which of the following would induce a negative impact on ICP? Select all that apply. A. BP of 110/79 B. Pneumothorax C. Intra-abdominal hypertension D. Respiratory acidosis E. Temperature of 98.6 F. Rapid change in position

B. Pneumothorax C. Intra-abdominal hypertension D. Respiratory acidosis F. Rapid change in position

- QUESTION: The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? A. Potential for injury. B. Powerlessness. C. Disturbed thought processes. D. Sexual dysfunction.

B. Powerlessness. - Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, with, in turn, causes the client to have a lack of control and feel powerless. Why it's not the other ones: A. Potential for injury. - Potential for injury is a physiological problem, not a psychosocial problem. C. Disturbed thought processes. - A disturbance in thought processes is a cognitive problem; with expressive aphasia the client's thought processes are intact. D. Sexual dysfunction. - Sexual dysfunction can have a psychosocial component or a physical component, but it is not related to expressive aphasia.

- QUESTION: What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

B. Pupil size and pupillary response - It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. An echocardiogram is not needed for the client with a thrombotic stroke.

- QUESTION: Which of the following visual changes should the nurse expect the older adult client to report? A. Increased tear secretion B. Reduced ability to differentiate blue and green colors C. Reduced vision during daylight hours D. Difficulty focusing on objects in the distance

B. Reduced ability to differentiate blue and green colors - Older adults report reduced ability to discriminate between blue and green colors. Why it's not the other ones: A. Increased tear secretion - They experience less tear secretion C. Reduced vision during daylight hours - Their vision is reduced at night. D. Difficulty focusing on objects in the distance - They have difficulty - focusing on near objects, not far objects.

- QUESTION: You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is: A. No stroke symptoms B. Severe stroke symptoms C. Mild stroke symptoms D. Moderate stroke symptoms

B. Severe stroke symptoms Scores on the NIH stroke scale range from 0 to 42 - 0 indicating NO Stroke symptoms - 21-42 indicating SEVERE Stroke symptoms

- QUESTION: A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a sick gallbladder. What rationale would underlie the nurses response? A. Surgery is delayed until the patient can eat a regular diet without vomiting. B. Surgery is delayed until the acute symptoms subside. C. The patient requires aggressive nutritional support prior to surgery. D. Time is needed to determine whether a laparoscopic procedure can be used.

B. Surgery is delayed until the acute symptoms subside. - Unless the patients condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). - There is no need to delay surgery pending an improvement in nutritional status, and deciding on a laparoscopic approach is not a lengthy process

- QUESTION: The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? A. Providing frequent small meals rather than three larger meals B. Teaching the patient to perform deep breathing and coughing exercises C. Keeping a urinary catheter in situ for the full duration of recovery D. Limiting intake of insoluble fiber

B. Teaching the patient to perform deep breathing and coughing exercises - Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. Why its not the other ones: - No particular need exists to provide frequent meals and normally fiber intake should not be restricted. - Urinary catheters should be discontinued as soon as possible

- QUESTION: Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease? A. The clients pain is controlled with the use of NSAIDs B. The client maintains lifestyle modifications C. The client has no signs and symptoms of hemoptysis D. The client take s antacids with each meal

B. The client maintains lifestyle modifications - Maintaining lifestyle changes such as following an appropriate diet and reducing stress indicate the client is complying with the medical regimen. Compliance is the goal of treatment to prevent complications.

- QUESTION: A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Current medications. B. Time of onset of current stroke. C. Complete physical and history. D. Upcoming surgical procedures.

B. Time of onset of current stroke. - The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. A complete history is not possible in emergency care. Upcoming surgical procedures will need to be delay if t-PA is administered. Current medications are relevant, but onset of current stroke takes priority

- QUESTION: A patient with chronic cholecystitis reports pruritus, clay-colored stools, and voiding dark, frothy urine. Which laboratory analysis is a priority in the nurse's assessment of this patient? A. Lipase level B. Total bilirubin C. Liver function tests D. White blood cell count

B. Total bilirubin - Excess circulating bilirubin present with chronic cholecystitis is responsible for pruritus and changes in stool and urine color. - Cholecystitis is associated with several risks including hepatic disease, pancreatitis, and peritonitis. - Monitoring liver function, pancreatic laboratory values, and white blood cell counts is also very important.

- QUESTION: Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? A. History of side effects experienced from all medications B. Use of non steroidal anti inflammatory drugs (NSAIDs) C. Any known allergies to drugs and environmental factors D. Medical histories of at lease 3 generations

B. Use of non steroidal anti inflammatory drugs (NSAIDs) - The usage of these places the client at risk for peptic ulcer and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid.

- QUESTION: Which of the following risk factors in the client's history is most likely to increase the potential in developing a CVA? Select all that apply. A. Age 50 or older B. Use of oral contraceptives for the past 10 years C. Presence of atherosclerosis D. Consumption of one beer per day E. Overweight by 50 pounds F. Of Caucasian race

B. Use of oral contraceptives for the past 10 years C. Presence of atherosclerosis E. Overweight by 50 pounds

Pre-Hepatic

BEFORE the Liver How RBCs are: - Hemolyzed: The pathological process of breakdown of red blood cells in blood - Destroyed - and Excreted

When RBCs break down, a substance called ____________ is formed

Bilirubin

- QUESTION: The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. "Take the person to the hospital if a headache lasts for more than 24 hours." B. "Stroke symptoms usually start when the person is awake and physically active." C. "A person with a transient ischemic attack has mild symptoms that will go away." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

- QUESTION: The RN is teaching a student nurse about the proper way to communicate with a patient who has aphasia due to a stroke. Which statement made by the student nurse indicates a need for further learning? A. "I will speak in a normal tone with the patient." B. "I will frame questions in a yes-or-no format." C. "I will not pretend to understand the patient if I do not." D. "I will try to force communication with the patient if the patient is upset."

D. "I will try to force communication with the patient if the patient is upset."

- QUESTION: A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which of the following? A. Impending brain death B. Decreasing intracranial pressure C. Stabilization of the patient's condition D. Increased intracranial pressure

D. Increased intracranial pressure - Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). - This is an emergency situation that requires intervention as the patient's condition is becoming more unstable & notification of the physician Why it's not the other ones: A. Impending brain death - Brain death is diagnosed by lack of brain waves and inability to maintain vital function.

- QUESTION: The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? A. Administer oral anticoagulants B. Assess the client's bowel sounds C. Prepare the client for a thoracentesis D. Institute and maintain bed rest

D. Institute and maintain bed rest - Bed rest reduces metabolic demands and tissue needs for oxygen. Why it's not the other ones: A. Administer oral anticoagulants - The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. B. Assess the client's bowel sounds - The client's respiratory system will be assessed, not the gastrointestinal system. C. Prepare the client for a thoracentesis - A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE.

- QUESTION: A pt has suffered a stroke. Which neurologic factor will the nurse assess and record? A. Speech B. Mobility C. Respiratory function D. Level of consciousness

D. Level of consciousness

- QUESTION: During the acute phase of stroke management, which nursing intervention is most important to decrease risk of aspiration? A. Placing an oral-pharyngeal airway at the bedside B. Elevating head of bed 30 degrees C. Placing suction equipment at the bedside D. Maintaining NPO status

D. Maintaining NPO status

- QUESTION: A patient presents in the ER with facial droop, one arm drift, slurred speech, and disorientation. After O2 has been administered and the CT scan comes back indicating ischemic stroke, which therapy should the nurse anticipate administering? A. Antiplatelet therapy B. Anticoagulant therapy C. 325 mg of Aspirin (chewed) D. Thrombolytic therapy

D. Thrombolytic therapy - This is tPA clot buster and dissolves a clot at an ACUTE ONSET of clinical signs of stroke. - Heparin Infusion?? Why it's not the other ones: A. Antiplatelet therapy - Not recommended during ACUTE ONSET of stroke b/c of risk of intracranial hemorrhage B. Anticoagulant therapy - Not recommended during ACUTE ONSET of stroke b/c of risk of intracranial hemorrhage C. 325 mg of Aspirin (chewed) - Not recommended during ACUTE ONSET of stroke b/c of risk of intracranial hemorrhage

- QUESTION: Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension

D. Use simple, short sentences accompanied by visual cues to enhance comprehension

- QUESTION: The nurse is planning an educational program about development and prevention of gallstones for a community group. Which population should the nurse identify to be most at risk for developing​ gallstones? A. Young adult Asian American women B. Middle-aged Caucasian American men C. African American clients D. Women over the age of 40

D. Women over the age of 40 - Genetic considerations and risk factors vary depending on the nature of the inflammatory disorder. - Female​ sex, being over the age of​ 40, American​ Indians, and Mexican Americans are most at risk for gallstones. - Family history is also associated with increased risk.

Agraphia

Difficulty writing

Bile

Digestive fluid produced in your Liver and stored in Gallbladder

Erosive Gastritis

Disruption of the Mucosal barrier- subjecting it to DIGESTIVE juices which then leads to thinning of the layer that is caused by Inflammation & Edema Can also lead to Scarring w/ Stenosis (narrowing) and Alterations in Nutritional Absorption

What complications comes with a Stroke?

Dysphagia and Aspirations

- QUESTION: Choose the BEST answer. Anything that causes _____ can cause ICP. A. Infection B. Edema C. Uremia D. Hemorrhage E. Inflammation

E. Inflammation

What are the characteristics of vomit that is caused by H. Pylori?

Either being BRIGHT RED or Looking like Coffee Grounds

- TNF: Cholecystitis is when a patient has Calculi (stone) in the Gallbladder

False Cholecystitis is inflammation of the gallbladder. It's Cholelithiasis

- TNF: Usually when a patient experiences stroke damage affecting only one side of the hemisphere, the prognosis for stabilizing urinary and defecating functionality is still bad.

False! If only one side is damaged, the prognosis is good

How often are incidences of PE?

For people aged between 60-70, there are typically 100,000 of cases

The _____________ consist of Bile

Galbladder

Planning Care for a pt. with Cholelithiasis?

Goals may include - Relief of Pain - Adequate Ventilation - Having Intact Skin - & IMPROVED Biliary Drainage Recommended Optimal Nutritional Intake Absence of Complications Pt should Understands Self-Care Routines

Gallstones

Hardened deposits of digestive fluid that can form in your Gallbladder

Lumbar Puncture (LP) or "Spinal Tap"

Inserting a Needle into the Lumbar region of the Spine in order to collect Blood in the Cerebral Spinal Fluid (fluid around the Brain and Spinal Cord) Can indicate signs of a Hemorrhagic Stroke (bleeding around the Brain)

Spiral (Helical) CT Scan/Angiography

Is the MOST FREQUENT used test to Diagnose PE - An IV Injection of Contrast media is required to view the Pulmonary Blood Vessels. - The scanner continuously rotates around the pt. while obtaining views (slices) of the pulmonary vasculature - it allows for all anatomic regions of the Lungs - Then they use Computer Software to reconstruct the data to provide a 3-dimensional picture to assist visualize the Emboli

Pulmonary Embolisms

Is the blockage of one or more pulmonary arteries by a thrombus, fat or air embolus, or tumor tissue. There is still active gas exchange in the lungs but there is no blood supply to the ventilated alveoli

What is Treatment of an Ischemic Stroke? (Thrombus or Embolic)

It can be REVERSED with Fibrinolytic Therapy- tPA (breakdown of clots) using Alteplase [Reteplase Recombinant] It has to be given WITHIN 3 to 4.5 hours of the INITIAL symptom manifestations (unless contraindicated) Medications ENDS in -ase

Esophagogastroduodenoscopy (EGD)

It is an INVASIVE Diagnostic Test that visualizes the Esophagus, Stomach, and Duodenum to ACCURATELY diagnose an Ulcer & Evaluate the effectiveness of the client's treatment.

What is the DISADVANATAGE of a D-Dimer test?

It's NEITHER Specific (many other conditions causes elevation) nor SENSITIVE as up to 50% of patients with small Pulmonary Emboli have normal results Patient's with suspected PE and an Elevated results from this test but still have NORMAL Venous Ultrasounds may need a Spiral CT or a Lung Scan

Thrombotic Stroke (type of Ischemic)

Occurs SECONDARY to the development of a Blood Clot on an Atherosclerotic Plaque in a Cerebral Artery (Cerebrum). - That then causes the Artery to shut off, causing Ischemia (deficient blood supply) distal to the Occlusion site. Symptoms occur over a period of several hours-days

What Medication could cause a 44-year-old Woman to have a Stroke?

Oral Contraceptives or Birth Control pills contain HIGH levels of Progestin and Estrogen

____ ranks 3rd in CV disease & death

PE

What is the Prognosis (outcome) of a Hemorrhagic Stroke?

POOR Because of the amount of Ischemia (deficient supply of blood) & increased Intracranial Pressure (ICP) caused by the expanding collection of blood

What is the no. 1 Intervention for Acute Gastritis?

PROMOTE Optimal Nutrition by: - NPO then progressing to > Clear Liquids GRADUALLY Evaluate and Report Sx the pt. might be experiencing & DISCOURAGING Irritating consumption of: - Caffeinated Beverages - Alcohol - Cigarette Smoking + Give referrals for the potential for Alcohol Counseling and Smoking Cessation

What is the no. 2 Intervention for Gastritis?

PROMOTING Fluid Balance by Monitoring I&O for: 1. Signs of Dehydration + 3L/day when NPO 2. Electrolyte Imbalance + IV Fluids at 125 cc's/hr + Dextrose Source 3. Hemorrhages (an abnormal discharge of blood) USE Diet and Medications needed to give relief for Pain

Assessment of a pt. with Cholelithiasis

Patient History Knowledge and Education Needs + Concern for Peritonitis Respiratory Status & Risk Factors for Respiratory Complications POST-Operative + OOB and Ambulating + Respiratory Toileting Nutritional Status + NG Until Bowel Functions Return + Gradually increase Diet when Signs of Bowel Functions RETURNING occurs Monitor for Potential Bleeding GI Symptoms occurring AFTER Laparoscopic Surgery - Assess for Loss of Appetite - Vomiting - Pain - Distention - Fever—potential an Infection or Disruption of GI tract

Cholelithiasis Pathysiology consists of what? (2)

Pigment Stones - Precipitate of Unconjugated Pigments (separate out as a solid) - MORE COMMON in Liver Disease & BiliaryTree Infections Cholesterol Stones - Found in 75% of Cases - Decreased Bile Acid - Increased Cholesterol - MORE COMMON in Women x2-3 than Men, people aging Older than > 40, Multiparous (more than 1 child), and is Obese

Hepatic

Relating to the Liver Disease: - Cirrhosis: A late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism - Hepatitis: Inflammation of the Liver

What can result in Pulmonary Hypertension?

Results from Hypoxemia or from the involvement of more than 50% of the area of the Normal Pulmonary Bed if this is a single occurrence of an Embolus, it doesn't typically result in this

Clinical Manifestations of Cholelithiasis

Results from an Inflammed Gallbladder or Obstruction of the Gallbladder Duct, then resulting in Swelling, Inflammation & even Gangrenous and Rupture ultimately leading to Peritonitis 1. None or Minimal Symptoms - Acute or Chronic 2. Pain 3. Biliary Colic 4. Jaundice - Hyperbilirubinemia - Pruritis 5. Changes in Urine or Stool Color 6. Vitamin Deficiency, Fat Soluble - Viitamins A, D, E, and K

Characteristics of Clinical Manifestations of PE

S&S in PE are VARIED and NONSPECIFIC, making diagnosis difficult. Depends on Size & Extent of the Case - Small Emboli's' may go UNDETECTED or produce Vague, Transient symptoms. Symptoms may begin SLOWLY or SUDDENLY

Hemorrhagic Stroke

SECONDARY to... - a Ruptured Artery in the Brain - or an Aneurysm (an abnormal bulge or ballooning in the wall of a blood vessel) that causes Bleeding The Prognosis

Bleeding can stop spontaneously but we should simultaneously treat ______ as it will result in ongoing damage to the pt.

Shock

Cushing's Triad

Signs of Increased Intracranial Pressure (ICP): 1. Hypertension 2. Bradycardia 3. Irregular Respirations

Peptic Ulcers (Duodenum)

The Erosion of a Mucous Membrane forms an Excavation in the Stomach, Pylorus, Duodenum, or Esophagus That is associated with the Infection of H. Pylori that can be obtained through the consumption of Food & Water

What causes for HIGH levels of Bilirubin?

When it's ALREADY MADE but can't REACH it's destination 1. Increased Production 2. Reduced Reuptake by Hepatic Cells 3. Disrupted Conjugation (combine with Protein) - INCREASE in Unconjugated Bilirubin 4. Disrupted secretion of Bilirubin into Bile Ducts 5. Duct Obstruction (FAILING to reach the Small Intestine) - INCREASE in Conjugated Bilirubin

Stroke (Cerebrovascular Accidents- CVA)

When the Brain LACKS Oxygen resulting in Long-term damage Typically caused by a disruption in the cerebral blood flow, secondary to ischemia, hemorrhage, brain attack, or embolism that happens

Receptive Aphasia (Wernicke's)

When the pt. is able to speak well and use long sentences, but what they say may not make sense.

Unconjugated Bilirubin (indirect)

When there are HIGH Levels of Bilirubin that is NOT deposited into the Small Intestine to be recirculated Can indicate Obstruction

Zollinger-Ellison Syndrome

When there is EXCESSIVE Gastrin-Secretion, causing for a Tumor in the Pancreas & Duodenum Associated with Peptic Ulcers

Chronic Gastritis

When there is prolonged inflammation and exposure to the bacteria Helicobacter Pylori that causes for benign or malignant ulcers

- QUESTION: Which nursing assessment data support that the client has experienced a pulmonary embolism? A. Calf pain with dorsiflexion of the foot - This is a sign of a deep vein thrombosis, which is a precursor to a PE, but it is not a sign of a pulmonary embolism. B. Sudden onset of chest pain and dyspnea - The most common signs of a PE are sudden onset of chest pain when taking a deep breath and shortness of breath. C. Left-sided chest pain and diaphoresis - These are signs of a myocardial infarction. D. Bilateral crackles and low-grade fever - These could be signs of pneumonia or other pulmonary complications, but not specifically a PE.

Why it's not the other ones:

Where to PE commonly affect the Lungs?

in the Lower Lobes

Where does Bile get made?

the Liver

Medical Management for Acute Gastritis?

‒ REFRAIN from Alcohol and Food until Symptoms SUBSIDE ‒ If due to STRONG Acid or Alkali Treatment to NEUTRALIZE the Agent we need to: + AVOID Emetics & Lavage due to the danger of Perforation and Damage to the Esophagus ‒ Supportive Therapy

How is Gastritis diagnosed?

- UGI X-ray - Endoscopy: Esophagastroduodenoscopy (EGD) - & Biopsy to check for Helicobacter Pylori

Ekos Catheter for PE

Uses an Ultrasound to deliver very LOW doses of a Clot-Dissolving Drug directly into the Clot through a Catheter A Cardiologist can place this after evaluating the criteria: - O2 Needs - Right Ventricle? (RV) Dilation - Hemodynamic Stability - Bleeding Risk

What is the antidote for Warfarin (Coumadin)?

Vitamin K+

What Medication is used for Afib in connection with Strokes?

Warfarin (Coumadin)

INR

- Not on warfarin: < 1 (0.8-1) - On warfarin: 2-3

Manifestations associated with Peptic Ulcers

1. a DULL Gnawing Pain 2. Burning in the Mid-Epigastrium 3. Heartburn 4. Vomiting

D-Dimer Test

A Laboratory Test that measures the amount of Cross-linked Fibrin fragments that result of Clot Degradation and are RARELY found in Healthy Individuals

Post-Hepatic

AFTER the Liver When there is obstruction of the Common Bile Duct (CBD), Pancreatic Duct or Hepatic Duct

- QUESTION: The nurse is providing dietary teaching to a client with a history of gallstones. Which diet should the nurse​ recommend? (Select all that​ apply.) A. High protein B. Low sodium C. Low fat D. High vitamin C E. High carbohydrate

A, C A. High protein - A​ low-carbohydrate, low-fat,​ high-protein diet reduces symptoms of cholecystitis. A. High protein - A​ low-carbohydrate, low-fat,​ high-protein diet reduces symptoms of cholecystitis.

- QUESTION: The nurse finds that the patient is unable to recognize familiar objects after a stroke. Which term would the nurse chart in the patient's medical record? A. Alexia B. Agnosia C. Aphasia D. Agraphia

B. Agnosia

- QUESTION: Which information would the nurse include in a teaching plan about the onset of embolic stroke? A. Embolic stroke rarely recurs. B. Embolic stroke occurs rapidly. C. Embolic stroke renders the patient unconscious. D. It is common to have a warning sign with an embolic stroke.

B. Embolic stroke occurs rapidly.

What Lab Test will be elevated in presence of a Clot?

D-dimer

- QUESTION: Which expected outcome would be appropriate for the client scheduled to have a cholecystectomy? A. Decreased pain management. B. Ambulate first day postoperative. C. No break in skin integrity. D. Knowledge of postoperative care.

D. Knowledge of postoperative care.

- QUESTION: A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? Select all that apply. A. Have suction equipment available for use B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth D. Assign a UAP to feed the client slowly E. Teach the client to swallow with her neck flexed

A. Have suction equipment available for use B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth E. Teach the client to swallow with her neck flexed

- QUESTION: A client is recovering from a laparoscopic cholecystectomy. Which nursing action should the nurse use to reduce this​ client's risk of​ infection? (Select all that​ apply.) A. Monitor vital​ signs, including​ temperature, every 4 hours. B. Administer antibiotics as prescribed. C. Coach to take deep breaths every 1dash2 hours while awake. D. Assess the abdomen every 4 hours. E. Place in Fowler position.

A, B, C, D A. Monitor vital​ signs, including​ temperature, every 4 hours. - To reduce the risk of​ infection, the nurse will monitor vital​ signs, including​ temperature, every 4​ hours, because changes may be the first sign of infection. B. Administer antibiotics as prescribed. - Antibiotics are used to control infection. C. Coach to take deep breaths every 1dash2 hours while awake. - Turning, breathing, and incentive spirometry help prevent postsurgical atelectasis and subsequent pneumonia. D. Assess the abdomen every 4 hours. - Assessment of the abdomen can reveal signs of a surgical wound infection Why it's not the other ones: E. Place in Fowler position. - Fowler position may enhance the​ client's comfort but will have no effect on postsurgical infection.

- QUESTION: A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? Select all that apply. A. Obtain adequate rest to reduce stimulation. B. Eat small, frequent meals throughout the day. C. Take all medications on time as ordered. D. Sit up for one hour when awakened at night. E. Stay away from crowded areas.

A, B, C, D A. Obtain adequate rest to reduce stimulation. - The nurse should encourage the client to reduce stimulation that may enhance gastric secretion. B. Eat small, frequent meals throughout the day. - The nurse can also advise the client to utilize health practices that will prevent recurrences of ulcer pain, such as avoiding fatigue and elimination of smoking. - Eating small, frequent meals helps to prevent gastric distention if not actively bleeding and decreases distension and release of gastrin. C. Take all medications on time as ordered. - Medications should be administered promptly to maintain optimum levels. D. Sit up for one hour when awakened at night. - After awakening during the night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an hour after eating.

- QUESTION: The nurse prepares discharge teaching for a client recovering from a cholecystectomy. Which topic should the nurse include in this​ teaching? (Select all that​ apply.) A. Surgical incision care B. Manifestations of postoperative complications C. Pain control measures D. Activity level E. High-fat diet

A, B, C, D A. Surgical incision care B. Manifestations of postoperative complications C. Pain control measures D. Activity level - The nurse will instruct the client on the prescribed activity​ level, manifestations of postoperative complications that must be reported to the healthcare​ provider, pain control​ measures, and surgical incision care.

- QUESTION: A client with acute cholecystitis is experiencing nausea and vomiting. Which nursing action should the nurse use to address this​ client's nutritional​ status? (Select all that​ apply.) A. Counseling regarding​ low-fat menu choices B. Administering antiemetics as prescribed C. Assessing height and weight D. Advising to consume a​ low-protein diet E. Reviewing serum electrolytes

A, B, C, E A. Counseling regarding​ low-fat menu choices B. Administering antiemetics as prescribed C. Assessing height and weight E. Reviewing serum electrolytes - Assessing height and​ weight, reviewing serum​ electrolytes, counseling on​ low-fat menu​ choices, and administering antiemetics as prescribed are all nursing actions that address the​ client's nutritional status.

- QUESTION: The nurse is assigned to care for a client with complete Right-Sided Hemiparesis from a Stroke (brain attack).Which characteristics are associated with this condition? Select all that apply. A. The client is aphasic (unable to communicate properly with others) B. The client has weakness on the right side of the body. C. The client has complete bilateral paralysis of the arms and legs. D. The client has weakness on the right side of the face and tongue E. The client has lost the abilityto move the right arm but is able to walk independently. F. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance

A, B, D A. The client is aphasic (unable to communicate properly with others) - Unable to discriminate words and letters B. The client has weakness on the right side of the body. - Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. - They are generally very cautious and get anxious when attempting a new task D. The client has weakness on the right side of the face and tongue - The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

- QUESTION: A​ middle-aged female client who is obese has been experiencing right upper quadrant abdominal pain for the past several hours. For which risk factors of gallstone development should the nurse assess this client during the health​ history? (Select all that​ apply.) A. Excess cholesterol B. Inflammation of the gallbladder C. Biliary colic D. Biliary stasis E. Abnormal bile composition

A, B, D, E A. Excess cholesterol - Excess cholesterol in bile is associated with​ obesity, a​ high-calorie and​ high-cholesterol diet, and drugs that lower serum cholesterol levels. B. Inflammation of the gallbladder D. Biliary stasis E. Abnormal bile composition Why it's not the other ones: C. Biliary colic - Biliary colic is the pain described in cholelithiasis. This pain is localized to the epigastrium and the right upper quadrant of the abdomen. - Biliary colic does not lead to the formation of gallstones.

- QUESTION: A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching? Select all that apply. A. How to use a sign board B. Transfer techniques C. Information about impulse control D. Time adjustment to complete activities E. Safety precautions for transferring

A, B, D, E A. How to use a sign board - The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage B. Transfer techniques - Transfer techniques would apply regardless of the side involved. D. Time adjustment to complete activities - The patient also might display overcautious behavior and might be slow to respond or complete activities E. Safety precautions for transferring Why it's not the other ones: C. Information about impulse control - Impulse control problems can arise with right-sided involvement.

- QUESTION: The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. A. Position the client to prevent shoulder adduction. B. Turn and reposition the client every shift. C. Encourage the client to move the affected side. D. Perform quadriceps exercises three (3) times a day. E. Instruct the client to hold the fingers in a fist.

A, C A. Position the client to prevent shoulder adduction. - Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. C. Encourage the client to move the affected side. - The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible. Why it's not the other ones: B. Turn and reposition the client every shift. - The client should be repositioned at least every two (2) hours to prevent contractures, pneumonia, skin breakdown, and other complications of immobility. D. Perform quadriceps exercises three (3) times a day. - These exercises are recommended, but they must be done at least five (5) times a day for ten (10) minutes to help strengthen the muscles for walking. E. Instruct the client to hold the fingers in a fist. - The fingers are positioned so that they are barely flexed to help prevent contracture of the hand.

- QUESTION: Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. A. Keep protamine sulfate readily available. B. Avoid applying pressure to venipuncture sites. C. Assess for overt and covert signs of bleeding. D. Avoid invasive procedures and injections. E. Administer stool softeners as ordered.

A, C, D, E A. Keep protamine sulfate readily available. - Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant. C. Assess for overt and covert signs of bleeding. - Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. D. Avoid invasive procedures and injections. - Invasive procedures increase the risk of tissue trauma and bleeding. E. Administer stool softeners as ordered. - Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids. Why it's not the other ones: B. Avoid applying pressure to venipuncture sites. - Firm pressure reduces the risk for bleeding into the tissues.

- QUESTION: The nurse is preparing health promotion teaching for a client with gallbladder disease. Which topic should the nurse include in the teaching​ session? (Select all that​ apply.) A. Role of a​ high-cholesterol diet on gallstone formation B. Role of hypolipidemia on gallstone formation C. Importance of a​ low-cholesterol diet D. Dangers of rapid weight loss E. Importance of a​ high-fiber diet

A, C, D, E A. Role of a​ high-cholesterol diet on gallstone formation C. Importance of a​ low-cholesterol diet D. Dangers of rapid weight loss E. Importance of a​ high-fiber diet - Clients should be taught about the role of​ obesity, hyperlipidemia, and a​ high-cholesterol diet on gallstone​ formation; the importance of a​ high-fiber, low-fat, and​ low-cholesterol diet to reduce the incidence of gallbladder​ disorders; and the dangers of rapid weight loss.

- QUESTION: The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

A. Facial droop

- QUESTION: The RN is teaching a student nurse about airway management for a patient who is at risk of aspiration. Which statement made by the student nurse indicates effective learning? A. "I will perform suctioning PRN." B. "I will discourage the patient from coughing." C. "I will encourage rapid breathing by the patient." D. "I will provide a small amount of food before the swallow evaluation."

A. "I will perform suctioning PRN."

- QUESTION: A patient is admitted to a unit with a diagnosis of left middle cerebral artery acute ischemic stroke and is NOT eligible for thrombolytic therapy. The nurse recognizes that this patient is at a high risk for which complication? A. Delirium B. Aspiration C. Bronchospasm D. Palpitations

B. Aspiration

- QUESTION: Which client would the nurse identify as being most at risk for experiencing a CVA? A. A 55-year-old African American male. B. An 84-year-old Japanese female. C. A 67-year-old Caucasian male. D. A 39-year-old pregnant female

A. A 55-year-old African American male. - African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women - African Americans suffer more extensive damage from a CVA than do people of other cultural groups. Why it's not the other ones: B. An 84-year-old Japanese female. - Females are less likely to have a CVA than males, but advanced age does increase the risk for CVA. - The Asian population has a lower risk, possibly as a result of their relatively high intake of omega-3 fatty acids, antioxidants found in fish. C. A 67-year-old Caucasian male. - Caucasians have a lower risk of CVA than do African Americans, Hispanics, and Native Pacific Islanders. D. A 39-year-old pregnant female - Pregnancy is of minimal risk factor for CVA

- QUESTION: A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? A. Administer a stool softener b.i.d. B. Encourage the client to cough hourly. C. Monitor neurological status every shift. D. Maintain the dopamine drip to keep BP at 160/90.

A. Administer a stool softener b.i.d. - The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore stool softeners would be appropriate. Why it's not the other ones: B. Encourage the client to cough hourly. - Coughing increases intracranial pressure and is discouraged for any client who has had a craniotomy. The client is encouraged to turn and breathe deeply, but not to cough. C. Monitor neurological status every shift. - Monitoring the neurological status is appropriate for this client, but it should be done much more frequently than every shift. D. Maintain the dopamine drip to keep BP at 160/90. - Dopamine is used to increase blood pressure or to maintain renal perfusion, and a BP of 160/90 is too high for this client.

- QUESTION: Which manifestations would the nurse expect to find in a patient who had a stroke and is having spatial-perceptual alterations? Select all that apply. A. Agnosia B. Apraxia C. Akinesia D. Expressive aphasia E. Homonymous hemianopsia

A. Agnosia B. Apraxia E. Homonymous hemianopsia

- QUESTION: You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can't write. This is known as what: A. Agraphia B. Alexia C. Hemianopia D. Apraxia

A. Agraphia

- QUESTION: Which laboratory value would the nurse expect to find indicating a chronic inflammation in the client with cholecystitis? A. An elevated white blood cell (WBC) count. B. A decreased lactate dehydrogenase (LDH) C. An elevated alkaline phosphatase. D. A decreased direct bilirubin level.

A. An elevated white blood cell (WBC) count.

- QUESTION: The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. An oral anticoagulant medication. B. A beta-blocker medication. C. An anti-hyperuricemic medication. D. A thrombolytic medication.

A. An oral anticoagulant medication. - The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke). Why it's not the other ones: B. A beta-blocker medication. - Beta blockers slow the heart rate and decrease blood pressure but would not be an anticipated medication to help prevent a TIA secondary to atrial fibrillation. C. An anti-hyperuricemic medication. - An anti-hyperuricemic medication is adminis- tered for a client experiencing gout and decreases the formation of tophi. D. A thrombolytic medication. - A thrombolytic medication is administered to dissolve a clot, and it may be ordered during the initial presentation for a client with a CVA, but not on discharge.

- QUESTION: You're educating a group of nursing students about Left-Side Brain Damage. Select all the signs and symptoms noted with this type of Stroke: A. Aphasia B. Denial about limitations C. Impaired math skills D. Issues with seeing on the right side E. Disoriented F. Depression and anger G. Impulsive H. Agraphia

A. Aphasia C. Impaired math skills D. Issues with seeing on the right side F. Depression and anger H. Agraphia

- QUESTION: The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? A. Apply a heating pad to the abdomen for 15 to 20 minutes. B. Administer morphine sulfate intravenously after diluting with saline. C. Contact the surgeon for an order to x-ray the right shoulder. D. Apply a sling to the right arm that was injured in surgery.

A. Apply a heating pad to the abdomen for 15 to 20 minutes. - Assist the migration of the CO2 used to insufflate the Abdomen

- QUESTION: What is the #1 drug used in stroke prevention for patients with TIA? A. Aspirin B. Clopidogrel (Plavix) C. Ticlopidrine D. Dipyridamole

A. Aspirin

- QUESTION: Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? A. Auscultate the clients bowel sounds in all four quadrants B. Palpate the abdominal area for tenderness C. Percuss the abdominal borders to identify organs D. Assess the tender area progressing to nontender

A. Auscultate the clients bowel sounds in all four quadrants - Auscultation should be used prior to palpitation or percussion when assessing the abdomen. - Manipulation of the abdomen can alter bowel sounds and give false information

- QUESTION: A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should identify that which of the following food choices can trigger cholecystitis? A. Brownie with nuts B. Bowl of mixed fruit C. Grilled turkey D. Baked potato

A. Brownie with nuts

- QUESTION: A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding

A. Fried chicken - The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. - Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. - The patient should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis.

- QUESTION: A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a A. CT scan B. Lumbar puncture C. Cerebral arteriogram D. Positron emission tomography (PET)

A. CT scan - A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke Why it's not the other ones: B. Lumbar puncture - Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. C. Cerebral arteriogram - Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information. D. Positron emission tomography (PET) - Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke.

- QUESTION: A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A. Cardiac and respiratory status B. Seizure activity C. Pain D, Fluid and electrolyte balance

A. Cardiac and respiratory status - Acute care begins with managing ABCs. Patients may have difficulty keeping an open and clear airway secondary to decreased LOC. - Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. - Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.

- QUESTION: Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first: A. Check the patient's gag reflex B. Order a soft diet for the patient C. Raise the head of the bed to sitting position D. Evaluate the patient's ability to swallow small sips of ice water

A. Check the patient's gag reflex - The first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. - The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position

- QUESTION: When assessing the client recovering from an open cholecystectomy, which signs and symptoms should the nurse report to the health-care provider? Select all that apply. A. Clay-colored stools. B. Yellow-tinted sclera. C. Dark yellow urine D. Feverish chills. E. Abdominal pain.

A. Clay-colored stools. B. Yellow-tinted sclera. C. Dark yellow urine D. Feverish chills. E. Abdominal pain.

- QUESTION: While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as: A. Dysarthria B. Apraxia C. Alexia D. Dysphagia

A. Dysarthria

- QUESTION: Which oral medication should the nurse question before administering to the client with peptic ulcer disease? A. E-mycin, an antibiotic B. Prilosec, a proton pump inhibitor C. Flagyl, an anti microbial agent D. Tylenol, a nonnarcotic analgesic

A. E-mycin, an antibiotic - E-mycinis irritating to stomach, and it's use in a client with peptic ulcer disease should be questioned

- QUESTION: Which type of stroke is a patient at risk for if atrial fibrillation is untreated? A. Embolic stroke B. Thrombotic stroke C. Intracerebral hemorrhage D. Subarachnoid hemorrhage

A. Embolic stroke

- QUESTION: The nurse is caring for a client diagnosed with rule out peptic ulcer disease. Which test confirms this diagnosis? A. Esophagogastroduodenoscopy (EGD) B. Magnetic resonance imaging C. Occult blood test D. Gastric acid stimulation.

A. Esophagogastroduodenoscopy (EGD) - The esophagogastroduodenoscopy (EGD) is an invasive diagnostic test which visualizes the esophagus, stomach, and duodenum to accurately diagnose an ulcer and evaluate the effectiveness of the clients treatment.

- QUESTION: The nurse is caring for a patient who is being transported to the emergency department with clinical manifestations of stroke. Which is the priority action upon arrival to the hospital? A. Establish the time that the patient was last known to be without symptoms. B. Draw blood for coagulation studies. C. Perform an electrocardiogram. D. Perform an EEG.

A. Establish the time that the patient was last known to be without symptoms. - Establishing the correct time of symptom onset is essential in guiding the response to this patient's signs and symptoms. - Results from coagulation are important in the event that thrombolytic therapy is considered. - A CT scan should be performed within 25 minutes of the patient arrival to the department to rule out hemorrhage.

- QUESTION: A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of ³ 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months

A. Evidence of hemorrhagic stroke Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Why its not the other ones: Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

- QUESTION: A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B. Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C. A laparoscopic approach allows for the removal of the entire gallbladder. D. A laparoscopic approach can be performed under conscious sedation.

A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. - Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). - As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. - Both approaches allow for removal of the entire gallbladder and must be performed under general anesthetic in an operating theater.

- QUESTION: A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of the patient's airway B. Positioning to promote cerebral perfusion C. Control of fluid and electrolyte imbalances D. Administration of tissue plasminogen activator (tPA)

A. Maintenance of the patient's airway

- QUESTION: A client is experiencing severe upper abdominal pain and jaundice. Which finding on the cholescintigraphy should indicate to the nurse that the client has​ cholelithiasis? A. Obstruction of the cystic duct by a gallstone B. Viral infection of the gallbladder C. Accumulation of fat in the wall of the gallbladder D. Accumulation of bile in the hepatic duct

A. Obstruction of the cystic duct by a gallstone - Cholelithiasis is almost always caused by a gallstone lodged in the cystic duct.

- QUESTION: The nurse is caring for an older adult male client who reports stomach pain and heartburn. Which syndrome is most significant in determining whether the client's ulceration is gastric or duodenal in origin? A. Pain occurs 1 1/2 to 3 hours after a meal, usually at night. B. Pain is worsened by the ingestion of food. C. The client has a malnourished appearance. D. The client is a man older than 50 years.

A. Pain occurs 1 1/2 to 3 hours after a meal, usually at night. - A key symptom characteristic of duodenal ulcers is that pain usually awakens the client between 1 AM and 2 AM, occurring 1 1/2 to 3 hours after a meal.

- QUESTION: Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A. Placing the client on the back with a small pillow under the head. B. Keeping portable suctioning equipment at the bedside. C. Opening the client's mouth with a padded tongue blade. D. Cleaning the client's mouth and teeth with a toothbrush.

A. Placing the client on the back with a small pillow under the head. - A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction, so having suction equipment at the bedside is necessary. Padded tongue blades are safe to use.

- QUESTION: The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis? A. Plasma D-dimer test B. Arterial blood gases C. Chest x-ray D. Magnetic resonance imaging (MRI)

A. Plasma D-dimer test - The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. Why it's not the other ones: B. Arterial blood gases - ABGs evaluate oxygenation level, but they do not diagnose a pulmonary embolism. C. Chest x-ray - ACXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. D. Magnetic resonance imaging (MRI) - MRI is a noninvasive test that detects a deep vein thrombosis, but it does not diagnose a pulmonary embolus.

- QUESTION: The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8 ° F (38.8 ° C). What should the nurse do in response to this reported assessment data? A. Promptly assess the client for potential perforation. B. Tell the assistant to change the thermometers and retake the temperature. C. Plan to give the client acetaminophen (Tylenol) to lower the temperature. D. Ask the assistant to bathe the client with tepid water.

A. Promptly assess the client for potential perforation. - A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. - The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock. Why it's not the other ones: B. Tell the assistant to change the thermometers and retake the temperature. - Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. C. Plan to give the client acetaminophen (Tylenol) to lower the temperature. - The nurse would not administer acetaminophen without further assessment of the client or without a physician's order; a suspected perforation would require that the client be placed on nothing-by-mouth status. D. Ask the assistant to bathe the client with tepid water. - Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.

- QUESTION: The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the patient speak to loved ones on the phone daily. C. Help the patient complete his or her sentences. D. Speak in a loud and deliberate voice to the patient.

A. Provide a board of commonly used needs and phrases. - The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. - A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the patient. This should be avoided because it may cause the patient to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. - The patient may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.

Embolic Stroke (type of Ischemic)

Caused by an Embolus (blood clot) traveling from another part of the body to a Cerebral artery (Cerebrum). Blood to the Brain distal to the occlusion site gets shut off causing Neurologic deficits.

- QUESTION: A nurse is orienting a new nurse to a unit. The experienced nurse evaluates that the new nurse understands information r/t a stroke resulting from a subarachnoid hemorrhage when which points are addressed by the new nurse? SELECT ALL THAT APPLY. A. Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm. B. Subarachnoid hemorrhage usually occurs while the client is sleeping and is noticed when the client awakens. C. Subarachnoid hemorrhage is accompanied by complaints of an extremely severe headache. D. Subarachnoid hemorrhage may be treated with thrombolytic therapy if no contraindications exist. E. Subarachnoid hemorrhage often results in blood cerebrospinal fluid (CSF). F. Subarachnoid hemorrhage causes nuchal rigidity.

A. Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm. C. Subarachnoid hemorrhage is accompanied by complaints of an extremely severe headache. E. Subarachnoid hemorrhage often results in blood cerebrospinal fluid (CSF). F. Subarachnoid hemorrhage causes nuchal rigidity.

- QUESTION: A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because: A. The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease B. The patient has probably experienced an asymptomatic lacunar stroke C. The symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours D. Neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off

A. The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

- QUESTION: A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this patient? A. The patient should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.

A. The patient should be approached on the side where visual perception is intact. - Patients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. - The patient can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. - The nurse should constantly remind the patient of the other side of the body and should later stand at a position that encourages the patient to move or turn to visualize who and what is in the room.

- QUESTION: Which action would help a nurse to communicate better with a stroke patient with aphasia? A. Utilizing touch B. Nodding at all times C. Talking as if to a child D. Speaking loudly and firmly

A. Utilizing touch

- QUESTION: A nurse is caring for a post-stroke client with a-fib. What should the nurse keep close by while the patient is on the unit? A. Vitamin K+ B. Suction C. Trach kit D. Loading dose of warfarin

A. Vitamin K+ - The patient will likely be on warfarin. K+ is the antidote because of increased risk of bleed.

- QUESTION: A nurse is updating the health history of a pt who has been admitted to the hospital with a stroke. What question should the nurse ask the patient's support person? A. What was the time of onset of symptoms? B. How much food did the pt eat the previous night? C. What was the position of the pt when the symptoms arose? D. Was the pt wearing tight clothes at the time of the stroke?

A. What was the time of onset of symptoms?

- QUESTION: The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? A. White female, age 60, with history of excessive alcohol intake B. White male, age 60, with history of uncontrolled hypertension C. Black male, age 60, with history of diabetes D. Black male, age 50, with history of smoking

A. White female, age 60, with history of excessive alcohol intake - Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. - Additional risk factors are increased age, male gender, and excessive alcohol intake. - Another high-risk group includes African Americans, where the incidence of first stroke is almost twice that as in Caucasians.

- QUESTION: The nurse is teaching a client with cholelithiasis about lifestyle modification. Which statement made by the client indicates that the​ nurse's teaching has been​ successful? A. ​"I will walk three times a week for 20 minutes each​ day." B. "I will eliminate salt from my​ diet." C. "I can fry food as long as I use olive oil instead of vegetable​ oil." D. "I will use more ground beef in my meal​ preparation."

A. ​"I will walk three times a week for 20 minutes each​ day." - Obesity is commonly associated with the development of gallbladder disease. - A balanced diet and exercise will help keep the​ client's weight within normal limits. Why it's not the other ones: B. "I will eliminate salt from my​ diet." - There is no reason to eliminate salt from the diet. C. "I can fry food as long as I use olive oil instead of vegetable​ oil." - Frying adds additional fat and should be avoided. D. "I will use more ground beef in my meal​ preparation." - Ground beef is high in fat and should be limited.

What are different ways that Hemorrhages can be managed?

ALL used to DECREASE the amount of Bleeding 1. Epinephrine Injections causes for: - Sclerose (hardening of tissue) - & Vasoconstriction 2. Cauterization - Is used to DESTROY tissue using a Hot or Cold instrument, an electrical current or a chemical that burns or dissolves the tissue 3. Clipping - When an incision is made in the skin to dissect the spaces where blood arises from and place a clip there 4. Surgical Consult for the pt. through either: - a Vagotomy (cutting one of the branches of your vagus nerve that communicates with your stomach to reduce Acid secretions) - Gastric Resection Surgery (removal of parts of the stomach) - or an Arteriography with Embolization (radiography of an Artery, then they use tiny gelatin sponges or beads to block the blood vessel)

- QUESTION: A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? A. "I will stop taking this medicine if I notice any bruising." B. "I will not eat spinach while I'm taking this medicine." C. "It will be OK for me to eat anything, as long as it is low fat." D. "I'll check my blood pressure frequently while taking this medication.

B. "I will not eat spinach while I'm taking this medicine." - Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of the drug. Why it's not the other ones: A. "I will stop taking this medicine if I notice any bruising." - Bruising is a common side effect, and the drug should not be stopped unless by prescriber order. C. "It will be OK for me to eat anything, as long as it is low fat." - Low-fat foods do not interfere with warfarin therapy, which is not prescribed to affect the blood pressure.

- QUESTION: A nurse is providing instruction to a patient regarding TIA. What should the nurse include in her teaching? A. "TIA is a neurological dysfunction that manifests as an acute infarction." B. "TIA causes ischemia." C. "Symptoms of TIA last less than 3 hours" D. "When the symptoms of TIA subside, a patient can be immediately discharged." E. "A patient who has a TIA does not have an increased risk of having a stroke." F. "Oftentimes, a patient with TIA is given nitroglycerin to help with the pain."

B. "TIA causes ischemia."

- QUESTION: If blood flow to the brain is interrupted, how quickly does cellular death occur? A. 2 minutes B. 5 minutes C. 30 minutes D. 30 seconds

B. 5 minutes

- QUESTION: Which patient is most at risk for stroke? A. A 32-year-old woman with a BMI of 34, who smokes and has unregulated T2DM. B. A 72-year-old African American male with HTN, a family history of stroke, who currently has sickle cell anemia. C. A 60-year-old Caucasian alcoholic male who eats McDonalds every night and has a cholesterol level of 220. D. A 45-year-old Asian woman who smokes 2 packs a day, has HTN, T2DM, and suffered a TIA last summer.

B. A 72-year-old African American male with HTN, a family history of stroke, who currently has sickle cell anemia.

- QUESTIONS: The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that: A. Involvement with his job will keep the client from becoming bored. B. A relaxed environment will promote ulcer healing. C. Not keeping up with his job will increase the client's stress level. D. Setting limits on the client's behavior is an important nursing responsibility.

B. A relaxed environment will promote ulcer healing. - A relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Why it's not the other ones: A. Involvement with his job will keep the client from becoming bored. - Being involved with his work may prevent boredom; however, this client is upset and argumentative. C. Not keeping up with his job will increase the client's stress level. - Not keeping up with his job will probably increase the client's stress level, but the nurse's response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. D. Setting limits on the client's behavior is an important nursing responsibility. - Nurses cannot set limits on a client's behavior; clients must make the decision to make lifestyle changes

- QUESTION: A client seeks medical attention at an ER after experiencing right-sided weakness and slurred speech. The client receives a diagnosis of ischemic stroke and is evaluated for treatment with thrombolytic therapy. A definite contraindication for thrombolytic therapy is: A. A normal CT scan of the brain B. A serious head injury 4 weeks earlier C. A hx of DM D. Onset of neurological deficits 2 hours earlier

B. A serious head injury 4 weeks earlier - Contraindications to thrombolytic therapy for a client with ischemic stroke include a serious head injury within the previous 3 months, This would put the patient at risk of developing serious bleeding problems (specifically hemorrhage). Why it's not the other ones: C. A hx of DM - History of DM is not a contraindication. D. Onset of neurological deficits 2 hours earlier - A negative CT scan and onset of neurological deficits within 3 hours are indications of administering thrombolytic therapy

- QUESTION: When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

B. Alteration in level of consciousness (LOC) - Alteration in LOC is the earliest sign of deterioration in a patient after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Why it's not the other ones: - Sudden headache may occur, but generalized pain is less common. - Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

- QUESTION: A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? A. Position the patient on her weak side the majority of the time. B. Alternate the patient's positioning between supine and side-lying. C. Avoid the use of pillows in order to promote independence in positioning D. Establish a schedule for the massage of areas where skin breakdown emerges.

B. Alternate the patient's positioning between supine and side-lying.

- QUESTION: What medications are used in stroke prevention for patients with a history of TIA? A. Anti-coagulants B. Anti-platelets C. Beta blockers D. Digoxin

B. Anti-platelets

- QUESTION: A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain? A. Aspirin every 4 to 6 hours as ordered B. Application of heat 15 to 20 minutes each hour C. Application of an ice pack for no more than 15 minutes D. Application of liniment rub to affected area

B. Application of heat 15 to 20 minutes each hour - If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Why it's not the other ones: A. Aspirin every 4 to 6 hours as ordered - Aspirin would constitute for risk of bleeding instead

- QUESTION: A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? A. Ineffective coping related to fear of diagnosis of chronic illness. B. Deficient knowledge related to unfamiliarity with significant signs and symptoms. C. Constipation related to decreased gastric motility. D. Imbalanced nutrition: Less than body requirements related to gastric bleeding.

B. Deficient knowledge related to unfamiliarity with significant signs and symptoms. - Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black. The odor of the stool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider. - The data do not support the other diagnoses.

- QUESTION: When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck

B. Elevation of the head of the bed Elevation of the head of the bed promotes venous drainage and lowers ICP; Why its not the other ones: - The nurse should avoid flexing or extending the neck or turning the head side to side. - The head should be in a neutral midline position. - Excessively frequent position changes are unnecessary.

- QUESTION: The family of a patient who has had a brain attack (CVA) asks if the patient will ever talk again. The nurse should do which of the following? A. Explain that the patient's speech will return to normal with time. B. Explain that it is difficult to know how far the patient will progress. C. Tell the family that nurses cannot discuss such issues. Tell them to ask the physician. D. Tell the family what they see today is all they can expect.

B. Explain that it is difficult to know how far the patient will progress. - Therapeutic communication is needed. It is important to allow hope but be honest by not promising progress, since no one knows how much the patient will improve. - Progress may depend on the extent and the areas affected. - The nurse does not know that speech will return in time. - It is not therapeutic to tell the family to ask the physician, and it does not display a professional, caring attitude.

- QUESTION: Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: A. Demonstrate appropriate use of analgesics to control pain. B. Explain the rationale for eliminating alcohol from the diet. C. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. D. Eliminate contact sports from his or her lifestyle.

B. Explain the rationale for eliminating alcohol from the diet. - Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Why it's not the other ones: A. Demonstrate appropriate use of analgesics to control pain. - Analgesics are NOT used to control ulcer pain; many analgesics are gastric irritants. C. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. - The client's hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected D. Eliminate contact sports from his or her lifestyle. - The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.

- QUESTION: The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

B. Impaired speech

- QUESTION: The client with a history of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement? A. Maintain a strict record of intake and output B. Insert a nasogastric tube and begin saline lavage C. Assist the client with keeping a detailed calorie count D. Provide a quiet environment to promote rest

B. Insert a nasogastric tube and begin saline lavage - Inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this directly stops the bleeding

- QUESTION: A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for? A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis

B. Ischemic embolism - If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.

- QUESTION: A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.

B. Maintain and improve cerebral tissue perfusion. - Each of the listed goals is appropriate in the care of a patient recovering from a stroke. - However, promoting cerebral perfusion is a priority physiologic need, on which the patient's survival depends.

- QUESTION: A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care? A. Elevate the head of the bed to 45 degrees. B. Maintain the patient on complete bed rest. C. Administer enemas when the patient is constipated. D. Avoid use of thigh-high elastic compression stockings.

B. Maintain the patient on complete bed rest. - Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Why it's not the other ones: - Visitors, except for family, are restricted. - The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remains flat to increase cerebral perfusion. - No enemas are permitted, but stool softeners and mild laxatives are prescribed. - Thigh-high elastic compression stockings or sequential compression boots may be ordered to decrease the patient's risk for deep vein thrombosis (DVT).

- QUESTION: The nurse is caring for a client diagnosed with hemorrhage and has a duodenal ulcer. Which collaborative interventions should a nurse implement? Select all that apply. A. Perform a complete pain assessment B. Assess the clients vital signs frequently C. Administer a proton pump inhibitor intravenously D. Obtain permission and administer blood products E. Monitor the intake of a soft, bland diet

C, D C. Administer a proton pump inhibitor intravenously - Requires order from an HCP D. Obtain permission and administer blood products - Collaborative, needs order from an HCP

- QUESTION: You're patient has expressive aphasia. Select all the ways to effectively communicate with this patient? A. Fill in the words for the patient they can't say. B. Don't repeat questions. C. Ask questions that require a simple response. D. Use a communication board. E. Discourage the patient from using words.

C, D C. Ask questions that require a simple response. - Patients with Expressive Aphasia can understand spoken words but they cannot respond back effectively or at all - Therefore we should let them speak, be direct, and ask simple questions that require a simple response D. Use a communication board.

- QUESTION: The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? A. The client awaiting hiatal hernia repair at 11 am. B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests. C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain. D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.

C. A client with peptic ulcer disease experiencing sudden onset of acute stomach pain. - 1ST: The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a perforated ulcer, which would require immediate medical attention Why it's not the other ones: A. The client awaiting hiatal hernia repair at 11 am. - Lastly, the nurse can assess the client before surgery. B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests. - 3rd: The nurse should then assess the client who is NPO for tests to ensure NPO status and comfort. D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw. - 2nd: It is also important for the nurse to thoroughly assess the nature of the client's pain. The client with the fractured jaw is experiencing pain and should be assessed next.

- QUESTION: The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention? A. Bowel sour s auscultated 15 times in 1 minute B. Belching after eating a heavy and fatty meal late at night C. A decrease in systolic BP of 20 mm Hg from lying to sitting D. A decreased frequency of distress located in the epigastric region

C. A decrease in systolic BP of 20 mm Hg from lying to sitting - A decrease of 20 mm Hg in blood pressure after changing position from lying, to sitting, to standing is orthostatic hypotension. This could indicate client is bleeding.

- QUESTION: The nurse is preparing to administer the Oral Anticoagulant Warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR 2.8. What action should the nurse implement? A. Assess the client for abnormal bleeding. B. Prepare to administer vitamin K (AquaMephyton). C. Administer the medication as ordered. D. Notify the HCP to obtain an order to increase the dose.

C. Administer the medication as ordered. - A therapeutic INR is 2-3; therefore, the nurse should administer the medication. Why it's not the other ones: A. Assess the client for abnormal bleeding. - The client would not be experiencing abnormal bleeding with this INR. B. Prepare to administer vitamin K (AquaMephyton). - This is the antidote for an overdose of anticoagulant and the INR does not indicate this. D. Notify the HCP to obtain an order to increase the dose. - There is no need to increase the dose; this result is within the therapeutic range.

- QUESTION: Which patient below is at most risk for a hemorrhagic stroke? A. A 65-year-old male patient with carotid stenosis. B. An 89-year-old female with atherosclerosis. C. An 88-year-old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. D. A 55-year-old female with atrial flutter.

C. An 88-year-old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. - A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) - All the other options are at risk for an ischemic type of stroke.

- QUESTION: The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? A. Bland foods. B. High-protein foods. C. Any foods that are tolerated. D. Large amounts of milk.

C. Any foods that are tolerated. - Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate.

- QUESTION: A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

C. Bleeding - Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding. Why its not the other ones: - Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

- QUESTION: Which type of food would the nurse feed the patient by mouth for the first time after a stroke? A. Thin liquids B. Pureed foods C. Crushed ice D. Milk products

C. Crushed ice

- QUESTION: The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of A. Furosemide (Lasix) B. Lovastatin (Mevacor) C. Daily low-dose aspirin D. Nimodipine (Nimotop)

C. Daily low-dose aspirin - The administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopidine (Ticlid), reduces the incidence of stroke in those at risk - Anticoagulants are also used for the prevention of embolic strokes but increase the risk of hemorrhage. Why it's not the other ones: A. Furosemide (Lasix) - Diuretics are not indicated for stroke prevention other than for their role in controlling BP B. Lovastatin (Mevacor) - Antilipemic agents have NOT been found to have a significant effect on stroke prevention D. Nimodipine (Nimotop) - The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.

Conjugated Bilirubin (direct)

Combined with Albumin and transported back to the Liver to create more Bile salts (less active and readily excreted)

Bilirubin (from the breakdown of RBC's)

Compromises a LARGE portion of Bile

- QUESTION: A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to A. Ignore undesirable behaviors manifested by the patient B. Provide directions to the patient verbally in small steps C. Distract the patient from inappropriate emotional responses D. Supervise all activities before allowing the patient to pursue them independently

C. Distract the patient from inappropriate emotional responses - Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. - The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. - Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.

- QUESTION: Loss of muscle control of speech is termed: A. Receptive aphasia B. Dysphasia C. Dysarthria D. Expressive aphasia E. Apraxia

C. Dysarthria

- QUESTION: A client who has had a stroke stare at a nurse but does not attempt to verbally respond to the nurse's questions. The client follows instructions without any problems. The nurse understands that the client is displaying symptoms consistent with: A. Receptive aphasia B. Global aphasia C. Expressive aphasia D. BOTH receptive and expressive aphasia

C. Expressive aphasia

- QUESTION: The nurse is preparing to administer medications to the following clients. Which medication would the nurse question administering? A. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. B. Regular insulin to a client with a blood glucose level of 218 mg/dL. C. Hanging the heparin bag to a client with a PT/PTT of 12.9/98. D. A calcium channel blocker to the client with a BP of 112/82.

C. Hanging the heparin bag to a client with a PT/PTT of 12.9/98. - A normal PTT is 39 seconds; therefore, 58-78 is 1.5 to 2 times the normal value and is within the therapeutic range. A PTT of 98 means the client is not clotting and the medication should be held. Why it's not the other ones: A. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. - An INR of 2-3 is therapeutic; therefore, the nurse would administer this medication. B. Regular insulin to a client with a blood glucose level of 218 mg/dL. - This is an elevated blood glucose level; therefore, the nurse should administer the insulin. D. A calcium channel blocker to the client with a BP of 112/82. - This is a normal blood pressure and the nurse should administer the medication.

- QUESTION: A physician orders several drugs for a client with a hemorrhagic stroke. Which drug order should the nurse question? A. Phenytoin (Dilantin) ▪ To prevent Seizures!! B. Methyldopa (Aldomet) ▪ To reduce blood pressure C. Heparin sodium ▪ Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. ▪ Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. D. Dexamethasone (Decadron) ▪ To decrease cerebral edema and pressure

C. Heparin sodium - Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. - Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. Why it's not the other ones: A. Phenytoin (Dilantin) - To prevent Seizures!! B. Methyldopa (Aldomet) - To reduce blood pressure D. Dexamethasone (Decadron) - To decrease cerebral edema and pressure

- QUESTION: A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception

C. Inability to recognize familiar objects

- QUESTION: In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in A. African Americans B. Individuals who smoke C. Individuals with hypertension D. Those who are obese with high dietary fat intake

C. Individuals with hypertension

- QUESTION: A client experienced a blow to the right frontal region of the head. If the client begins to develop increased intracranial pressure, which manifestation should the nurse see first? A. Decreased heart rate B. Sluggish response by pupils to light C. Irritability D. Projectile vomiting

C. Irritability - The earliest sign of increased intracranial pressure is level of consciousness. - Irritability, personality changes, restlessness, and disorientation are early manifestations of ICP. Why it's not the other ones: A. Decreased heart rate - Decreased heart rate is seen in a later stage of IICP. B. Sluggish response by pupils to light - Slow pupil response is seen in a late, not early, stage of IICP. D. Projectile vomiting - Projectile vomiting is seen during later, not early, stages of IICP.

- QUESTION: How would the nurse explain a transient ischemic attack (TIA) to the spouse of a patient who just had a TIA? A. It is usually neurologically damaging. B. It is a signal of progressive brain damage. C. It can be a warning of an impending stroke. D. It is nothing to be concerned about because it is not a stroke.

C. It can be a warning of an impending stroke.

- QUESTION: A nurse is providing discharge education to a patient who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A. High-fiber foods B. Low-purine, nutrient-dense foods C. Low-fat foods high in proteins and carbohydrates D. Foods that are low-residue and low in fat

C. Low-fat foods high in proteins and carbohydrates - The nurse encourages the patient to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. - "I may experience some discomfort when I am eating a high fat meal"

- QUESTION: A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain and nausea, and has vomited several times. Based on these data, which nursing action would have been the highest priority for intervention at this time? A. Manage anxiety B. Restore fluid loss C. Manage the pain D. Replace nutritional loss

C. Manage the pain - The priority for nursing care at this time is to decrease the client's severe abdominal pain. - The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasm.

- QUESTION: A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? A. Place the patient in the prone position for 30 minutes/day. B. Assist the patient in acutely flexing the thigh to promote movement. C. Place a pillow in the axilla when there is limited external rotation. D. Place patient's hand in pronation.

C. Place a pillow in the axilla when there is limited external rotation. - A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. Why it's not the other ones: A. Place the patient in the prone position for 30 minutes/day. - The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip joints, essential for normal gait. B. Assist the patient in acutely flexing the thigh to promote movement. - To promote venous return and prevent edema, the upper thigh should not be flexed acutely. D. Place patient's hand in pronation. - The hand is placed in slight supination, not pronation, which is its most functional position.

- QUESTION: A client is diagnosed with a stroke that affects the right hemisphere of the brain. A nurse, receiving report prior to care of this client, should expect the client to have which symptom? A. Right hemiparesis B. Expressive aphasia C. Poor impulse control D. Marked anxiety when learning new tasks

C. Poor impulse control

- QUESTION: Which is a risk factor for gallbladder​ disease? A. Male gender B. Hypocalcemia C. Rapid weight loss D. Hypolipidemia

C. Rapid weight loss

- QUESTION: A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician? A. Decreased breath sounds B. Drainage of bile-colored fluid onto the abdominal dressing C. Rigidity of the abdomen D. Acute pain with movement

C. Rigidity of the abdomen - Increased abdominal tenderness and rigidity should be reported immediately to the physician, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure. Why it's not the other ones: A. Decreased breath sounds - The location of the subcostal incision will likely cause the patient to take shallow breaths to prevent pain, which may result in decreased breath sounds. - The nurse should remind patients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. B. Drainage of bile-colored fluid onto the abdominal dressing - Abdominal splinting or application of an abdominal binder may assist in reducing the pain. - Bile may continue to drain from the drainage tract after surgery, which will require frequent changes of the abdominal dressing. D. Acute pain with movement - Acute pain is an expected assessment finding following surgery; analgesics should be administered for pain relief

- QUESTION: A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is of priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA) B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consult.

C. Schedule for A STAT computer tomography (CT) scan of the head. - A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA. - This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. - Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. - Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol. Why it's not the other ones: A. Prepare to administer recombinant tissue plasminogen activator (rt-PA) - The drug rt-PA may be administered, but a cerebrovascular accident (CVA) must be verified by diagnostic tests prior to administering it. rt-PA helps dissolve a blood clot, and it may be administered if an ischemic CVA is verified, rt-PA would not be given if the client were experiencing a hemorrhagic stroke. B. Discuss the precipitating factors that caused the symptoms. - Teaching is important to help prevent another CVA, but it is not the priority intervention on admission to the emergency department. Slurred speech indicates problems that may interfere with teaching. D. Notify the speech pathologist for an emergency consult. - The client may be referred for speech deficits and/or swallowing difficulty, but referrals are not priority in the emergency department.

- QUESTION: The nurse and unlicensed assistive personnel (UAP) is caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The assistant places a gait belt around the client's waist prior to ambulating. B. The assistant places the client on the back with the client's head to the side. C. The assistant places her hand under the client's right axilla to help him/her move up in bed. D. The assistant praises the client for attempting to perform ADLs independently.

C. The assistant places her hand under the client's right axilla to help him/her move up in bed. - This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client's and nurse's safety. All the other actions are appropriate. Why it's not the other ones: A. The assistant places a gait belt around the client's waist prior to ambulating. - Placing a gait belt prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. B. The assistant places the client on the back with the client's head to the side. - Placing the client in a supine position with the head turned to the side is not a problem position, so the nurse does not need to intervene. D. The assistant praises the client for attempting to perform ADLs independently. - The client should be encouraged and praised for attempting to perform any activities independently, such as combing hair or brushing teeth.

- QUESTION: The neurologic functions that are affected by a stroke are primarily related to: A. The amount of tissue area involved B. The rapidity of onset of symptoms C. The brain area perfused by the affected artery D. The presence or absence of collateral circulation

C. The brain area perfused by the affected artery

- QUESTION: The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data would warrant immediate intervention from the nurse? A. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. B. The client's telemetry exhibits occasional premature ventricular contractions. C. The client's pulse oximeter reading is 90%. D. The client's urinary output for the 12-hour shift is 800 mL.

C. The client's pulse oximeter reading is 90%. Why it's not the other ones: - The normal pulse oximeter reading is 93%-100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. A. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. - These ABGs are within normal limits and would not warrant immediate intervention. B. The client's telemetry exhibits occasional premature ventricular contractions. - Occasional premature ventricular contractions are not unusual for any client and would not warrant immediate intervention. D. The client's urinary output for the 12-hour shift is 800 mL. - A urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/ hour, and this would not warrant immediate intervention by the nurse.

- QUESTION: You're reading the physician's history and physical assessment report. You note the physician wrote that the patient has Apraxia. What assessment finding in your morning assessment correlates with this condition? A. The patient is unable to read. B. The patient has limited vision in half of the visual field. C. The patient is unable to wink or move his arm to scratch his skin. D. The patient doesn't recognize a pencil or television.

C. The patient is unable to wink or move his arm to scratch his skin.

- QUESTION: The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patient's plan of care? A. The patient's hip joint should be maintained in a flexed position. B. The patient should be in a supine position unless ambulating. C. The patient should be placed in a prone position for 15 to 30 minutes several times a day. D. The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion.

C. The patient should be placed in a prone position for 15 to 30 minutes several times a day. - If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. - A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. - This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures.

- QUESTION: A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking the cerebral flow D. To determine the cause of the TIA

C. To remove atherosclerotic plaques blocking the cerebral flow - The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke inpatients with occlusive disease of the extracranial arteries. - An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

- QUESTION: The patient was exhibiting symptoms of a stroke for 45 minutes before the symptoms resolved. Which condition may this patient have experienced? A. Embolic brain stroke B. Acute brain infarction C. Transient ischemic attack D. Subarachnoid hemorrhage

C. Transient ischemic attack

- QUESTION: The client is six (6) hours postoperative open cholecystectomy and the nurse finds a large amount of red drainage on the dressing. Which intervention should the nurse implement? A. Measure the abdominal girth. B. Palpate the lower abdomen for a mass. C. Turn client onto side to assess for further drainage. D. Remove the dressing to determine the source.

C. Turn client onto side to assess for further drainage.

- QUESTION: Which finding is consistent with a left-hemispheric stroke? A. Impaired judgment B. Unilateral weakness of the left extremities C. Unilateral weakness of the right extremities D. Spatial-perceptual deficits

C. Unilateral weakness of the right extremities

- QUESTION: Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus is effective? A. "I am going to use a regular-bristle toothbrush." B. "I will take antibiotics prior to having my teeth cleaned." C. "I can take enteric-coated aspirin for my headache." D. "I will wear a medic alert band at all times."

D. "I will wear a medic alert band at all times." - The client should wear a medic alert band at all times so that if any accident or situation occurs, the health-care providers will know the client is receiving anticoagulant therapy. Why it's not the other ones: A. "I am going to use a regular-bristle toothbrush." - The client should use a soft-bristle toothbrush to reduce the risk of bleeding. B. "I will take antibiotics prior to having my teeth cleaned." - This is appropriate for a client with a mechanical valve replacement, not a client receiving anticoagulant therapy. C. "I can take enteric-coated aspirin for my headache." - Aspirin, enteric-coated or not, is an antiplatelet, which may increase bleeding tendencies and should be avoided.

- QUESTION: The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? A. "We need to discourage him from wearing eyeglasses." B. "We need to place objects in his impaired field of vision." C. "We need to approach him from the impaired field of vision." D. "We need to remind him to turn his head to scan the lost visual field."

D. "We need to remind him to turn his head to scan the lost visual field." - Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. - The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. - The nurse encourages the use of personal eyeglasses, if they are available.

- QUESTION: Which patient is more likely to develop gallstones? A. 45-year-old Caucasian female with a family history of gallstones B. 55-year-old African-American male with a history of diabetes mellitus C. 62-year-old Hispanic/Latino female with a history of irritable bowel syndrome D. 60-year-old obese, American-Indian female with a history of diabetes mellitus

D. 60-year-old obese, American-Indian female with a history of diabetes mellitus

- QUESTION: The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation B. A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea C. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches D. A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco

D. A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco

- QUESTION: The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto- Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective? A. A decrease in alcohol intake B. Maintaining a bland diet C. A return to previous activities D. A decrease in gastric distress

D. A decrease in gastric distress - Antibiotics, proton pump inhibitors, and Pepto-Bismol are administered to decrease the irritation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medication is effective

- QUESTION: A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? A. Range-of-motion exercises to prevent contractures B. Encouraging independence with ADLs to promote recovery C. Early initiation of physical therapy D. Absolute bed rest in a quiet, nonstimulating environment

D. Absolute bed rest in a quiet, nonstimulating environment - The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Why it's not the other ones: - Visitors are restricted. The nurse administers all personal care. - The patient is fed and bathed to prevent any exertion that might raise BP.

- QUESTION: Which nursing diagnosis would be highest priority for the client who had an open cholecystectomy surgery? A. Alteration in nutrition. B. Alteration in skin integrity. C. Alteration in urinary pattern. D. Alteration in comfort.

D. Alteration in comfort.

- QUESTION: A patient who is recovering from a stroke cannot complete a sequence of commands. This is termed: A. Receptive aphasia B. Expressive aphasia C. Dysphasia D. Apraxia

D. Apraxia

- QUESTION: A patient returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the patient for signs and symptoms of what serious potential complication of this surgery? A. Diabetic coma B. Decubitus ulcer C. Wound evisceration D. Bile duct injury

D. Bile duct injury - The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Why it's not the other ones: A. Diabetic coma - Patients do NOT face a risk of diabetic coma. B. Decubitus ulcer - A decubitus ulcer is unlikely because immobility is not expected. C. Wound evisceration - Evisceration is highly unlikely, due to the laparoscopic approach.

- QUESTION: Which ethnic group has the highest incidence of stroke? A. Asians B. Mexicans C. Caucasians D. Black

D. Black

- QUESTION: A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the patient for a few minutes. B. Administer an analgesic. C. Inform the nurse-manager. D. Call the physician immediately.

D. Call the physician immediately. - A headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. Why its not the other ones: - The physician will decide whether administration of an analgesic is indicated. - Informing the nurse-manager is not necessary. - Sitting with the patient is appropriate, once the physician has been notified of the change in the patient's condition.

- QUESTION: A client is admitted to an intensive care unit because of a leaky cerebral aneurysm. A family member asks a nurse why the client is awakened and questioned about his orientation so frequently when he needs to rest. The nurse answers the family member based on the knowledge that the earliest sign of ICP is: A. Pupillary changes B. Drop in BP C. Altered sensation D. Changes in LOC

D. Changes in LOC

- QUESTION: The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? A. Administer a nonnarcotic analgesic. B. Prepare for STAT magnetic resonance imaging (MRI). C. Start an intravenous infusion with D5W at 100 mL/hr. D. Complete a neurological assessment.

D. Complete a neurological assessment. - The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action. Why it's not the other ones: A. Administer a nonnarcotic analgesic. - The nurse should not administer any medication to a client without first assessing the cause of the client's complaint or problem. B. Prepare for STAT magnetic resonance imaging (MRI). - An MRI may be needed, but the nurse must determine the client's neurological status prior to diagnostic tests. C. Start an intravenous infusion with D5W at 100 mL/hr. - Starting an IV is appropriate, but it is not the action the nurse should implement when assessing pain, and 100 mL/hr might be too high a rate for an 85-year-old client.

- QUESTION: The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? A. Gets angry with family if they interrupt a task B. Experiences bouts of depression and irritability C. Has difficulty with using modified feeding utensils D. Consistently uses adaptive equipment in dressing self

D. Consistently uses adaptive equipment in dressing self - Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Why it's not the other ones: - Options A and B are not adaptive behaviors but behaviors that you might expect for someone who has a Stroke; - Option C indicates a not yet successful attempt to adapt, but the correct option has the best outcome.

- QUESTION: The patient recovering from a stroke who is confined to bed for most of the day is at risk for which condition? A. Fatigue B. Malnutrition C. Dehydration D. Constipation

D. Constipation

- QUESTION: A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patient's plan of care? A. Adult failure to thrive B. Post-trauma syndrome C. Hyperthermia D. Disturbed sensory perception

D. Disturbed sensory perception - The patient who has experienced a stroke is at a high risk for disturbed sensory perception. - Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.

- QUESTION: Which statement is accurate about the recommendations for BP management after an ischemic stroke? A. A lower BP is a protective response to maintain cerebral perfusion. B. The BP must be lower than 160/70 mm Hg to receive fibrinolytic agents. C. Elevated BPs are expected after a stroke, and drug therapy should be initiated. D. Drugs to lower BP are recommended if the BP is 220/120 mm Hg or higher.

D. Drugs to lower BP are recommended if the BP is 220/120 mm Hg or higher.

- QUESTION: A patient who had a stroke three days ago has constipation. Which interventions would be done first for a patient who had a stroke three days ago and has constipation? Select all that apply. A. Start laxatives. B. Give an enema. C. Provide suppositories. D. Encourage physical activity. E. Encourage fluid and fiber intake.

D. Encourage physical activity. E. Encourage fluid and fiber intake.

- QUESTION: What should be included in the patient's care plan when establishing an exercise program for a patient affected by a stroke? A. Schedule passive range of motion every other day. B. Keep activity limited, as the patient may be over stimulated. C. Have the patient perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

D. Exercise the affected extremities passively four or five times a day. - The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. - Active ROM exercises should ideally be performed more than once per day.

- QUESTION: Which assessment would the nurse teach a patient to report as part of the warning signs of stroke, using the mnemonic FAST? A. Foot Drop B. Arm strength C. States disoriented D. Facial drooping

D. Facial drooping

- QUESTION: Which condition presents with a sudden onset of a headache, vomiting, and decreased level of consciousness? A. Embolic stroke B. Brain infarction C. Cerebral edema D. Hemorrhagic stroke

D. Hemorrhagic stroke

- QUESTION: A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? A. Conduct physical activity in the morning so that he can rest in the afternoon. B. Have the family agree to perform the necessary yard work at home. C. Give up jogging and substitute a less demanding hobby. D. Incorporate periods of physical and mental rest in his daily schedule.

D. Incorporate periods of physical and mental rest in his daily schedule. - It would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. - Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environments Why it's not the other ones: A. Conduct physical activity in the morning so that he can rest in the afternoon. - Scheduling physical activity to occur only in the morning would not be restful or practical. C. Give up jogging and substitute a less demanding hobby. - There is no need for the client to avoid yard work or jogging if these activities are not stressful.

- QUESTION: The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? A. Obtain a rubber mat to place under the dinner plate. B. Purchase a long-handled bath sponge for showering. C. Purchase clothes with Velcro closure devices. D. Obtain a raised toilet seat for the client's bathroom.

D. Obtain a raised toilet seat for the client's bathroom. - Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife. Why it's not the other ones: A. Obtain a rubber mat to place under the dinner plate. - The rubber mat will stabilize the plate and prevent it from slipping away from the client learning to feed himself, but this does not address generalized weakness. B. Purchase a long-handled bath sponge for showering. - A long-handled bath sponge will assist the client when showering hard-to-reach areas, but it is not a home modification, nor will it help with generalized weakness. C. Purchase clothes with Velcro closure devices. - Clothes with Velcro closures will make dress- ing easier, but they do not constitute a home modification and do not address generalized weakness.

- QUESTION: A patient has just experienced an ischemic stroke on the right side of his brain. What clinical manifestations would the nurse NOT expect to see in the patient? SELECT ALL THAT APPLY: A. Left-sided hemiplegia B. Left-sided neglect C. Patient minimizes or denies problems D. Patient is depressed and anxious because he/she is aware of their deficits E. Cannot solve math problems F. Impulsively bolts out of wheelchair G. Cannot gauge distances H. Aphasia I. Apraxia J. Impaired time concept

D. Patient is depressed and anxious because he/she is aware of their deficits E. Cannot solve math problems H. Aphasia I. Apraxia

- QUESTION: The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? A. Observe the client when swallowing for possible aspiration. B. Position the client in a semi-Fowler's position when sleeping. C. Place a suction setup at the client's bedside during meals. D. Refer the client to an occupational therapist for an evaluation.

D. Refer the client to an occupational therapist for an evaluation. - A collaborative intervention is an intervention in which another healthcare discipline—in this case, occupational therapy—is used in the care of the client. Why it's not the other ones: A. Observe the client when swallowing for possible aspiration. - Agnosia is the failure to recognize familiar objects; therefore, observing the client for possible aspiration is not appropriate. B. Position the client in a semi-Fowler's position when sleeping. - A semi-Fowler's position is appropriate for sleeping, but agnosia is the failure to recognize familiar objects; therefore, this intervention is inappropriate. C. Place a suction setup at the client's bedside during meals. - Placing suction at the bedside will help if the client has dysphagia (difficulty swallowing), not a

- QUESTION: A client has undergone a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the discharge teaching? A. Empty the bile bag daily B. Breathe deeply into a paper bag when nauseated C. Keep adhesive dressings in place for 6 weeks D. Report bile-colored drainage from any incision

D. Report bile-colored drainage from any incision - There should be no bile colored drainage coming from any of the incisions postoperatively. Why it's not the other ones: A. Empty the bile bag daily - A laparoscopic cholecystectomy does not involve a bile bag. B. Breathe deeply into a paper bag when nauseated - Breathing into a paper bag will prevent a person from passing out due to hyperventilation; it does not alleviate nausea C. Keep adhesive dressings in place for 6 weeks - If the adhesives have not already fallen off, they are removed by the surgeon in 7-10 days, NOT 6 weeks.

- QUESTION: After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include a low-fat diet? A. Cheese omlet B. Peanut butter C. Ham salad sandwich D. Roast Beef

D. Roast Beef - Lean meats, such as beef, lamb, veal, and well trimmed lean ham and pork, are low in fat. - Cheese omlet, peanut butter, and ham salad are high in fat.

- QUESTION: The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

D. Subarachnoid hemorrhage

- QUESTION: A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? A. He didn't arrive within the time frame for that therapy B. Not every is eligible for this drug. Has he had surgery lately? C. You should discuss the treatment of your husband with your doctor D. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head - tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. - The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.

- QUESTION: A nurse is teaching a group of caregivers the warning signs of stroke. Which type of assessment data obtained from the patients would the nurse teach the caregivers to consider an emergency? Select all that apply. A. The patient is unable to sleep. B. The patient cannot hear properly. C. The patient has a loss of appetite. D. The patient suddenly has blurry vision. E. The patient suddenly has slurred speech.

D. The patient suddenly has blurry vision. E. The patient suddenly has slurred speech.

- QUESTION: A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the mid-epigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? A. An intestinal obstruction has developed. B. Additional ulcers have developed. C. The esophagus has become inflamed. D. The ulcer has perforated.

D. The ulcer has perforated. - The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually with extreme pain. - Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation.

Why is NSAIDs Contraindicated for Gastric & Peptic Ulcers or Inflammation?

They DISRUPT The Mucous Barrier causing for DIRECT Inflammation & Injury Leaving the pt. MORE VULNERABLE to H. Pylori exposure

What might be assumed if a pt. has a BP greater than 180 mm Hg?

They may be having an Ischemic Stroke because of the occlusion site, causing for higher pressure of blood flow

H. Pylori Management

Triple Therapy for 10-14 days - PPIs x2 a day (bid) - Clarithromycin - Amoxicillin/Metronidazole Quadruple Therapy for 10-14 days - Bismuth Subsalicylate - Tetracycline - Metronidazole - PPIs

- TNF: Cholelithiasis is when a patient has Calculi (stone) in the Gallbladder

True