Test 4

Blood agents

Hydrogen Cyanide and Cyanogen Chloride. Inhalation. Tachypnea, tachycardia, coma, seizures, bright red skin. Rapid administration of Amyl Nitrate, sodium Thiosulfate, Sodium Nitrite, Sodium Thiocyanate, Hydroxocabalamin is essential after pt is intubated and placed on vent. Soap and water. Smell is bitter almonds.

Decompensated Liver Cirrhosis

Liver fails to synthesize proteins, clotting factors, and other substances. Presents w/ s/s or portal HTN, ascites, varices, and hepatic encephalopathy. Purpura due to decreased platelet count.

Late Cirrhosis

Liver shrinks as scar tissue contracts and if it is palpable is nodular

Secondary - from debris from scene or shrapnel from the bomb acting as projectiles

Penetrating trunk, skin, and soft-tissue injuries. Fx, traumatic amputations.

Which diagnostic test distinguishes between conductive and sensorineural hearing loss?

Your Response:Rinne test Rationale: Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. In the whisper test, the client with normal acuity can correctly repeat what was whispered from 1 to 2 feet away. Audiometry is used to detect hearing loss. The Weber test uses bones conduction to test lateralization of sound.

Which dietary modification is used for a client diagnosed with acute pancreatitis?

Correct Response:Elimination of coffee Rationale: A high-carbohydrate, low-fat, and low-protein diet should be implemented. Alcohol, caffeine, and spicy foods should be avoided.

Which enzyme aids in the digestion of fats?

Correct Response:Lipase Rationale: Lipase is a pancreatic enzyme that aids in the digestion of fats. Amylase aids in the digestion of carbohydrates. Secretin is responsible for stimulating secretion of pancreatic juice. Trypsin aids in the digestion of protein.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have?

Your Response:Bile-stained vomiting Rationale: Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

A client is admitted to the health care center with hyperglycemia, a 15-pound weight loss, and reports of vague upper and midabdominal pain that increases in intensity at night. The client' health history indicates alcoholism, smoking of a pack of cigarettes daily, and diabetes for the past 20 years. Upon examination the nurse finds swelling in the feet and abdominal ascites. Based on the clinical manifestations, which condition is the most likely diagnosis?

Your Response:Pancreatic carcinoma Rationale: Pain, jaundice, and weight loss are considered classic signs of pancreatic carcinoma. Other signs include rapid, profound, and progressive weight loss as well as vague upper or midabdominal pain or discomfort unrelated to any gastrointestinal function that is often difficult to describe. It is often more severe at night and is accentuated when lying supine. The formation of ascites is common. An important sign is the onset of symptoms of insulin deficiency: glucosuria, hyperglycemia, and abnormal glucose tolerance. Therefore, diabetes may be an early sign of carcinoma of the pancreas.

chemical weapons

Chemical agent used to cause disability and mortality in the general population or military.

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels?

Your Response:Frequent vomiting, leading to loss of fluid volume Rationale: Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

The nurse recognizes which methods are not correct for removing a foreign body from the ear?

Correct Response:Manual pressure Rationale: The three standard methods for removing foreign bodies are the same as those for removing cerumen: irrigation, suction, and instrumentation. Manual pressure is not a correct method for removing a foreign body from the ear.

Which joint is most commonly affected in gout?

Correct Response:Metatarsophalangeal Rationale: The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of clients); this is referred to as podagra. The wrists, fingers, and elbows are less commonly affected. The tarsal area, ankle, and knee are not the most commonly affected in gout.

Which condition is characterized by the formation of abnormal spongy bone around the stapes?

Correct Response:Otosclerosis Rationale: Otosclerosis is more common in females than males and is frequently hereditary. A middle ear effusion is denoted by fluid in the middle ear without evidence of infection. Chronic otitis media is defined as repeated episodes of acute otitis media, causing irreversible tissue damage and persistent tympanic membrane perforation. Otitis externa refers to inflammation of the external auditory canal.

What is the priority intervention for a client who has been admitted repeatedly with attacks of gout?

Rationale: Clients with gout need to be educated about dietary restrictions in order to prevent repeated attacks. Foods high in purine need to be avoided, and alcohol intake has to be limited. Stressful activities should also be avoided. The nurse should assess to determine what is stimulating the repeated attacks of gout. The other interventions are not appropriate for a client with this problem.

A client is admitted to the health care center with severe abdominal pain rated 10 on a 1-to-10 scale, tachycardia, hypertension, and muscle spasms. The nurse immediately administers morphine sulfate 4 mg slow intravenous pyelogram (IVP), as ordered. The nurse plans for which goal after administration of this mediation?

Your Response:To increase the client's pain threshold Rationale: Morphine, fentanyl, and hydromorphone act by depressing the central nervous system, thereby increasing the client's pain threshold.

Nursing management of the client with acute symptoms of benign paroxysmal positional vertigo includes

Your Response:bed rest. Rationale: Bed rest is recommended for clients with acute symptoms. Canalith repositioning procedures may be used to resolve attacks of vertigo, and clients with acute vertigo may be medicated with meclizine for 1 to 2 weeks. The Epley procedure is not recommended for clients with acute vertigo. The Dix-Hallpike test is an assessment test used to evaluate for benign paroxysmal positional vertigo.

Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia

Your Response:may feel as if their symptoms are not taken seriously. Rationale: Because clients present with widespread symptoms that are often vague in nature, health care providers may misdiagnose them. Clients feel as though people are not listening to them. Nurses need to provide support and encouragement. Symptoms of disease vary from client to client and respond to different treatments. Clients do not lose their ability to walk.

A nurse is teaching a client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis?

Correct Response:Self-digestion of the pancreas by its own proteolytic enzymes Rationale: Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. Of clients with acute pancreatitis, 80% had undiagnosed chronic pancreatitis. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum. Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.

Triage Category: Yellow (Delayed)

Injuries are significant and require medical care but can wait hours w/o threat to life or limb. Individuals in this group should be moved away from main triage area. Typical conditions: Stable abd wounds w/o evidence of significant hemorrhage; soft tissue injuries; maxillofacial wounds w/o airway compromise; vascular injuries w/ adequate collateral circulation; GU tract disruption; fx requiring open reduction, debridement, and external fixation; most eye and CNS injuries.

A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which symptom as that most commonly reported by clients with pancreatitis?

Your Response:Severe, radiating abdominal pain Rationale: Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. The pain occurs in the midepigastrium. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion; it may be diffuse and difficult to localize.

Fibromyalgia is a common condition that involves

Rationale: Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathological characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals.

Which statements correctly match the nursing diagnosis with its appropriate nursing intervention for a client suffering with vertigo? Select all that apply.

Correct Response:Risk for trauma: Assist with ambulation., Risk for injury: Encourage vestibular therapy., Risk for deficient fluid volume intake: Encourage oral fluids., Anxiety: Provide information about vertigo and its treatment. Rationale: A client with vertigo is at risk for deficient fluid volume and should be encouraged to drink noncaffeinated and low-sugar fluids. A client with vertigo is at risk for injury, and encouraging the client to do vestibular therapy can decrease the risk for injury. The client with vertigo is also at risk for trauma and should have assistance when ambulating. Providing information about vertigo and its treatment may decrease the anxiety in a client with vertigo. The nurse may contribute to a feeling of powerlessness in the client if the nurse provides a daily schedule of activities. The client should be allowed to participate in determining his or her schedule.

Which terms refers to the progressive hearing loss associated with aging?

Correct Response:Presbycusis Rationale: Age-related changes of both the middle and inner ear result in hearing loss. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

Which is a clinical manifestation of cholelithiasis?

Correct Response:Clay-colored stools Rationale: The client with gallstones has clay-colored stools and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.

Which action by the nurse has the highest priority when caring for a client diagnosed with vertigo?

Correct Response:Educate the client on using the call light for assistance with ambulation. Rationale: The client should restrict movement and change positions slowly to prevent an injury related to the vertigo. The prevention of injury related to the vertigo should be the highest priority nursing intervention; therefore, the nurse needs to teach the client about using the call light for assistance with ambulation. All other interventions are appropriate but do not address safety. The client should keep his or her eyes open and focus on one spot to reduce vertigo.

A nurse is preparing a client for endoscopic retrograde cholangiopancreatography (ERCP). The client asks what this test is used for. Which statements by the nurse explains how ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply.

Correct Response:"It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts.", "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts.", "It can evaluate the presence and location of ductal stones and aid in stone removal." Rationale: ERCP can determine the difference between pancreatitis and other biliary disorders and is generally used in chronic pancreatitis. It is particularly useful in diagnosis and treatment of clients who have symptoms after biliary tract surgery, clients with intact gallbladders, and clients for whom surgery is particularly hazardous. It can be used to assist with the removal of stones. ERCP is a useful tool in providing anatomic details about the pancreas and biliary ducts. It can evaluate the presence and location of ductal stones and detect changes in the anatomy of the client with pancreatitis, such as obstruction in the pancreatic duct and tissue necrosis due to premature release of pancreatic enzymes, and assess for abscesses and pseudocysts and atrophy of the glands in the body. ERCP is rarely used in the diagnostic evaluation of acute pancreatitis because the clients is acutely ill; however, it may be valuable in treating gallstone pancreatitis.

Osteomyelitis

Bone infection caused by bacteria. Staph is culprit 70-80% of the time.

Which term most precisely refers to the incision of the common bile duct for removal of stones?

Choledocholithotomy Rationale: Choledocholithotomy refers to incision of the common bile duct for the removal of stones. Cholecystostomy refers to opening and draining the gallbladder. Choledochotomy refers to opening into the common duct. Choledochoduodenostomy refers to anastomosis of the common duct to the duodenum.

biological weapons

A biological agent used to spread disease among the general population or the military.

systemic lupus erythematosus SLE

Affects the connective tissues of multiple organ systems and can lead to major organ failure.

Which finding is consistent with the diagnosis of rheumatoid arthritis?

Correct Response: Cloudy synovial fluid Rationale: In a client with rheumatoid arthritis, arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.

A client who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the past year. The nurse attributes which factor as the most likely cause of this weight loss?

Correct Response:Skipping meals out of fear of painful attacks Rationale: Weight loss is a major problem in chronic pancreatitis. More than 80% of clients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.

degenerative joint disease (DJD) aka osteoarthritis

Dx by arthrocentesis, arthroscopy, x-ray of affected joint, symptoms. Tx: Epidural injections, medication, PT, rest, sx.

Early Cirrhosis

Fatty enlarged liver, feels firm upon palpating and has sharp edge w/ possible abdominal pain.

Tertiary: from pressure wave that causes victim to be thrown

Head injuries, Fx including skull.

discoid lupus erythematosus DLE

Only affects the skin.

The side effect of bone marrow depression may occur with which medication used to treat gout?

Rationale: A client taking allopurinol needs to be monitored for the side effects of bone marrow depression, vomiting, and abdominal pain.

The digestion of carbohydrates is aided by

Rationale: Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas.

Which term refers to fixation or immobility of a joint?

Rationale: Ankylosis is the fixation or immobility of a joint. It may result from a disease process or from scarring due to trauma. Hemarthrosis refers to bleeding into a joint. Diarthrodial refers to a joint with two freely moving parts. Arthroplasty refers to replacement of a joint.

The nurse teaches the client that the presence of crystals in the synovial fluid obtained from arthrocentesis confirms which disease process?

Rationale: The presence of crystals is indicative of gout; the presence of bacteria is indicative of infective arthritis.

Which phrase defines ossiculoplasty?

Your Response:Surgical reconstruction of the middle ear bones Rationale: Ossiculoplasty is performed to restore hearing. Surgical repair of the eardrum is termed tympanoplasty. Tympanotomy, or myringotomy, is the term used to refer to incision into the tympanic membrane.

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status?

Your Response:To avoid inflammation of the pancreas Rationale: Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.

Level C PPE

air-purified respirator, coverall with splash hood, chemical resistant gloves and boots

Level B PPE

high level of respiratory protection (SCBA) but lesser skin and eye protection; chemical-resistant suit

Nerve Agents

sarin, soman, tabun, VX, Organophosphate. Causes cholinergic symptoms. Bronchospasms. Soap, water, supportive care. Benzo's, Pralidoxime, and Atropine.

Level A PPE

self-contained breathing apparatus (SCBA) and vapor-tight chemical resistant suit, gloves, and boots

Vesicant agents

sulfur mustard (H), lewisite (L) Phosgene oxime (CX) Blistering agents. Superficial to partial thickness burn w/ vesicles that coalesce; Conjunctivitis, nasal irritation. These usually cause the most damage to damp or moist areas of the body (armpits, groin and respiratory tract) (Bullae) Lewisite tx - Dimercaprol IV/Topical Soap and water. Blot; do not rub dry. Do not use hypochlorite solution.

Level D PPE

typical work uniform

Which is an appropriate nursing intervention in the care of the client with osteoarthritis?

Correct Response: Encourage weight loss and an increase in aerobic activity Rationale: Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening, are important approaches to pain management. Clients should be assisted to plan their daily exercise at a time when the pain is least severe, or plan to use an analgesic, if appropriate, before an exercise session. Gastrointestinal complications, especially bleeding, are associated with the use of nonsteroidal anti-inflammatory drugs. Topical analgesics such as capsaicin and methyl salicylate may be used for pain management.

Quaternary: Preexisting conditions exacerbated by the force of the blast or by post blast injury complications.

Severe injuries w/ complex injury patters- burns, crush injuries, head injuries. Common preexisting conditions that become exacerbated-COPD, asthma, cardiac conditions, diabetes, and HTN.

Radiologic Weapon

- byproducts of radiation contamination that are used to cause morbidity and mortality in the general population or the military

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones?

Rationale: Six to 12 months of therapy with UDCA is recommended in clients to dissolve the stones.

Medication-induced lupus erythematosus

Can be caused by medications (procainamide, hydralazine, isoniazid) findings resolve when the medication is discontinued.

Lupus Erythematosus

Characterized by periods of exacerbations (flares) and remissions. Classified as discoid or systemic. A temporary lupus can be medication induced.

The nurse is caring for a client who is being treated for fibromyalgia. What intervention will best assist the client to restore normal sleep patterns?

Correct Response: Tricyclic antidepressants Rationale: Tricyclic antidepressants and sleep hygiene measures are used to improve or restore normal sleep patterns in clients with fibromyalgia. Increasing activity during the day or using range-of-motion exercises will not increase the client's ability to sleep. Narcotics are generally not needed for pain control with this disorder.

A client is admitted with an acute attack of gout. What interventions are essential for this client? Select all that apply.

Correct Response:Probenecid, Corticosteroid therapy, Dietary consult, Pain medication, Serum uric acid concentration Rationale: Steroids may be used in clients who have not responded to other therapies. They have been shown to decrease inflammation and pain in attacks of gout. Probenecid will assist in the excretion of uric acid, the causative agent. Serum uric acid concentrations will guide therapy and treatment. A dietary consult can wait until the client the acute, painful period is over but will be a necessary nursing intervention for a client experiencing gout.

A client is newly diagnosed with otitis externa. Which information should the nurse teach the client before the client leaves the clinic?

Correct Response:Proper instillation of prescribed ear drops Rationale: Otitis externa is usually treated with antimicrobial otic drops. The nurse should anticipate teaching the client how to instill the ear drops properly. Otitis externa is usually not treated with oral antibiotics because it is not a systemic issue. A cotton-tipped applicator should not be used in the ear canal because it can cause trauma, which may lead to otitis externa. Otitis externa may cause temporary conductive, not sensorineural, hearing loss.

The nurse is caring for an 86-year-old client with hearing impairment. The nurse is preparing to educate the client on the diagnosis and discharge plan. What action(s) should the nurse take when talking with the client? Select all that apply.

Correct Response:Provide written instructions and information., Always face the client when talking. Rationale: The nurse, when talking, should always face the client who is hearing impaired. The nurse should provide written instructions and information based on a third-grade, not eighth-grade, reading level. Older adults lose the ability to hear high-pitched tones first; therefore speaking loudly in high-pitched tones will not help with communication for this client. Standing in front of a window can place a shadow on the nurse's face, not allowing the client to see the nurse's face or read lips.

Triage Category: Expectant (black)

Injuries extensive; chance of survival unlikely even w/ definitive care. Persons from this group should be separated from other casualties, but not abandoned. Comfort measures should be provided if possible. Typical Conditions: PTs unresponsive w/ penetrating head wounds, high spinal cord injuries, wounds involving multiple anatomic sites and organs, second/third degree burns in excess of 60% of TBSA, seizures or vomiting within 24 hrs after radiation exposure, profound shock w/ multiple injuries, atonal respirations, no pulse, no b/p, pupils fixed and dilated.

Compensated Liver cirrhosis

Less severe, often vague s/s. Could be incidental finding. Fever, vascular spiders, epistaxis, ankle edema, palmar erythema, vague morning indigestion, flatulent dyspepsia, abd pn, firm and enlarged liver, splenomegaly.

Pulmonary Agents

Phosgene and Chlorine. Separation of alveoli from capillary bed. (Fluid-filled alveoli) Pulmonary edema, bronchospasm, blurry vision; phosgene can result in pain then blisters followed by partial to full thickness burn. Copious flushing. Move to fresh air—away from gases. Ventilatory support. Bronchoscopy. The smell is freshly mown hay.

The result of which diagnostic study is decreased in the client diagnosed with rheumatoid arthritis?

Rationale: Clients diagnosed with rheumatic diseases have a decreased red blood cell count. ESR is increased in inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis.

Which is a gerontological consideration associated with the pancreas?

Response:Increased amount of fibrous material Rationale: An increase in fibrous material and some fatty deposition occurs in the normal pancreas of people older than 70 years of age. There is a decreased rate of pancreatic secretion and decreased bicarbonate output in older adults. Decreased calcium absorption may also occur.

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client?

Your Response: "This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." Rationale: If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

Which symptoms may a client with Ménière disease report before an attack?

Your Response:A full feeling in the ear Rationale: Clients with Ménière disease experience symptoms of headache and a full feeling in the ear before an attack. Nystagmus is an episodic symptom that occurs during an attack, and, at times, the client is symptom free. Ménière disease does not cause low blood pressure or photosensitivity.

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing

Your Response:facial nerve paralysis. Rationale: If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss.

Which precaution should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance?

Correct Response:Have the client wait for help before moving Rationale: The nurse should have the client wait to move until help arrives. Safety measures such as assisted ambulation are implemented to prevent falls and injury. The client should restrict movement. The client should keep his or her eyes open and focus on one spot to reduce vertigo.

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues?

Rationale: Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

Which manifestation is the most problematic for the client diagnosed with Ménière disease?

Rationale: Vertigo is usually the most troublesome complaint related to Ménière disease. Other clinical manifestations include tinnitus, diaphoresis, and hearing loss.

Which statement describes benign paroxysmal positional vertigo (BPPV)?

Your Response: The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired. Rationale: BPPV is a brief period of incapacitating vertigo that occurs when the position of the client's head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however, generally, hearing impairment does not occur. The onset of BPPV is sudden and followed by a predisposition to positional vertigo, usually for hours to weeks but occasionally months or years. BPPV is thought to be caused by the disruption of debris within the semicircular canal. This debris forms from small crystals of calcium carbonate from the inner ear structure, the utricle. BPPV is frequently stimulated by head trauma, infection, or other events.

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test?

Your Response:Serum amylase Rationale: Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

A client undergoing mastoid surgery asks the nurse about the pain following the surgery. Which response by the nurse is appropriate?

Correct Response:"Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours." Rationale: The incisional pain from mastoid surgery is usually mild and controlled by prescribed pain medications. The client should be taking medications routinely the first 24 hours and as needed after 24 hours. Incisional pain usually does not last 3 weeks. The client may feel a sharp shooting pain when the eustachian tube is open for 2 to 3 weeks following surgery. A constant throbbing pain may indicate an infection and should be investigated.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

Response:Measure blood glucose concentration every 4 to 6 hours Rationale: Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

The nurse just completed educating a client on hearing aid care. Which statement by the client indicates that the teaching was effective?

Your Response:"I will use a small pipe cleaner to clean the cannula on the hearing aid." Rationale: The cannula on the hearing aid should be cleaned with a small pipe cleaner or pipe cleaner-like object. Only the ear mold should be cleaned daily using soap and water; no other part of the hearing aid should be cleaned with soap and water. The client should be taught to troubleshoot if the hearing aid whistles. Many times the client can fix the issue when this happens. The ears should not be dried using a cotton-tipped applicator because it can cause trauma and lead to otitis externa.

A 78-year-old client reports decreased hearing in the right ear. The doctor orders irrigation of the right ear to remove cerumen. Which is the priority action by the nurse?

Correct Response:Assess for a ruptured tympanic membrane Rationale: The ear should not be irrigated if the patient has a ruptured tympanic membrane or otitis externa. All other interventions are appropriate when irrigating the ear, but if the patient has a ruptured tympanic membrane the nurse should not irrigate the ear.

Triage Category: Red (Immediate)

Injuries are life-threatening but survivable w/ minimal intervention. This group can progress rapidly to expectant if tx is delayed. Typical conditions: Sucking chest wounds, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abd wounds, incomplete amputations, open fx of long bones, and 2nd/3rd degree burns 15-40% TBSA.

Triage Category: Minimal (Green)

Injuries are minor, and tx can be delayed hours to days. Move away from main triage area. Typical conditions: Upper ext fx, minor burns, sprains, small lacs w/o significant bleeding, behavioral disorders or psych disturbances.

The nurse knows that the serum amylase concentration returns to normal within which time frame?

Rationale: Serum amylase usually returns to normal within 48 to 72 hours.

A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client?

Rationale: Nonsteroidal anti-inflammatory drugs are the mainstay of treatment for rheumatoid arthritis pain. They help to decrease inflammation in the joints. Heat, rather than ice packs, is used to relieve pain. Paraffin baths may also help. Surgery is reserved for joint replacement when the joint is no longer functional; it is not an intervention specific to relieving pain.

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment?

Your Response:"The tube allows the gastrointestinal tract to rest." Rationale: Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply.

Your Response:Alteration of self-concept, Pain, Fatigue Rationale: Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases.

Which statement is consistent with acute otitis media?

Your Response:Conductive hearing loss may occur. Rationale: Approximately three in four children experience an ear infection by the time they are 3 years of age. The infection usually lasts less than 6 weeks. Conductive hearing loss may occur due to a purulent exudate. Bacteria and viruses, not fungi, are the most common causes of otitis media.

Osteoarthritis is known as a disease that

Correct Response: is the most common and frequently disabling of joint disorders. Rationale: The functional impact of osteoarthritis on quality of life, especially for elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy that affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis, polyarthritis, and spondylitis, requires early treatment because of early damage caused by disease. Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues, making them rigid and decreasing mobility; it is usually diagnosed in the second or third decade of life.

It is important for the nurse to educate clients newly diagnosed with Ménière disease to avoid which foods in their diet? Select all that apply.

Correct Response:Caffeine, High-salt foods, Alcohol, Monosodium glutamate Rationale: Alcohol, high salt, monosodium glutamate, and caffeine can worsen symptoms of Ménière disease by affecting fluid levels in the inner ear. There are no restrictions on spicy food for clients displaying symptoms of Ménière disease. Milk and whole grains are encouraged in a client diagnosed with Ménière disease.

Which foods should be avoided following acute gallbladder inflammation?

Correct Response:Cheese Rationale: The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

Which term refers to an altered sensation of orientation in space?

Correct Response:Dizziness Rationale: Dizziness may be associated with inner ear disturbances. Tinnitus refers to a subjective perception of sound with internal origin. Nystagmus refers to involuntary rhythmic eye movement. Ataxia is the failure of muscle coordination and may be present in clients with vestibular disease.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?

Your Response:Assisting the client to turn, cough, and deep breathe every 2 hours Rationale: Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas?

Your Response:Decreases in the physiologic function of major organs Rationale: Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger clients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

primary blast injury - initial blast or air wave

Affects primarily air filled organs. Tympanic membrane rupture, middle ear injury-permanent deafness may occur. Pulmonary: Pneumo, Pulmonary contusion, air embolus. Head injuries, including concussion, other severe brain injuries. Abd hollow organ perf, hemorrhage

Risk factors for Lupus

Age 20-40 Asian, Hispanic, or Native American descent Environmental or Genetic factors Incidence declines in females following menopause but remains steady in males.

Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage?

Rationale: Tophi, when problematic, are surgically excised. Subchondral bone refers to a bony plate that supports the articular cartilage. Pannus refers to newly formed synovial tissue infiltrated with inflammatory cells. Joint effusion refers to the escape of fluid from the blood vessels or lymphatic vessels into the joint cavity.

Which intervention should be included in the plan of care for a client who has undergone a cholecystectomy?

Correct Response:Assessing the color of the sclera every shift. Rationale: If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. Because jaundice may result, the nurse should assess the color of the sclerae.

Which term refers to surgical repair of the tympanic membrane?

Correct Response:Tympanoplasty Rationale: Tympanoplasty may be necessary to repair a scarred eardrum. A tympanotomy, or myringotomy, are incisions into the tympanic membrane. An ossiculoplasty is a surgical reconstruction of the middle ear bones to restore hearing.

A client is diagnosed with otitis externa. Which instruction is most appropriate for the nurse to give?

Correct Response:Avoid swimming for 7 to 10 days. Rationale: The nurse should advise the client to avoid swimming for 7 to 10 days to allow the ear canal to heal completely. Keeping the ear covered with a scarf is not necessary. Keeping a dry cotton ball in the ear may cause further trauma to the ear canal. A cotton ball covered in a water-soluble solution can be used to keep water out while showering or washing hair. Avoiding cold water does not help to improve the client's condition.

Which portion of the middle ear equalizes pressure?

Correct Response:Eustachian tube Rationale: The eustachian tube drains secretions of the middle ear and equalizes pressure in the middle ear with that of the atmosphere. Ossicles, which are held in place by joints, muscles, and ligaments, assist in the transmission of sound. The auricle collects sound waves and directs vibrations into the external auditory canal. The cochlea is a winding, snail-shaped bony tube that forms a portion of the inner ear and contains the organ of Corti, which is the transducer of hearing.

A client with a minor burn would be triaged as

Correct Response:minimal. Rationale: A minor burn would be triaged as minimal. Conditions related to the immediate category include a sucking chest wound and shock. Conditions related to the delayed category include soft-tissue injuries and most eye and central nervous system injuries. Conditions related to the expectant category include unresponsive clients with penetrating head wounds.

A client admitted with severe epigastric abdominal pain radiating to the back is vomiting and reports difficulty breathing. Upon assessment, the nurse determines that the client is experiencing tachycardia and hypotension. Which actions are priority interventions for this client? Select all that apply.

Correct Response:Assist the client to a semi-Fowler position, Administer plasma, Administer pain-relieving medication, Administer electrolytes Rationale: The nurse promptly reports decreased blood pressure (BP) and reduced urine output, which indicate hypovolemia and shock or renal failure. The treatment goals for acute pancreatitis focus on relieving pain, maintaining circulatory and fluid volume, and decreasing the production of pancreatic enzymes. Intravenous replacement of fluid and electrolytes should begin immediately because of the loss of fluid in the body. If hypotension is evident, plasma should be administered to maintain BP within an acceptable range. Fluids are administered intravenously and may be accompanied by infusion of blood or blood products to maintain blood volume and to prevent or treat hypovolemic shock. Low serum calcium and magnesium concentrations may occur and require prompt treatment. The nurse maintains the client in a semi-Fowler position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A low-fat diet, with small frequent meals, should be initiated after control of symptoms; it is not an immediate priority.