Week 4 PrepU 270
The nursing student asks the nurse how to tell the difference between ventricular tachycardia and ventricular fibrillation on an electrocardiogram strip. What is the best response?
"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes." Ventricular fibrillation is irregular with undulating waves and no QRS complex, while ventricular tachycardia is usually regular and fast with wide QRS complexes. The rhythms look different on the electrocardiogram strip. The QRS is wide and bizarre or undefined in ventricular fibrillation. The P-R interval is not present in the ventricular dysrhythmias.
A client received burns to the entire back and left arm. Using the Rule of Nines, the nurse can calculate that the client has sustained burns on what percentage of the body?
27% According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.
Which client has the highest risk of ovarian cancer?
45-year-old woman who has never been pregnant The incidence of ovarian cancer increases in women who have never been pregnant, are older than age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken hormonal contraceptives, have had multiple births, or have had a first child at a young age.
A nurse is assessing the client's readiness for discharge from the postanesthesia care unit (PACU). The nurse can rouse the client by calling the client's name. The client can move all extremities and has a blood pressure of 134/82. Baseline preoperative blood pressure was 128/78. The most recent pulse oximetry reading was 94% on room air; the client's respirations are deep and easy at a rate of 12 breaths/minute. What is the calculated Aldrete score?
9 The Aldrete score is used to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the client's condition in the PACU. The client's total Aldrete score is 9 because the client is aroused when name is called (1), moves all extremities (2), is able to breath deeply and cough (2), exhibits circulation (blood pressure) 20% or more above the preanesthesia level (2), and is able to maintain a oxygen saturation level >92% on room air (2).
Which type of glaucoma presents an ocular emergency
Acute- angle-closure glaucoma Acute angle-closure glaucoma results in rapid progressive visual impairment. Normal tension glaucoma is treated with topical medication. Ocular hypertension is treated with topical medication. Chronic open-angle glaucoma is treated initially with topical medications, with oral medications added at a later time.
A client who had intracavity radiation treatment for cervical cancer 1 month earlier reports small amounts of vaginal bleeding. This finding most likely represents:
An expected effect of the radiation therapy After intracavity radiation, some vaginal bleeding occurs for 1 to 3 months. Intermittent, painless vaginal bleeding is a classic symptom of cervical cancer, but given the client's history, bleeding in more likely a result of the radiation. The passage of feces through the vagina, not vaginal bleeding, is a sign of rectovaginal fistula. Vaginal infections are indicated by various types of vaginal discharge, not vaginal bleeding.
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia?
Apply prolonged pressure to needles sites or other sources of external bleeding For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is
Aspirin If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
A client returns to the recovery room following a mastectomy. An initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?
Assessing the vital signs and oxygen saturation level The nurse prioritizes vital signs and breathing based on principles of ABCs.
A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take?
Call for assistance to remove the client from the area The nurse should attempt to redirect the client away from the other client with assistance prior to attempting to use force. Stepping in front of the client who is violent may result in the nurse or other personnel becoming injured. Restraints should be a last measure to keep the client under control and avoid injury to the client or others. Injecting a client without their consent is a form of chemical restraint.
A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate?
Candidiasis Candidiasis is a yeast infection caused by the Candida albicans microorganisms. It may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in folds of the skin. It is often called thrush when located in the mouth. Inspection of the mouth, throat, or vagina reveals areas of white plaque that may bleed when mobilized with a cotton-tipped swab. Kaposi's sarcoma is a purple lesion and is an opportunistic cancer. Hairy leukoplakia is also an indication of oral cancer. Coccidioidomycosis causes diarrhea in the immunosuppressed client.
A client is color blind. The nurse understands that this client has a problem with:
Cones Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.
A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:
Cover the opening with petroleum gauze If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.
The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists?
Dehiscence Dehiscence is a disruption. Of the incision
Which of the following would lead a nurse to suspect that a client has a rotator cuff tear?
Difficulty lying on affected side Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.
When assessing a client prescribed hemodialysis, the nurse notes the client's blood pressure is 140/82 mm Hg, heart rate is 82 beats/min, and respirations are 12 breaths/min. The nurse also notes a continuous vibration over the client's fistula. What is the appropriate action by the nurse?
Document presence of a thrill The continuous vibration noted when palpating a hemodialysis fistula is known as a thrill. This is an expected finding so the nurse should document the presence of the thrill. There is no need to contact the healthcare provider or to hold the hemodialysis. The nurse should not administer oxygen as there is no indication that the client is in need of oxygen at this time.
The nurse is providing care to a client who has been admitted to the hospital for treatment of an infection. The client is visually impaired. Which of the following would be most appropriate for the nurse to do when interacting with the client?
Face the client when speaking directly to them When interacting with a client with a visual impairment, the nurse should face the client and speak directly to the client using a normal tone of voice. It is not necessary to raise the voice unless the client asks the nurse to do so and it is not necessary to avoid the terms, "see" or "look" when interacting with the client. The nurse should identify himself or herself when approaching the client and before making any physical contact.
A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time?
Fetal heart rate of 80 bpm A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean birth to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.
When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?
Frequent position changes Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.
Which precaution should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance?
Have the client wait for help before moving 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.
A client with acromegaly has been given the option of a surgical approach or a medical approach. The client decides to have a surgical procedure to remove the pituitary gland. What does the nurse understand this surgical procedure is called?
Hypophysecomy The treatment of choice is surgical removal of the pituitary gland (transsphenoidal hypophysectomy) through a nasal approach. The surgeon may substitute an endoscopic technique using microsurgical instruments to reduce surgical trauma. A hysteroscopy is a gynecologic procedure. The thyroid gland is not involved for a surgical procedure. Ablation is not a removal of the pituitary gland.
A patient who has been on penicillin therapy for several days has developed inflamed oral mucous membranes and swelling in the tongue and the gums. The primary health care provider has diagnosed it as a fungal superinfection of the oral cavity resulting in impaired oral mucous membranes. Which of the following interventions should the nurse perform?
Inspect math and gums regularly The nurse should regularly inspect the patient's mouth and gums to assess the patient's progress. The nurse should instruct the patient to use a soft-bristled toothbrush. The patient need not follow a liquid diet; a nonirritating soft diet can be recommended. Gargling every two hours may not help relieve the symptoms and may even aggravate the existing condition.
NPH is an example of which type of insulin
Intermediate-acting
The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate?
International normalizedration (INR) The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of warfarin.
A pelvic examination reveals that a woman's uterus is retroflexed. Which of the following best depicts this position?
It faces the wrong way! Points to the spine instead of to the belly button In retroflexion, the uterus bends posteriorly, as shown in option B. In retroversion, the uterus turns posteriorly as a whole unit, as shown in option A. In anteversion, the uterus tilts forward as a whole unit, as shown in option C. In anteflexion, the uterus bends anteriorly, as shown in option D
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?
Lamictal Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).
The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated?
Liver function study The liver metabolizes and biotransforms the medications ingested. Geriatric clients who experience polypharmacy or multiple medications have an elevated risk of liver impairment. Routine liver function studies monitor the status of the liver and its ability to metabolize.
A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?
Lung sounds A client with COPD is at risk for developing pneumothorax. The description given is consistent with possible pneumothorax. Though the nurse will assess all the data, auscultating the lung sounds will provide the nurse with the information if the client has a pneumothorax.
A 75-year-old patient with a history of renal impairment is admitted to the primary health care center with a UTI and has been prescribed a cephalosporin. Which of the following interventions is most important for the nurse to perform when caring for this patient?
Monitoring blood creatinine levels An elderly patient is more susceptible to the nephrotoxic effects of the cephalosporins. Since renal impairment is present, it is important for the nurse to closely monitor the patient's blood creatinine levels. The nurse should conduct a test for occult blood if blood and mucus occur in the stool and monitor the fluid intake if there is a decrease in urine output. The nurse does not need to monitor for increased glucose levels unless the patient has a history of diabetes.
A nurse receives a report that a client has had an overdose of heparin. Which action by the nurse is most important in managing the overdose?
Obtain an order to give protamine sulfate Protamine sulfate is the reversal agent for heparin. Administering this would be the best way to treat the client. The other options do not reverse heparin and therefore will not treat the overdose.
A 71-year-old client reports to the nurse that he often notices a pink tinge to his urine. Upon further questioning, he states that he experiences no pain when voiding and has not noticed any change in the frequency of his voiding. Which response by the nurse is best?
Promptly report this finding to the client's health care provider Painless hematuria should be reported promptly because it is associated with bladder cancer. Frequency, urgency, and dysuria occasionally accompany the hematuria, but this is not always the case. It would be irresponsible to delay referral by suggesting diet changes or watchful waiting. Catheterization is unnecessary to obtain a urine specimen.
When providing care to a client with a viral infection, the nurse knows that ribavirin (Virazole) for inhalation is used to treat which virus?
RSV Ribavirin is an antiviral used to treat RSV. AIDS is not a virus; it is the condition caused by HIV.
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
Restricting fluid To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load
The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply.
Reverses decreased respiratory rate of 10 Reverses decreased level of consciousness Reverses blood pressure of90/58 Therapeutic effect includes reversal of respiratory depression, sedation, and hypotension. Therapeutic effect does not include increasing nerve pain or increasing inflammation.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
Serum sodium level of 124 mEq/L In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Temperature of 102.5 F Intra operative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
The client was recently diagnosed with a hiatal hernia. The healthcare provider orders an antacid that has reduced adverse effects. What should the nurse include in the client's teaching about the side effects of antacids?
The major side effect of an anti acid is diarrhea Major side effects of antacids include diarrhea, constipation, dry mouth, gas, nausea, and stomach pain. These should be explained to the client. Side effects do not include profuse sweating, decreased urge to urinate, or fast breathing. Some antacids, depending on the type, can cause dry mouth, increased urge to urinate, and slow breathing.
A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth?
Umbilical cord prolpse Indications for cesarean birth include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean birth, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. Insufficient perineal stretching; rapid, progressive labor; and fetal prematurity aren't indications for cesarean birth.
Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?
Vital signs within normal limits, absence of chill and cough Pneumonia is characterized by chills, fever, tachypnea, tachycardia, and sometimes cough.
A client has just begun treatment with busulfan, 4 mg by mouth daily, for chronic myelogenous leukemia. The client receives busulfan until their white blood cell (WBC) count falls to between 10,000/mm3 and 25,000/mm3. Then the drug is stopped. When should treatment resume?
When the WBC count rises to 50,000 mm3 Busulfan treatment should resume when the WBC count rises to 50,000/mm3. Hair growth and anemia aren't appropriate markers for resuming busulfan treatment.
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?
extravasation The nurse needs to monitor IV administration of antineoplastics (especially vesicants) to prevent tissue necrosis to blood vessels, skin, muscles, and nerves. Stomatitis, nausea/vomiting, and bone pain can be symptoms of the disease process or treatment mode but does not require immediate action.
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?
A liver biopsy A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.
A nurse is evaluating a client's morning laboratory values. Which result requires that the nurse notify the health care provider?
Creatinine: 10.6 mg/dL A rise in the serum creatinine level to three times its normal value suggests that there is a 75% loss of renal function, and with creatinine values of 10 mg/dL or more, it can be assumed that approximately 90% of renal function has been lost.
A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?
Elevated ST segments Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.
A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for?
Esssential thrombocytopenia Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.
A client visits the clinic reporting a circular rash on the upper right arm. The rash is diagnosed as tinea corporis. For what type of infection does the nurse anticipate the client will be treated?
Fungus One type of fungal infection is superficial (dermatophytoses), which affect the skin, hair, and nails; examples include tinea corporis, or ringworm, and tinea pedis, also known as athlete's foot. Rickettsiae, protozoans, and mycoplasma have different characteristics and transmission than fungus.
A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication?
Labetalol This client is showing signs and symptoms of a hypertensive crisis, or hypertensive emergency, and the nurse should anticipate treatment/medications to lower the blood pressure. Labetalol is a beta-blocker medication given intravenously that is often a first-line treatment for hypertensive crisis. Norepinephrine is not indicated for this client as it is a vasopressor and increases blood pressure. Amiodarone is given for cardiac arrythmias and would not help lower blood pressure. Methotrexate is an antineoplastic medication used for treating various cancers and severe rheumatoid arthritis.
A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next?
Ondansetron An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).
Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?
Providing supportive care vCJD is a progressive fatal disease, and no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although client isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.
A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?
Rh-negative mother; Rh-positive child A mother who is Rh negative and gives birth to an Rh positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh negative mother. An Rh-negative mother can carry an Rh-negative child without being at greatest risk for a febrile nonhemolytic reaction; however, these mothers are often treated prophylactically. An Rh-positive mother may carry either an Rh-positive or Rh-negative child without increased risk.
A client in a long-term care facility has signed a form stating that the client does not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?
The client should be treated with antibiotic for pneumonia The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.
A 5-year-old child returns to the pediatric unit following a cardiac catheterization using the right femoral vein. The child has a thick elastoplast dressing. Which assessment finding requires immediate intervention?
The pedal pulse of the right leg is not detected Using the femoral vein during catheterization can cause the affected blood vessels to spasm or cause a blood clot to develop, altering circulation in the leg. The inability to detect the pedal pulse in the affected leg is an ominous sign and requires immediate intervention. Small amounts of coolness or pallor are normal. These findings should improve. Although the nurse should continue to monitor a dressing with a small amount of blood on it, this finding is not the priority in this situation.
Laboratory testing is ordered for a male client during a clinic visit for routine follow-up assessment of hypertension. When interpreting lab values, the nurse knows:
A normal value represents the test results that fall within he bell curve What is termed a normal value for a laboratory test is established statistically from results obtained from a selected sample of people. A normal value represents the test results that fall within the bell curve or the 95% distribution. Some lab values (like hemoglobin) are adjusted for gender, other comorbidities, or age. If the result of a very sensitive test is negative, it tells us the person does not have the disease and the disease has been ruled out or excluded.
The nurse notes that the client demonstrates generalized pillow and recognizes that this finding may be indicative of
Anemia In light-skinned individuals, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance. Albinism is a condition of total absence of pigment in which the skin appears whitish pink. Vitiligo is a condition characterized by the destruction of melanocytes in circumscribed areas of skin, resulting in patchy, milky-white spots. Local arterial insufficiency is characterized by marked localized pallor.
A patient sustains a fracture of the arm. When does the nurse anticipate pendulum exercise should begin?
As soon as tolerated, after a reasonabl period of immobilization Many impacted fractures of the surgical neck of the humerus are not displaced and do not require reduction. The arm is supported and immobilized by a sling and swathe that secure the supported arm to the trunk (Fig. 43-10). Limitation of motion and stiffness of the shoulder occur with disuse. Therefore, pendulum exercises begin as soon as tolerated by the patient. In pendulum or circumduction exercises, the physical therapist instructs the patient to lean forward and allow the affected arm to hang in abduction and rotate. These fractures require approximately 4 to 10 weeks to heal, and the patient should avoid vigorous arm activity for an additional 4 weeks. Residual stiffness, aching, and some limitation of ROM may persist for 6 months or longer (NAON, 2007).
A nurse assesses that a patient is at increased risk for depression based on which of the following
Co-existing medical problems Risk factors for depression include a medical comorbidity, family history, stressful situations, female gender, prior episodes of depression, an onset before age 40 years, past suicide attempts, lack of support systems, history of physical or sexual abuse, and current substance abuse. Sporadic alcohol ingestion does not indicate substance abuse.
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?
Mastitis Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy.
After receiving large doses of an ovulatory stimulant such as menotropins, a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. Based on this assessment, what should the nurse do next?
Notify the healthcare provider Ovarian hyperstimulation syndrome is caused by an excessive response to the medications used to produce eggs and make them grow. With the increased number of growing follicles, the estradiol levels are increased, leading to fluid leaks in the abdomen. There is increased vascular permeability that causes rapid accumulation of fluid in the peritoneal cavity, thorax, and pericardium. Some symptoms of the problem are an increased weight gain of 3 pounds or more over a 2-day period, shortness of breath, abdominal pain, dehydration, vomiting, and the production of blood clots. The healthcare provider should be notified as soon as possible. The woman may require hospitalization and a paracentesis. If the woman is not admitted to the hospital, the woman should be instructed to stop the medication, rest, and drink large amounts of electrolyte fluids.
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.