Z- NUR 180: Module 2 Exam
Which client would the nurse identify as being most at risk for experiencing a CVA 1. A 55-y.o. African American male 2. an 84 yo Japanese female 3. a 67 yo caucasian female 4. a 39 yo pregnant female
Answer: 1 Rationale: 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
The nurse is assessing the client diagnosed with CHF. Which lab data would indicate that the client is in severe CHF. 1. Elevated B type natriuretic peptide (BNP) 2. Elevated Creatine kinase 3. A positive D-dimer 4. A positive ventilation/perfusion scan
Answer: 1 Rationale: BNP is a specific diagnostic test. Levels higher than normal indicate CHF, with the higher the number the more severe the CHF
The nurse is caring for a client diagnosed with rule out peptic ulcer disease. which test confirms the diagnosis? 1. Esophagogastroduodenoscopy 2. MRI 3. Occult blood test 4. Gastric acid stimulation
Answer: 1 Rationale: The esphagogastroduodenoscopy (EGD) is an invasive diagnostic test which visualizes the esophagus, stomach, and duodenum to accurately diagnose an ulcer and evaluate the effectiveness of the client's treatment
The Client is admitted to the telemetry unit diagnosed with acute exacerbation of CHF. Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet 2. Thick white sputum and crackles that clear with cough 3. The client sleeping with no pillow and eupnea 4. Radial pulse rate of 90 and capillary refill time less than 3 seconds
Answer: 1 Rationale: the client with CHF would exhibit tachycardia, dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status
The client with CAD asks the nurse " Why do I get chest pain" which statement would be the most appropriate by the nurse? 1. Chest pain is caused by decreased oxygen to heart muscle 2. there is ischemia to the myocardium as a result of hypoxemia 3. the heart muscle is unable to pump effectively to perfuse the body 4. chest pain occurs when the lungs cannot adequately oxygenate the blood
Answer: 1 Rationale: this is a correct statement presented in laymans terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain
The nurse is preparing to administer a beta blocker to the client diagnosed with CAD. Which assessment data would cause the nurse to question administering the medication? 1. Bp of 110/70 2. Apical pulse of 56 3. Complaint of headache 4. Potassium level 4.5 mEq/L
Answer: 2 Rationale: A beta blocker decreases sympathetic stimulation of the heart, thereby decreasing the heart rate. An apical rate of 56 is lower than normal heart rate and should make the nurse question administering the med because it will further decrease the heart rate
The nurse is developing a nursing care plan for a client diagnosed with CHF. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge 2. Have an audible S1 and S2 with no S3 heard by end of shift 3. Turn, cough, and deep breathe every 2 hours 4. have a pulse ox reading of 98% by day 2 of care
Answer: 2 Rationale: Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening
The health care provider has ordered an angiotensin converting enzyme inhibitor for the client diagnosed with CHF. Which discharge instructions should the nurse include? 1. instruct client to take a cough suppressant if a cough develops 2. teach the client how to prevent orthostatic hypotension 3. encourage the client to eat bananas to increase potassium levels 4. explain the importance of taking medication with food
Answer: 2 Rationale: Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored
The client diagnosed with CHF is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. check the client for peripheral edema and make sure the client takes a diuretic early in the day 2. monitor the client's potassium level and assess the client's intake of bananas and orange juice 3. determine if the client has gained weight and instruct the client to keep the legs elevated 4. instruct the client to ambulate frequently and perform calf muscle stretching
Answer: 2 Rationale: the most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. perform passive ROM 2. assess the client's neurovascular status 3. keep the client in high fowlers position 4. assess the gag reflex prior to feeding patient
Answer: 2 Rationale: the nurse must make sure that blood is circulating to the right leg so the client should be assessed for pulses, paresthesia, coldness, and pallor
The nurse is developing a discharge teaching plan for the client diagnosed with CHF. Which interventions should be included in the plan? Select all that apply 1. Notify health care provider of a weight gain of more than 1 pound in a week 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside 3. Instruct client to remove the saltshaker from the dinner table 4. Encourage client to monitor urine output for change in color to become dark 5. Discuss the importance of taking loop diuretics at bedtime
Answer: 2,3 Rationale: The client should not take digoxin if the radial pulse is less than 60. The client should be on a low sodium diet to prevent water retention
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 priority? 1. Prepare to administer recombinant tissue plasminogen 2. Discuss the precipitating factors that caused the symptoms 3. Schedule for a STAT CT scan of the head 4. Notify the speech pathologist for an emergency consult.
Answer: 3 Rationale: a CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If CVA is diagnosed a CT scan can determine if its hemorrhagic or ischemic accident and guide treatment
The nurse is assessing the client diagnosed with CHF. Which signs/symptoms would indicate that the medical treatment has been effective? 1. the clients peripheral pitting edema has gone from 3+ to 4+ 2. the client is able to take the radial pulse effectively 3. The client is able to perform ADLs without dyspnea 4. The client has minimal JVD
Answer: 3 Rationale: Being able to perform ADLs without shortness of breath would indicate the client's condition is improving. The client's heart is more effective pump and can oxygenate the body better with out increasing fluid in the lungs
The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced nurse? 1. the client diagnosed with CHF who is being discharged in the morning 2. the client who is having frequent incontinent liquid BMs and vomiting 3. the client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62 4. The client who is complaining of chest pain with inspiration and nonproductive cough.
Answer: 3 Rationale: This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client
The nurse is planning care for a client experiencing agnosia secondary to CVA. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration 2. position the client in a semi fowler's position when sleeping 3. place a suction set up at the client's bedside during meals 4. Refer client to an occupational therapist for evaluation
Answer: 4 Rationale: A collaborative intervention is an intervention in which another health care discipline- in this case, OT
The nurse enters the room of a client diagnosed with CHF. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the clients forehead 2. obtain a pulse ox reading 3. take the clients vital signs 4. assist the client to a sitting position
Answer: 4 Rationale: The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse ox and then sponge the clients forehead
The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with CHF. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. measure I &O 2. provide 2 g sodium diet 3. weight client daily 4. plan for frequent rest periods
Answer: 4 Rationale: scheduling activities and rest periods allows the client to participate in his or her own care and assesses the desired outcome
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette 2. Transport the client to the ICU via stretcher 3. Provide client going home discharge teaching instructions 4. Help position the client who is having a portable X-ray done
Answer: 4 Rationale: the UAP can assist the X-ray tech in positioning the client for the portable X-ray. this does not require judgment
What are we looking for on the CBC with Gastroenteritis
Are both hematocrit and hemoglobin low enough they need a transfusion? Are their white blood cells elevated and showing they have an infection
Diagnostic testing for GERD
Barium swallow, EGD, 24 hr ambulatory pH monitoring, esophageal manometry
Blood tests for Gastroenteritis
CBC, Chem 7
Bacterial causes of gastroenteritis
Campylobacter bacterium, E. Coli enteritis, salmonella, shigellosis, staphylococcus, Yersinia, Parasites
Diagnostic procedures for PUD
EGD (esophagogastroduodenoscpy)
GERD stands for
Gastroesophageal Reflux Disease
PUD Risk factors
H. pylori infection, NSAID drugs, Corticosteroid usage, Severe stress, Hypersecretory states, Type O blood, Excess alcohol ingestion, Chronic pulmonary or kidney disease, Zollinger-ellison syndrome
Laboratory tests for PUD
H.pylori testing, Urea breath testing, IgG serologic testing, Stool sample, Hct, Hgb
Acid Controlling medications for PUD
H2 receptor antagonists, tagamet, pepcid, zantac, axid, PPI
Common NSAIDs
Ibuprofen, Naproxen, Tolectin, Indomethacin, feldene, clinoril, mobic, daypro, toradol, celebrex
Gastroenteritis tends to spread quickly through what areas of living?
LTC, dorms, homes, prisons, and cruise ships
Symptoms of Gastroenteritis
Loss of appetite, bloating, nausea, vomiting, diarrhea, abdominal pain and cramps, bloody stool possible, pus in stools possible, lethargy, fever and weakness
If a patient with gastroenteritis presents with the following lab values which F&E imbalance do they have and why? pH: 7.28 CO2: 43 HCO3: 20 PaO2: 88 SaO2: 96
Metabolic Acidosis rationale: its caused by the diarrhea since the patient is loosing all the electrolytes and fluids rapidly
Treatment for gastroenteritis
NPO, IV hydration, oral hydration, antibiotics, anti nausea medication, pain medication, resume diet when able
Viral causes of gastroenteritis
Norovirus, rotavirus, astrovirus, and adenovirus
Clinical manifestations of PUD
Pain is the first symptom usually seen, feelings of emptiness along with pyrosis and eructions
PPI meds
Prilosec (omeprazole), Prevacid (lansoprazole), Protonix (pantoprazole) Nexium (esomeprazole), Aciphex (rabeprazole)
peptic ulcer
a break in the mucous lining of GI tract exposed to acid-pepsin secretions, including the esophagus, stomach, and duodenum
Peptic Ulcer Disease (PUD)
a break in the mucous lining of the GI tract where it comes in contact with gastric juices
What is GERD
a disease in which stomach contents flow back up into the esophagus
What do gastric juices contain?
acid, pepsin, and bile which are all corrosive substances
Cycloprotective agents; Carafate
acts locally to form a barrier over the ulcerated area, protects from further erosion; does nothing to neutralize or decrease acid secretion
Gastroenteritis definition
an infection or inflammation of the digestive tract, particularly the stomach and intestines
Intractability
an ulcer that refuses to respond to treatment
The nurse on the telemetry unit has just received the am shift report. which client should the nurse assess first? 1. the client diagnosed with MI who has audible S3 heart sounds 2. The client diagnosed with CHF who has 4+ sacral pitting edema 3. The client diagnosed with pneumonia who has a pulse ox reading of 94% 4. The client with chronic renal failure who has an elevated creatinine level
answer: 1 Rationale: an S3 heart sound indicated left ventricular failure, and the nurse must assess this client first because it is an emergency situation
Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? 1. Auscultate the client's bowels in all four quadrants 2. palpate the abdominal area for tenderness 3. percuss the abdominal borders to identify organs 4 Assess the tender area progressing to nontender
answer: 1 Rationale: auscultation should be used prior to palpation or percussion when assessing the abdomen. manipulation of the abdomen can alter bowel sounds and give false information
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? 1. An oral anticoagulant medication 2. a betta blocker medication 3. an anti-hyperuricemic medication 4. a thrombolytic medication
answer: 1 Rationale: the nurse would anticipate an oral anticoagulant, warfarin, to prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. the thrombi can become embolic and may case a TIA or CVA
The client diagnosed with a right sided CVA is admitted to the rehab unit. Which interventions should be included in the nursing care plan? Select all that Apply 1. Position the client to prevent shoulder adduction 2. Turn and reposition the client every shift 3. encourage the client to move the affected side 4. Perform quadricep exercises 3x a day 5. Instruct the client to hold the fingers in a fist
answer: 1, 3 Rationale: Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible
The nurse is assessing a client experiencing motor loss as a result of left sided CVA. Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia 2. Paralysis of the right side of the body and ataxia 3. Homonymous hemianopsia and diplopia 4. Impulsive behavior and hostility toward family.
answer: 2 Rationale: The most common motor dysfunction of a CNA is paralysis of one side of the body, hemiplegia; in this case with left sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement
Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications 2 use of NSAIDS 3. any known allergies to drugs and environment 4. medical histories of at least three generations
answer: 2 Rationale: Use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach which is protective mechanism to prevent damage from hydrochloric acid
The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply 1. perform a complete pain assessment 2. Assess the client's vital signs frequently 3. Administer a PPI intravenously 4. obtain permission and administer blood products 5. monitor intake of a soft, bland diet
answer: 3,4 Rationale: this is a collaborative intervention the nurse should implement. it requires an order from the HCP 4) administering blood products is collaborative, requiring an order from the HCP
The male client is diagnosed with CAD and is prescribed sublingual nitro. Which statement indicates the client needs more teaching? 1. I should keep the tablets in the dark colored bottle they come in 2. if the tablets do not burn under my tongue they are not effective 3. i should keep the bottle with me in my pockets at all times 4. if my chest pain is not gone with one tablet, i will go the ER
answer: 4 Rationale: the client should take one tablet every five minutes and if no relief occurs after the third table, have someone drive him to the emergency department or call 911
Which assessment data support to the nurse the client's diagnosis of gastric ulcer? 1. presence of blood in the client's stool for the past month 2. reports of a burning sensation moving like a wave 3. sharp pain in the upper abdomen after eating a heavy meal 4. complaints of epigastric pain 30-60 minutes after ingesting food
answer: 4. Rationale: in a client diagnosed with a gastric ulcer, pain usually occurs 30-60 minutes after eating, but not at night. In contrast, a client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs 1-3 hours after a meal
Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. alteration in bowel elimination patterns 2. knowledge deficit in the causes of ulcers 3. inability to cope with changing family roles 4. potential for alteration in gastric emptying
answer: 4. rationale: 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
Drug causes of gastroenteritis
antibiotics can cause gastroenteritis in susceptible people and can irritate the digestive tract
Pyloric Obstruction
area distal to pyloric sphincter becomes scarred and stenosed from spasm, edema, scar tissue
Nursing interventions for PUD
avoid alcohol consumption, smoking cessation, manage stress, avoid NSAIDs, take medications, notify cpp if any signs of bleeding is noted, don't crush or chew tablets, change diet- refer to a dietition
PPI (protein pump inhibitors)
block both gastrin stimulated and basal acid secretion. used for long term treatment of hypersecretory conditions and for short term treatment of PUD
How do NSAIDS exert topical injury?
by crossing the lipid membrane of gastric epithelial cells, damaging the cells themselves
Greatest complication of Gastroenteritis
dehydration. The risk for dehydration increases as symptoms are prolonged. Dehydration should be suspected if a dry mouth,, increased or excessive thirst, or scanty urination is experienced
PUD pt education
discuss smoking cessation and stress management, educate on foods to avoid that cause excessive HCL production, medication regime, educate on the importance of med compliance, Don't crush, chew, or break SR tablets
What is the most frequent site of PUD
duodenal site
Parasitic causes of Gastroenteritis
entamoeba, histolytica, giardia lamblia, cryptosporidum
Nursing interventions for Gastroenteritis
establish rapport with pt, check vital signs, assess bowel sounds, assess pain, assess neurostatus, assess what OTC treatments they have done, assess for any edema, NPO until normal diet can be resumed, Medicate as ordered
Ulcerogenic substances besides NSAIDS
excessive alcohol, caffeine, ASA, aminophylline, and steroids
Patient education of gastroenteritis
handwashing, keep cold foods cold, hot foods hot, uses paper towels instead of cloth towels when drying hands, cook food throughly, keep bathrooms clean, be aware of traveling alerts, vaccines
Symptoms of GERD
heartburn, dysphagia, regurgitation, chest pain, pain after eating, belching, night time cough, early morning sore throat
Complications of PUD
hemorrhage, perforation, pyloric obstruction, intractability
What do blood cultures show in terms of bacteria?
how long it takes to grow, and what antibiotics it responds to and is resistant to.
Where do duodenal ulcers usually develop
in the proximal portion of the duodenum
Causes of GERD
increased gastric volume, transient relaxation of the lower esophageal sphincter, an incompetent lower esophageal sphincter, increased pressure in the stomach, hiatal hernia, positioning that allows gastric contents to remain close to gastroesophageal junction
Another name for Gastroenteritis
intestinal flu
Diagnosis of gastroenteritis
it is important to establish the cause as different types of gastroenteritis respond to different treatments.
Chemical causes of gastroenteritis
lead poisoning, food poisoning
Diagnostic methods for Gastroenteritis
medical history, physical examination, blood tests, stool tests
PUD nursing interventions
monitor for orthostatic changes in vital signs and tachycardia as these findings are suggestive of GI bleed, administer saline lavage via NG tube if ordered, Administer meds as ordered, decrease environmental stress, encourage rest periods
s/s of pyloric obstruction
nausea, vomiting, constipation, epigastric fullness, anorexia, weight loss
COX-1 Enzyme
necessary to maintain the integrity of gastric mucosa
Risk factors of GERD
obesity, excessive alcohol consumption, smoking, hiatal hernia, pregnancy
Treatment of perforation
only treatment is surgery
how might the pain of perforation be referred to
pain may be referred to right shoulder due to irritation of phrenic nerve in the diaphragm
Pain of PUD
pain typically described as gnawing, burning, aching, or hunger like and is experienced in epigastric region sometimes radiating to the back and is relieved by eating with a classic pain, food, relief pattern
chemical food poisoning
poisoning occurs after ingesting poisonous species such as shell fish or mushrooms
Use of Cycloprotective agents is contraindicated in
pregnancy
Common causes of PUD
presence of H.pylori or C. pylori, the use of apirin and NSAIDS/Steroids, gastric hyperactivity as in Zollinger-Ellison Syndrome, smoking, Type O blood, Alcohol abuse
What is one goal of gastroenteritis care
prevent dehydration and manage diarrhea
Antacid Therapy
remain the mainstay of symptomatic treatment, want to inactivate pepsin and do this by keeping pH of gastric secretions at 3.5 or higher
COX-2 Enzyme
responds to inflammatory stimulation
Perforation
rupture, as in the penetration of ulcer through mucosal wall
S/S of perforation
sudden severe upper abdominal pain, vomiting, fainting, shock/death if left untreated
Treatment of intractability
surgery may be needed- typically last choice for treatment, vagotomy, pyloraplasty, bilroth I or bilroth II procedures
When to seek prompt treatment for Gastroenteritis
symptoms lasting longer than a week, fever greater than 102F, blood in stool or vomitus, severe abdominal swelling and pain
How does gastroenteritis spread
the infection is highly contagious illness that spreads through close contact with the people who are infected, or through contaminated food or water
What does a nurse need to know in terms of giving broad spectrum antibiotics?
they can cause kidney problems
How do NSAIDS contribute to PUD
though both systemic and topical mechanisms of injury. NSAIDs interrupt prostaglandin synthesis by disrupting the action of the two COX enzymes
Treatment of hemorrhage
treat hypovolemia, iced saline lavage, endoscopic procedures to coagulate bleeders with lasers, heat probes, injection of epinephrine, partial gastrectomy may be needed
Treatment of pyloric obstruction
treat with NG tube, surgery may be needed
H.Pylori
unique to colonizing in the stomach and decreases cells ability to produce mucous
Hemorrhage
upper GI bleeding is most common complication, 30-40% mortality rate, large upper GI bleed-hematemesis, coffee ground emesis
Cycloprotective agents; Cytotec
used specifically to prevent NSAID induced PUD in those at high risk or in those with a history of same; used when person taking NSAIDs; replaces gastric prostaglandins depleted by NSAID therapy
Barium Swallow
used to see any pathological abnormalities to evaluate the esophagus, stomach, and upper small intestine
Prognosis of gastroenteritis
usually resolved within 2-3 days and there are no long term effects. if dehydration occurs recovery is extended by a few days
