AH HESI

s/s hypocalcemia

- muscle twitches/tetany - tingling at the fingertips - hyperactive DTRs - positive Chvostek's sign (tapping on the facial nerve triggering facial twitching) - positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation) - seizures

A 12-year-old child with type 2 diabetes is scheduled for abdominal surgery. Which factors are most important for the nurse to consider during the postoperative period? Select all that apply. 1 Infection will likely occur at the surgical site. 2 Ketoacidosis frequently occurs later in the postoperative period. 3 The blood glucose level will increase because of the stress of surgery. 4 Urine test results are the most useful gauge of diabetic control after surgery. 5 Diabetic control is usually maintained with insulin after surgery.

3,5 The stress of surgery causes the release of epinephrine and glucocorticoids, which increase the blood glucose level. Most individuals with type 2 diabetes who control their diabetes through diet and exercise require insulin during the recovery period. Although the child with diabetes is at risk for infection, surgical aseptic technique should prevent infection. Ketoacidosis is associated with type 1, not type 2, diabetes. Urine test results are affected by many variables and therefore are not reliable indicators of the blood glucose level.

Hydrocephalus develops in an infant who was born with a meningomyelocele, and a ventriculoperitoneal shunt is inserted. What nursing intervention is most important in this infant's care during the first 24 hours after surgery? 1 Placing in the high Fowler position 2 Administering the prescribed sedative 3 Positioning on the same side as the shunt 4 Monitoring for increasing intracranial pressure

4 The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid in the head; the accumulated fluid causes an increase in intracranial pressure, which in turn leads to brainstem hypoxia. Positioning the infant flat helps prevent complications resulting from too-rapid reduction of intracranial fluid. Although pain management is essential to minimize an increase in intracranial pressure, sedation is contraindicated because it will mask the infant's level of consciousness. The infant is positioned on the side opposite the shunt to prevent pressure on the valve and incision area.

What is the color of a client's wound caused by skin tears?

A wound that is caused by skin tears is red in color. A wound caused by a full-thickness or third-degree burn is gray or black in color. Wounds with nonviable necrotic tissue that create an ideal situation for bacterial growth are yellow in color.

A client is scheduled for an abdominal surgery. What is the priority preoperative nursing objective when caring for this client? Recording accurate vital signs Alleviating the client's anxiety Teaching about early ambulation Maintaining the client's nutritional status

Alleviating the client's anxiety

Robert Jones Bandage

Dense, thick multilayered bandage incorporating wood or metal splints to restrain and support an injured leg.

s/s hypokalemia

Dysrhythmias, muscle weakness, decreased BP, prolonged QT wave

s/s hypoglycemia

Headache, tachycardia, cool, clammy skin Headache is a neuroglycopenic response directly related to brain glucose deprivation. Tachycardia occurs with hypoglycemia because of a neurogenic adrenergic response; it is a sympathetic nervous system response precipitated by a low blood glucose level. Cool, clammy skin is a neurogenic cholinergic response; it is a sympathetic nervous system response precipitated by a low serum glucose level.

dumping syndrome

Rapid emptying of gastric contents into small intestines. Client experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia. Small meals with low carbohydrate, moderate fat, and high protein are recommended to avoid this; these are digested more readily and prevent rapid stomach emptying.

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? Relieving muscle spasm and pain Preventing contractures from developing Keeping the client from turning and moving in bed Maintaining the limb in a position of external rotation

Relieving muscle spasm and pain

A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin

The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.

ascites

abnormal accumulation of fluid in the peritoneal cavity

cellulitis

diffuse, acute bacterial infection of the skin marked by local heat, redness, pain, and swelling

acromegaly

do NOT think buffalo hump The client with acromegaly would experience a barrel-shaped chest, thickened lips, and enlarged hands and feet.

Fat Embolism Syndrome (FES)

embolization of fat globules that occurs in a small percentage of patients with fractures. The average time of onset of FES is 18 to 24 hours after injury to long bones or a crushing injury petechial rash is most common s/s

A client is admitted to the hospital with diabetic ketoacidosis. The nurse concludes that the client's elevated ketone level is caused by incomplete oxidation of which nutrient? fats protein carbohydrates potassium

fats incomplete oxidation of fat results in fatty acids that further break down to ketones. Protein metabolism produces nitrogenous waste, causing elevated blood urea nitrogen (BUN), not ketones. Potassium is not oxidized; potassium is not directly associated with ketones. Carbohydrates do not contain fatty acids that are broken down into ketones.

what does liver do?

filter and make RBCs. if liver isn't functioning, RBCs wont be being prodcued and increased chance of bleeding occurs

What are the primary causes of adrenal insufficiency? Select all that apply.

hemmorhage, aquired immune difficiency, TB

gout

hereditary metabolic disease that is a form of acute arthritis, characterized by excessive uric acid in the blood and around the joints

meningocele

herniation of the meninges

Best exercise for building bone mass?

high-impact aerobic (running, tennis, biking, dancing)

after hip replacement surgery

hip should not be flexed >90 so best postion is sitting in a firm chair with foot flat on the floor

Cushing's syndrome

hypersecretion of cortisol, kidneys retain sodium and excreting potassium so they need a low-sodium, high K diet monitor for hypertension

s/s hyperkalemia

irritability, abdominal cramping,

Toxic epidermal necrolysis (TEN)

is a rare acute drug reaction that manifests as diffused redness and large blisters on the skin.Elderly clients on chemotherapy are at greater risk for TEN. also barbiturates use (epilepsy)

serum albumin level

measures the main protein in the blood and is used to determine protein status normal is 3.5-5

A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease? Estrogens Androgens Glucocorticoids Mineralocorticoids

mineralocorticoids

Myelomeningocele (spina bifida)

most severe form of spina bifida in which the spinal cord and meninges protrude through the spine

cast syndrome

occurs when a brace is tightly applied, compressing the superior mesenteric artery against the duodenum.

erythema

redness of the skin due to capillary dilation

Acute osteomyelitis

the infection of bone caused by bacteria, viruses, or fungi. The symptoms of acute osteomyelitis are fever (temperature above 101° F), erythema, and tenderness near the affected area.

parasentesis

the perforation of a cavity of the body or of a cyst or similar outgrowth, especially with a hollow needle to remove fluid or gas.

To treat hypoglycemia

use simple sugar (like packet of sugar) followed by a complex carbohydrate (like bread) and protein. this creates both an initial and a sustained response

Raloxifene

used to treat osteoporosis, estrogen antagonist

s/s hyperglycemia

vomitting (r/t metabolic acidosis) tachypnea (r/t metabolic acidosis)