Exam 1 Medsurg

What helps corrects hyperkalemia?

Acidosis

The nurse is assessing the genitourinary status of an older adult female patient who is experiencing stress incontinence. What finding is a common gerontologic finding for this population? A) Renal filtration rate increases B) Urine is more dilute in the older population. C) Bladder capacity decreases with advanced age. D) All patients develop urinary tract infections.

C) Bladder capacity decreases with advanced age.

What foods can the nurse recommend for the patient with hypokalemia?

Fruits such as bananas and apricots

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

ABG analysis

What are some major causes of hyperkalemia?

- Decreased renal excretion -Rapid administration of potassium -Pt with hypoaldosteronism or Addison disease

What can cause hypocalcemia?

- Vitamin D deficiency - Hypoparathyroidism - pts with kidney injures

What are nursing interventions of hypocalcemia?

-Assess for muscle for weakness -Assess for flank pain--> kidney stones -Assess airway(stridor can occur) -Setup up seizure precautions

What are the contributing factors of hypomagnesemia?

-Chronic alcoholism -Parental nutrition - chronic laxative use

What frequently leads to hypokalemia?

-Gastric suctioning -Vomiting

isotonic solutions

-Lactated Ringer's solution - .9% NaCl - D5W

What medications can induce hypokalemia?

-Potassium-losing diuretics (ex: loop and thiazide diuretics)

What can occur because of hypocalcemia?

-Seizures -Osteoporosis -numbness and tingles of toes

What ECG changes are specific to hypokalemia?

-flat T wave -ST depression -elevated U wave -prolonged PR interval

A nurse is preparing a teaching plan based on MyPyramid recommendations to promote healthy nutrition for an adult. The nurse would recommend a daily milk intake of how many cups?

3

How long is a person expected to keep a record of food consumed over a period of time?

3 to 7 days

A waist circumference greater than which value indicates excess abdominal fat in men?

40 in

When calculating ideal body weight for women, how many pounds should a nurse add for each additional inch over 5ft?

5 lb

Isotonic Lactated ringers

5% dextrose in 0.2% saline (D5W)

The nurse is assisting an older adult patient with dietary planning. The nurse emphasizes the importance of adequate intake of fruits, vegetables, and fish. What should the patient's daily carbohydrate intake be?

55% to 60%

When calculating ideal body weight for men, how many pounds should a nurse add for each additional inch over 5ft?

6 lb

What pH levels indicate acidosis?

<7.4

What pH levels indicate alkalosis?

> 7.4

When assessing an older adult's gastrointestinal system, the nurse would identify an increase in which of the following as normal? A) Feeling of fullness B) Gastric motility C) Calcium absorption D) Stomach emptying

A) Feeling of fullness

The nurse is describing hospice services to the family of a patient with end-stage heart failure. Which of the following would the nurse be least likely to include as a major focus of care? A) Invasive therapy B) Emotional support C) Pain control D) Symptom management

A) Invasive therapy

.9% NaCl is used with?

Administration of blood transfusions

What is prebycusis?

Age related hearing loss

What is the sixth leading cause of death for older adults?

Alzheimer Disease

A hospitalized older adult complains of increased coughing and shortness of breath. The nurse assesses the vital signs as temperature 100.2°F oral, respirations 18, pulse 88, and BP 128/80. What action should the nurse do next?

Assess lung sounds and sputum.

Which condition is characterized by a decline in intellectual functioning? A)Delirium B)Delusion C)Dementia D)Depression

C) Dementia

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate? A) Place the client in a secluded room until calm. B) Continue taking the vital signs. C) Distract the client with a familiar object or music. D) Document the inability to assess vital signs due to client's agitation.

C) Distract the client with a familiar object or music.

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. What decreased laboratory results does the nurse observe when the patient's laboratory work has returned?

Calcium

What is the major anion of ECF?

Chloride

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Confusion and seizures

You would be aware that a patient with ill-fitting dentures and a limited intake of high-fiber foods is at risk for what problem?

Constipation

To what resources should you refer your colleague to obtain appropriate dietary recommendations for a elderly Greek patient?

Culturally sensitive materials, such as the Mediterranean Pyramid

An older adult has a score of 12 on the Geriatric Depression Scale (GDS). What action should the nurse complete first? A)Encourage the client to participate in exercise activities. B)Encourage the client to discuss feelings. C)Notify the physician. D)Assess for the potential for self-harm.

D) Assess for the potential for self-harm.

A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease? A) IV B) III C) I D) II

D) II

An elderly client exhibits blood pressure of 110/76 while prone, 100/72 sitting, and 92/64 standing. The nurse instructs the client to... A) Minimize the use of stool softeners. B) Take daily hot showers. C) Use whirlpool baths for relaxation. D) Ingest five or six small meals each day.

D) Ingest five or six small meals each day.

hypotonic solutions

D25W( 2.5 % dextrose in water) .45% NaCl or 1/2 NS

hypertonic solution

D5NS (5% dextrose in normal saline) D5LR (5% dextrose in lactated ringer solution)

What solution is both isotonic and hypotonic?

D5W

When the nurse is percussing for measurement of the patient's liver span, what type of response should be heard?

Dull sound

An elderly client reports to the nurse that food does not taste right. During a dietary assessment, the nurse learns that the client uses a lot of sugar and salt. The client states, "It makes the food taste better." The nurse intervenes by... A) Encouraging the client to use lemon, spices, and herbs in the diet B) Increasing the amount of hot foods served to the client C) Bringing 8 ounces of the client's favorite drink to the client D) Instructing the client to eat small, frequent meals

Encouraging the client to use lemon, spices, and herbs in the diet

A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to... A) Ensure that the mother does not have access to car keys or drive an automobile. B) Turn off lights at night so that the mother differentiates night and day. C) Encourage the mother to take responsibility for cooking and cleaning the house. D) Allow the mother to smoke cigarettes outside on the porch without supervision

Ensure that the mother does not have access to car keys or drive an automobile.

What is a sign of hypokalemia?

Excessive thirst

What is the leading cause of death among the elderly? A) Heart disease B) Cancer C) Pneumonia D) Cerebrovascular disease

Heart disease

Which of the following electrolyte imbalances occur with adrenal insufficiency?

Hyperkalemia

What a treatment of hypocalcemia?

IV administration of calcium salt * too rapid IV calcium can cause cardiac arrest, preceded by bradycardia*

Early signs of hypervolemia include:

Increased breathing effort and weight gain

When preparing to perform a physical assessment of a patient, the nurse performs the steps below. Place the steps in the order in which they most typically are completed.

Inspection Palpation Percussion Auscultation

What is urinary incontinence?

Involuntary loss of urine

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?

Jugular vein distention

What is a treatment for hyperkalemia?

Kayexalate

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?

Limit sodium and water intake

What is the most common causes of hypercalcemia?

Malignant tumors

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Metabolic acidosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Metabolic alkalosis

What is a priority nursing intervention for a client with hypervolemia?

Monitoring respiratory status for signs and symptoms of pulmonary complication

When assessing a patient who has an acute staphylococcal infection what is the most effective technique for assessing the lymph nodes of the patient's neck?

Palpation

Older adults, who are more subject to falls, may fracture one or more ribs and be more susceptible to which condition after a rib fracture?

Pneumonia

What supplement can be given to a pt with hypokalemia?

Potassium

Which of the following electrolytes is a major cation in body fluid?

Potassium

What refers to the decrease in lens flexibility that occurs with age, resulting in the near point of focus getting farther away?

Presbyopia

A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient's serum calcium level is 7.6 mg/dL. What physical examination findings is consistent with this electrolyte imbalance?

Presence of Trousseau's sign

Low serum albumin and prealbumin levels are most often signs of?

Protein deficiency in adults

What is false hyperkalemia?

Pseudohyperkalemia

When assessing an older adult, the nurse anticipates an increase in which component of respiratory status? A) Vital capacity B) Gas exchange and diffusing capacity C) Residual lung volume D) Cough efficiency

Residual lung volume

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

Respiratory alkalosis

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?

Tachycardia

What is the most characteristic manifestation of hypocalcemia?

Tetany

Which of the following results in decreased gas exchange in older adults?

The alveolar walls contain fewer capillaries.

What is osmotic pressure?

The amount of pressure required to stop the osmotic flow of water.

What does it indicate when a patient BMI is 45?

The patient is extremely obese

What is the primary significance of a patient informing you that their mother has type I diabetes?

The patient may be at risk for developing diabete

A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unitwith signs and symptoms of hypovolemia—minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?

Third-spacing

A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation?

Tingling or twitching sensation in the fingers

A pt who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this pt? a) Digoxin toxicity may occur. b) A higher dose of digoxin (Lanoxin) may be needed. c) A diuretic may be needed. d) Fluid volume deficit may occur.

a) Digoxin toxicity may occur.

What does a positive Chvostek's sign indicate? a) Hypocalcemia b) Hyponatremia c) Hypokalemia d) Hypermagnesemia

a) Hypocalcemia

A pt with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this pt's plan of care? a) Request a dietitian consult for selecting foods high in phosphorous b) Provide aluminum hydroxide antacids as prescribed c) Instruct pt to avoid poultry, peanuts, & seeds d) Instruct to avoid the intake of sodium phosphate

a) Request a dietitian consult for selecting foods high in phosphorous

A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following? a) hyperkalemia b) hypokalemia c) hypercalcemia d) hypocalcemia

a) hyperkalemia

An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia? a) hypotension, warmth, & sweating b) nausea & vomiting c) hyperreflexia d) excessive urination

a) hypotension, warmth, & sweating

The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for developing? a) intracellular fluid deficit b) intracellular fluid overload c) extracellular fluid deficit d) interstitial fluid deficit

a) intracellular fluid deficit

A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented? a) seizure b) infection c) neutropenic d) high-risk fall

a) seizure

An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following? a) hypernatremia b) hyponatremia c) fluid volume excess d) hyperkalemia

b) hyponatremia

Which of the following is considered an isotonic solution? a. Dextran in normal saline b. 0.9% normal saline c. 0.45% normal saline d. 3% NaCl

b. 0.9% normal saline

What is a major indicator of fluid volume deficit? a. full and bounding pulse b. drop in postural blood pressure c. elevated temperature d. pitting edema of lower extremities

b. drop in postural blood pressure

A 77-year-old retired male client visits your general practice office twice monthly to maintain control of his congestive heart failure. He measures his weight daily and phones it to your office for his medical record. In a 24-hour period, how much fluid is this client retaining if his weight increases by 2 lb? a) 1250 mL b) 500 ml c) 1 L d) 1500 ml

c) 1 L

What is the average daily urinary output in an adult? a. 0.5L b. 1.0L c. 1.5L d. 2.5L

c. 1.5L

Which of the following is the most common cause of symptomatic hypomagnesemia? a. IV drug use b. Burns c. Alcoholism d. Sedentary lifestyle

c. Alcoholism

Manifestations of fluid volume excess

edema, distended neck veins, abnormal lung sounds, tachycardia, increased BP pulse presure and CVP, increased weight, increased urinary output, SOB, wheezing

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis

What are some s/s of hypermagnesemia?

-flushing -hypotension -hypoactive reflexes

What can cause hypernatremia?

Diabetes Insipidus

What is the correct route of administration for potassium?

Oral

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. What clinical manifestations would the nurse assess with phlebitis?

-Reddened area along the path of the vein -Tender area around the insertion site

What are the nursing interventions for hypokalemia?

-encourage pt to eat foods high in potassium and lean meats -monitor pt for digitalis toxicity -NEVER give potassium as a IV push

What are some s/s of hypomagnesemia?

-increased deep tendon reflexes -positive Trousseau and Chvostek sign

What are the ECG changes related to hyperkalemia?

-narrow tall T waves -ST depression -shortened QT interval -prolonged PR interval -absent P waves -widening of the QRS complex

A patient is ordered to receive hypotonic IV solution to provide free water replacement. What solution would the nurse administer?

0.45% NaCl

What is a hypotonic solution?

0.45% NaCl

Isotonic Normal saline

0.9%

1 L of fluid weighs approximately?

1 kg or 2.2 lb

To calculate the ideal body weight for a woman, the nurse allows

100 lb for 5 ft of height.

Which is the most common affective or mood disorder among older adults? A)Anxiety disorder B)Phobias C)Depression D)Schizophrenia

C) Depression

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? A)Increased norepinephrine level B)Decreased acetylcholine level C)Increased acetylcholine level D)Decreased norepinephrine level

Decreased acetylcholine level

Which is an age-related change in the respiratory system? A) Decreased gas exchange B) Increased blood pressure C) Difficulty swallowing D) Loss of muscle strength and size

Decreased gas exchange

Which factor alters urinary elimination patterns in older adults?

Decreased muscle tone

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. What is the most common fluid imbalance in older adults?

Dehydration

A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate? a) Risk for Imbalanced Fluid Volume b) Excess Fluid Volume c) Imbalanced Nutrition d) Ineffective Tissue Perfusion

a) Risk for Imbalanced Fluid Volume

A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess: a) Trousseau's sign. b) Homans' sign. c) Hegar's sign. d) Goodell's sign.

a) Trousseau's sign