Exam 2

what is vernix caseosa?

cheese-like substance on the skin

Which predisposing condition would the nurse anticipate in the client observed to have edema at the dorsum of the foot and ankle? a. neurotrauma b. hypothyroidism c. hyperthyroidism d. congestive heart failure

d. congestive heart failure

The nurse educator is providing information about different insulin types. Which type of insulin can be safely mixed with regular human insulin in the same syringe? a. insulin glargine b. insulin detemir c. insulin lispro mix 75/25 d. isophane insulin neutral protamine hagedorn (NPH)

d. isophane insulin neutral protamine hagedorn (NPH)

venous ulcer

due to pooling of blood irregular shape border

dawn phenomenon

early morning rise in blood sugar

Which adverse effect would a nurse monitor for in a client taking clopidogrel?

epistaxis (nosebleed)

PVD arterial

feet should be down/flat implement exercise inspect foot regularly, keep foot dry (white socks)

somogy effect

hypoglycemic episode at night

claudication

pain in arms and legs due to inadequate blood flow to those muscles

types of cirrhosis

post necrotic = lack of blood flow laennec's = alcohol induced biliary = chronic biliary obstruction (bile can't get through)

3 main functions of the liver

production of bile drug metabolism regulating blood clotting

thromboangiitis obliterans

recurring inflammatory vasculitis in extremities which starts distally

Which clinical finding would the nurse expect for a client with hypertensive emergency?

severe pounding headache

PVD arterial

- pallor of feet - ulcers on the toes - delayed capillary refil

PVD venous

-thick, hardened skin on legs - warm extremities

Which action would the nurse take when a client with chronic venous insufficiency has ankle edema? a. restrict fluids b. elevate the legs c. apply a Unna boot d. discuss sclerotherapy

b. elevate the legs

what happens when the BP cuff is too small?

higher blood pressure

what type of fluids should you give someone with type 1 D

isotonic

PVD = venous insufficiency

sequential compression devices calories for healing compressionn stockings *** ELEVATE legs above the heart for 20 min 4-5x a day

Which factor contributes to a client's slow rate of healing? select all that apply. a. diabetes b. cataract c. smoking d. dematitis e. alcohol abuse

a. diabetes c. smoking e. alcohol abuse

Which clinical manifestation would the nurse observe in a client experiencing anaphylactic shock from a type 1 latex allergic reaction? a. stridor b. fissuring c. hypotension d. dyspnea e. cracking of the skin

a. stridor c. hypotension d. dyspnea

Which feature is associated with the maturation phase of normal wound healing? a. The scar is firm and inelastic on palpation b. fibrin strands form a scaffold or framework c. white blood cells migrate into the wound d. epithelial cells are grown over the granulation tissue bed

a. the scar is firm and inelastic on palpation

Which antihypertensive medication class would the nurse identify as the likely cause of the cough in a client taking mulitple medications for hypertension who develops a persistent, hacking cough?

angiotensin-converting enzyme (ACE) inhibitors

Upon pressure application, which degree of edema would the nurse document for a 6-mm deep indentation? a. 4+ b. 3+ c. 2+ d. 1+

b. 3+ The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a edema of 3+ degree. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

Acute peripheral artery occlusion

blockage in an area supplied by an artery causes ischemia and cell death

Which laboratory result will be important for the nurse to review when a client is admitted to the hospital with a long history of uncontrolled hypertension?

blood urea nitrogen hypertension leads to changes in renal blood flow and eventually to decreased renal function which is tested with blood urea nitrogen levels

Which term would the nurse use to describe the exudate characteristic of a serosanguineous wound? a. greenish-blue pus b. creamy yellow exudate c. blood-tinged amber fluid d. beige pus with a fishy odor

c. blood-tinged amber fluid

stasis dermatitis

brown color to lower legs --> seen with venous insufficiency

what is the best handoff between shift

nurse to nurse bedside report

DVT

bedrest--> gradual ambulation as tolerated DO NOT message antiembolism stockings (after DVT resolved)

when should you not take oral contraceptives

history of DVT

Which term will the nurse use to document when a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance?

intermittent claudication

atherosclerosis

thickening of the arteries results in decreased perfusion to tissues and damage to body organs

What is lichenification?

thickening of the skin with accentuated normal skin markings

what is the purpose of a time-out?

to verify right patient, right site, and right procedure

Which mechanism would the nurse attempt to increase to prevent postoperative deep vein thrombosis?

velocity of the venous return

Which factors can predispose a client with type 1 diabetes to a diabetic ketoacidotic coma? a. taking too much insulin b. getting too much exercise c. excessive emotional stress d. running a fever with the flu e. eating fewer calories than prescribed

c. excessive emotional stress d. running a fever with the flu

Which insulin will the nurse prepare for the emergency treatment of ketoacidosis? a. glargine b. NPH insulin c. insulin aspart d. insulin detemir

c. insulin aspart (rapid-acting)

what is normally given for raynauds syndrome

calcium channel blockers

Which information would the nurse provide to a client with type 1 diabetes who requests information about the differences between penlike insulin delivery devices and syringes? a. the penlike devices have a shorter injection time b. penlike devices provide a more accurate dose delivery c. the penlike delivery system uses a smaller-gauge needle d. penlike devices cost less by having reusable insulin cartridges

b. penlike devices provide a more accurate dose delivery

Which intervention would the nurse prioritize when planning a teaching program for a child who was recently diagnosed with type 1 diabetes? a. exploring the child's feelings about diabetes b. explaining how to calculate carbohydrate intake c. ensuring that the child learns to monitor blood glucose d. helping the child practice administering insulin injections

a. exploring the child's feelings about diabetes

Which action would the nurse prioritize after applying pressure to the nose of a client who is being treated for uncontrolled hypertension and develops a nosebleed?

assess the client's blood pressure

A child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 am each day. Which time would the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur? a. before noon b. in the afternoon c. within 30 minutes d. during the evening

b. in the afternoon

Paresthesia

abnormal sensation of numbness and tingling without objective cause

essential hypertension

not caused by an existing health problem related to risk factors (non-modifiable and modifiable)

Which statement indicates to the nurse providing discharge medication education to a client prescribed warfarin that teaching was effective?

I will avoid taking aspirin and nonsteroidal anti-inflammatory drugs

Raynaud's syndrome

small arteries constrict in response to various stimuli (cold, nicotine, caffeine, stress) --> white fingers

arterial ulcer

due to lack of blood smooth borders

insulin

glargine at night = long acting lispro at meals = short acting

What is contact dermatitis?

a manifestation of delayed hypersensitivity in which absorbed agents act as antigens

Which finding will be most important to communication to the health care provider when the clinic nurse is assessing a client with thromboangiitis obliterans (bueger disease)?

continued tobacco use

PVD

peripheral vascular disease

heparin (lovenox)

prevents DVT in post op patients

What is the antidote for heparin?

protamine sulfate

Which physiological changes would the nurse expect to find in a client with a 20-year history of type 2 diabetes? a. blurry, spotty, or hazy vision b. arthritic changes in the hands c. hyperactive knee and ankle jerk reflexes d. dependent pallor of the feet and lower legs

a. blurry, spotty, or hazy vision

Which insulin can be administered IV? a. Lispro insulin b. aspart insulin c. regular insulin d. glargine insulin e. glulisine insulin

a. lispro b. aspart c. regular e. glulisine

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. Which rationale for the treatment would the nurse provide? a. limit the formation of blood clots b. to decrease the phantom limb sensation c. to prevent hemorrhage and cover the incision d. to support the soft tissue and minimize swelling

d. to support the soft tissue and minimize swelling

hypoglycemia

sweating dizziness cool clammy and confused

Which laboratory test would the nurse expect to be prescribed that will reveal the effectiveness of a diabetic regiment for a child with type 1 diabetes? a. serum glucose b. glucose tolerance c. fasting blood sugar d. glycosylated hemoglobin

d. glycosylated hemoglobin this test provides an accurate long-term index of the average blood glucose level for the 100-120 days before the test

Which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons? a. stage 1 b. stage 2 c. stage 3 d. stage 4

d. stage 4

cardiac hypertrophy

the heart gets bigger to try and compensate causing it to not get enough blood

Which instruction from the primary health care provider would the nurse anticipate reinforcing with a client who is on metformin therapy and is scheduled to undergo renal computed topography (CT) with contrast dye? a. discontinue metformin 1 day before the procedure b. discontinue metformin 1 week before the procedure c. discontinue metformin 3 days after the procedure d. discontinue metformin 7 days after the procedure

a. discontinue metformin 1 day before the procedure

Which mechanism of action explains how glyburide decreases serum glucose levels? a. stimulates the pancreas to produce insulin b. accelerated the liver's release of stored glycogen c. increases glucose transport across the cell membrane d. decreases absorption of glucose from the gastrointestinal system

a. stimulates the pancreas to produce insulin

Which nursing interventions require the nurse to wear gloves? Select all that apply. a. giving a back rub b. cleaning a newborn immediately after delivery c. emptying a portable wound drainage system d. interviewing a client in the emergency department e. obtaining the blood pressure of a client who is positive for human immunodeficiency virus (HIV)

b. cleaning a newborn immediately after delivery c. emptying a portable wound drainage system

Which predisposing condition may be present in a client with pitting edema? a. shock b. kidney disease c. hypothyroidism d. severe dehydration

b. kidney disease

Which client would the nurse anticipate to have decreased skin turgor? a. trauma b. severe dehydration c. anxiety d. chronic eczema

b. severe dehydration

When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes which clinical presentation about type 1? a. onset of the disease is slow b. excessive weight is a contributing factor c. complications are not present at the time of diagnosis d. treatment involves diet, exercise, and oral medications

c. complications are not present at the time of diagnosis

Which adverse effect of metformin will a nurse teach a client with type 2 diabetes to monitor for when used as monotherapy? a. weight gain b. constipation c. lactic acidosis d. hypoglycemia

c. lactic acidosis

Which eye problem is the leading cause of blindness in clients with diabetes? a. cataracts b. glaucoma c. retinopathy d. astigmatism

c. retinopathy it is the damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina)

The nurse is caring for a client who had an above-the-knee amputation 1 week ago. Which action would the nurse take to control edema of the residual limb? a. administer a diuretic as needed b. restrict the client's oral fluid intake c. rewrap the elastic bandage as necessary d. keep the residual limb elevated on a pillow

c. rewrap the elastic bandage as necessary

secondary hypertension

can be caused by kidney disease cushing's disease medications pregnancy brain tumors... etc.

A 9-year-old child who has cerebral palsy, scoliosis, contractures of elbows and wrists and is also incontinent. Which nursing action will best achieve the goal of skin integrity? a. padding the child's lower extremities b. repositioning the child every 4 hours c. replacing the bed linens with sterile linens d. changing disposable diapers every 2-3 hours

d. changing disposable diapers every 2-3 hours