last minute review exam 1

The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition?

Boerhaave syndrome Explanation: Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

metabolic acidosis Diarrhea

Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates, leading to metabolic acidosis. Loss of acid, which occurs with severe vomiting, may lead to metabolic alkalosis. Diarrhea leads to hypokalemia. Elevated neutrophils are associated with infection and not frequent diarrhea. Rovsing sign is associated with appendicitis.

hypervolemia

Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.

An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom?

Esophageal tumor Explanation: Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.

A client is diagnosed with Zollinger-Ellison syndrome. The nurse knows to assess the client for which characteristic clinical feature of this syndrome?

Hyperacidity in the duodenum inactivates pancreatic enzymes causing steatorrhea and ulcer diathesis.

dehydration in diabetes insipidus.

Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.

syndrome of inappropriate antidiuretic hormone (SIADH).

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.

hypervolemia

Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.

The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal?

Maintaining skin integrity Explanation: Fecal incontinence can disrupt perineal skin integrity. Maintaining skin integrity is a priority, especially in the debilitated or older adult patient.

Misoprostol

Misoprostol is a synthetic prostaglandin that protects the gastric mucosa from agents that cause ulcers, and also increases mucus production and bicarbonate levels. It is a pregnancy category X medication and should not be taken by a pregnant client as it can soften the cervix and result in miscarriage or premature labor. This medication does not cause constipation. Sucralfate needs to be taken without food. Misoprostol can cause diarrhea and cramping; however, this is not the reason to question giving the client a dose of the medication.

Oncotic pressure

Oncotic pressure is a pulling pressure exerted by proteins such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when urine output increases as a result of excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.

surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing. The edges of a wound healing by second intention are not approximated. The wound may be cleaned using sterile saline, but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed, impairing healing.

The nurse advises the patient who has just been diagnosed with acute gastritis to:

Refrain from food until the GI symptoms subside. Explanation: It usually takes 24 to 48 hours for the stomach to recover from an attack. Refraining from food until symptoms subside is recommended, but liquids should be taken in moderation. Emetics and vomiting can cause damage to the esophagus.

A client with a cyst has been brought for care. The nurse who is contributing to the client's care knows that treatment will be chosen based on what risk?

Risk for infection Explanation: Pilonidal cysts frequently develop into an abscess, necessitating surgical repair. These cysts do not contribute to bowel incontinence, constipation, or impaired tissue perfusion.

While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. What interventions would the nurse anticipate including in this client's care plan? Select all that apply.

The client who has a chemical burn of the oral mucosa and esophagus will experience pain and may experience respiratory distress. Based the anticipated orders by the health care provider, the nurse will administer medication for pain and assess respiratory status. The client will be NPO, and IV fluids will be administered. Vomiting is avoided to prevent additional trauma from the caustic agent.

regarding regional enteritis (Crohn's disease)?

The clusters of ulcers take on a cobblestone appearance. It is characterized by remissions and exacerbations. The pain is located in the lower right quadrant. The lesions are not in continuous contact with one another and are separated by normal tissue.

s/p surgery vitals schedule

The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Thereafter, they are measured less frequently if they remain stable. The temperature is monitored every 4 hours for the first 24 hours.

tuberculin skin test is test is considered positive if the induration is

The size of the induration, not including the surrounding area of erythema, is measured in millimeters. The measurement determines whether the reaction is significant. For example, a tuberculin skin test is test is considered positive if the induration is 10 mm or greater in persons with no known risk factors for TB; smaller measurements are significant in certain risk groups, such as immunocompromised clients. The other answers are not indicative of positive results.

A client weighing 165 lb. (75 kg) is being treated for acute gastritis. Which amount of urine output for 4 hours would indicate an adequate fluid balance if the output should be 1 mL/kg/hour?

To determine the client's weight in kg, divide the weight in lb. by 2.2 or 165 / 2.2 = 75 kg. Fluid balance for this client would be 75 mL/hr. For four hours, the client's output would need to be 300 mL as an indication of fluid balance.

When hemoconcentration occurs due to a hypovolemic state,

When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.

wound healing stages

When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together. Reference:

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?

duodenum Explanation: The duodenum, which is approximately 10 inches long, is the first region of the small intestine and the site where bile and pancreatic enzymes enter.

The nurse prepares to administer the lavage solution to a client having a colonoscopy completed. The nurse stops and notifies the physician when noting that the client has which condition?

inflammatory bowel disease Explanation: The nurse stops administering the lavage solution and notifies the physician when the nurse notes that the client has inflammatory bowel disease. Another contraindication for use of lavage solution is intestinal obstruction. Chronic obstructive pulmonary disease (COPD), congestive heart failure, and pulmonary hypertension are not contraindications to administration of lavage solution in preparation for a colonoscopy.

A client with chronic peptic ulcers is considering a vagotomy. Which information will the nurse provide to the client about this surgical procedure?

Adverse effects such as dumping syndrome and gastritis can occur. Explanation: A vagotomy is the severing of the vagus nerve to make the cells in the stomach less responsive to gastrin. Adverse effects of this procedure include dumping syndrome and gastritis. A pyloroplasty enlarges the pylorus. The Billroth II procedure can cause anemia, weight loss, and malabsorption. A Billroth I procedure attaches the stomach to the duodenum.

Which of the following digestive enzymes aids in the digesting of starch?

Amylase Explanation: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Bile is secreted by the liver and is not considered a digestive enzyme.

A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply. Nizatidine Lansoprazole Famotidine Cimetidine Esomeprazole

Nizatidine Famotidine Cimetidine H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton-pump inhibitors.

A client is having a colonic transit study to diagnose a gastrointestinal disorder. Which instruction will the nurse provide to the client after taking a capsule containing radionuclide markers?

Colonic transit studies are used to evaluate colonic motility and obstructive defecation syndromes. The client is given a capsule containing 20 radionuclide markers and instructed to follow a regular diet and usual daily activities. There is no reason for the client to follow a clear liquid diet, take over-the-counter laxatives, maintain nothing by mouth status, take oral medications, eat a low-fat diet, or take proton pump inhibitor medications.

A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?

Colonoscopy Explanation: Diverticulosis is typically diagnosed by colonoscopy, which permits visualization of the extent of diverticular disease and biopsy of tissue to rule out other diseases. In the past, barium enema was the preferred diagnostic test, but it is now used less frequently than colonoscopy. CT with contrast agent is the diagnostic test of choice if the suspected diagnosis is diverticulitis; it can also reveal abscesses.

The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client?

Diagnosed with malabsorption syndrome Explanation: Various tube feeding formulas are available commercially. Polymeric formulas are the most common and are composed of protein (10% to 15%), carbohydrates (50% to 60%), and fats (30% to 35%). Standard polymeric formulas are undigested and require that the client has relatively normal digestive function and absorptive capacity. This type of formula should be questioned because the client is diagnosed with malabsorption syndrome. There is no reason to question the client for a history of diverticulitis, treatment for internal hemorrhoids, or removal of polyps.