Chronic Q/A FINAL

A patient with Type 2 Diabetes is started on the medication Glyburide. Which of the following statements by the patient causes concern?

"I will consume no more than 8 oz. of alcohol per week." What is Glyburide? Glyburide lowers blood sugar by causing the pancreas to produce insulin (a natural substance that is needed to break down sugar in the body) and helping the body use insulin efficiently. This medication will only help lower blood sugar in people whose bodies produce insulin naturally.

You're working on a medical surgical floor. Select the patients that are at risk for a pressure injury.

- A 19 year old female who is quadriplegic. - A 35 year old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint. - A 45 year old with Braden Scale score of 7.

Which of the following are good foot care tips for people with diabetes, that the nurse can use to educate the diabetic patient on footcare. (Select all that apply).

- Do daily foot care and inspections. - Have good blood glucose control. - Never walk around barefoot. - Have your doctor check your feet at least once a year. - Try to do some form of exercise several times per week.

A patient has severe peripheral venous disease. What important information below will the nurse provide to the patient about how to alleviate signs and symptoms associated with the disease?

- Elevate the lower extremities about heart level frequently. - Application of compression stockings - Limit long periods of standing and sitting.

A patient has peripheral arterial disease (PAD). What statement by the patient indicates misunderstanding about self- management activities?

"I can use a heating pad on my legs if it's set on low."

Which statements by the patient indicate good understanding of foot care in peripheral vascular disease?

"I will keep my feet dry, especially between the toes." "Lotion is important to keep my feet smooth and soft." "Washing my feet in room-temperature water is best."

The nurse caring for a patient with intermittent claudication pain related to peripheral disease. Which statement made by the patient indicates understanding of proper self management?

"I will start to exercise gradually, stopping when I have pain." What is claudication pain? Pain in thigh, calf, or buttocks that occurs when walking.

You're caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?

1500 mL

Nurse John Joseph is totaling the intake and output of Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client's intake?

2470

When evaluating the hydration status of an 84 year old patient in a nursing home, the nurse observes tenting of the skin on the back of the patient's hand. What is the nurse's best action?

Assess the skin turgor on the patient's forehand.

An adult is admitted to the hospital. X-ray reveals a fractured tibia and a cast is applied. Of the following, which nursing action would be most important to check after the cast is applied?

Assessing for capillary refill.

A client with very dry mouth, skin and mucous membranes is diagnosed with having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

Assessing urinary intake and output fluid volume deficit -dehydration

A patient is prescribed a new medication for the treatment of hypertension. While supine, the patient's blood pressure is 112/70 mmHg and the heart rate is 80/minute. The healthcare provider assesses the patient when the patient changes to a sitting position. Which of the following indicates the patient is experiencing orthostatic hypotension?

BP 88/62, HR 100 Orthostatic hypotension - A decrease in blood pressure (20 mm Hg systolic and/or 10 mm Hg diastolic) that occurs during the first few seconds to minutes after changing from a sitting or lying position to a standing position. Also called postural hypotension. *Increases risk for falls and fractures

A patient was admitted this morning with an incomplete spinal cord injury and is placed in a halo fixator vest after surgery. Which assessment finding will the nurse report immediately to the healthcare provider?

BP of 80/40 What is an incomplete spinal cord injury? Having some motor or sensory function below the injury Halo Fixator: A static traction device used for immobilization of the cervical spine. Four pins or screws are inserted into the skull, and a metal halo ring is attached to a plastic vest or cast when the spine is stable, allowing increased patient mobility.

While performing a skin assessment on a patient who is immobile, you note a purplish-black area on the patient's left heel. The skin is intact. On palpation, the site feels heavy and spongy. You suspect this maybe?

Deep-tissue injury: Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

You're caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and the duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing dumping syndrome, a complication associated with this procedure?

Dizziness and sweating What is a peptic ulcer? Dumping syndrome: A constellation of vasomotor symptoms that typically occur within 30 minutes after eating; believed to occur as a result of the rapid emptying of gastric contents into the small intestine, which shifts fluid into the gut and causes abdominal distention. Early manifestations include vertigo, tachycardia, syncope, sweating, pallor, and palpitations.

True or False: The Somogyi effect causes the patient to experience an increase in their blood glucose during the hours of 2-3 am.

False Somogyi Effect: states that early morning hyperglycemia occurs due to a rebound effect from late-night hypoglycemia.

A 73 year old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver?

High-protein diet venous ulcers: leg ulcers caused by problems with blood flow (circulation) in your leg veins venous insufficiency Alteration of venous efficiency by thrombosis or defective valves; caused by prolonged venous hypertension, which stretches the veins and damages the valves, resulting in further venoushypertension, edema, and, eventually, venous stasis ulcers, swelling, and cellulitis.

A patient is admitted with diabetic ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient's labs are the following: pH 7.25, glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next?

Hold the insulin and notify the doctor of the potassium level of 2.5 Diabetic Ketoacidosis: when your body produces high levels of blood acids called ketones. The condition develops when your body can't produce enough insulin. What are normal ranges of: - pH: blood ph 7.35-7.45 - Glucose: <140mg/dL (normal) >200mg/dL (Diabetic) between 140-199mg/dL (prediabetic) - Potassium: 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L

A nurse is caring for four patients. Which one would the nurse see first?

Hypertensive patient with a blood pressure of 188/92

When assessing a patient diagnosed with osteoarthritis (OA), the nurse looks for which characteristic of his condition?

Joint crepitus What is osteoarthritis (OA)? The most common arthritis and a major cause of impaired mobility and disability. It is the progressive deterioration and loss of cartilage and bone in one or more joints. The production of synovial fluid also decreases. Noninflammatory form of arthritis characterized by the progressive deterioration and loss of cartilage in one or more joints; most common form of arthritis. Symptoms of OA? Pt complains of chronic joint pain and stiffness. Symptoms include crepitus, enlarged joints, Heberden's or Bouchard's nodes, joint effusions, and loss of function or decreased mobility. What is joint crepitus? A grating sound caused by loosened bone and cartilage. This is due to the disintegration of cartilage in OA, which causes pieces of bone and cartilage to "float" in the diseased joint.

An unresponsive patient who has diabetes is brought to the emergency department with slow, deep respirations. Additional findings include: Blood glucose 450 mg/dL (24.9 mmol/L), Arterial pH 7.2, and urinalysis of ketones and glucose.

Lack of insulin causes increased counterregulatory hormones and fatty acid release.

A patient received a right ORIF after a fall. In the immediate postoperative period, the nurse should:

Maintain the leg in an abducted position. Rationale: After an ORIF the affected leg should be kept ABducted. ADDuction may dislocate the hip. The hip should NOT be flexed more than 90 degrees for the first 2 months and even less for the first couple weeks. What is an ORIF? Open reduction and internal fixation (surgery is used to heal a broken bone)

Your patient has severe Peripheral Arterial Disease. When the lower extremities are elevated you would expect them to appear ______ and, when they are in the dependent position you would expect them to appear _______.

Pallor; Rubor Pallor: pale appearance Rubor: red appearance

A student nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the faculty member to intervene?

Palpating both carotid arteries at the same time.

Anne returned from hand surgery, her hand and arm must remain elevated above her heart after surgery. She asks the nurse why? The nurse responds by saying:

Reduce postoperative swelling

Jerod is experiencing an acute episode of ulcerative colitis. Which is the priority for this patient?

Replace lost fluid and sodium. UC: beings in rectum, proceeds to cecum; 10-20 liquid/bloody stool per day; causes hemorrhaging and nutritional deficiencies; infrequent need for surgeries

A 24 year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for ______ ______.

Smoking History What is superficial thrombophlebitis? an inflammatory condition of the veins due to a blood clot just below the surface of the skin.

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?

Sodium What is the role of Potassium? K+ is the chief cation in intracellular fluid; depolarization and generation of action potentials, as well as regulation protein synthesis and glucose use and storage. What is the role of Chloride? Cl- maintains fluid balance inside and outside the cells, proper blood volume, bloodpressure, and pH of your body fluid. What is the role of Phosphate? PO3- is needed for activating vitamins and enzymes, forming adenosine triphosphate, and assisting in cell growth and metabolism; can be found in bones; food sources include meats, fish, dairy, and nuts.

The nurse is assessing an older bedridden patient who is admitted for a pressure ulcer. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?

Stage 3

The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?

Start an IV and administer IV fluids.

A nurse is collecting a wound culture. Which techniques should be used?

Swab an area of the wound bed that is clean and viable

An 86 year old female patient is immobile and is in the right lateral recumbent position. As the nurse, you know that the sites below are at most risk for pressure injury in this position?

ear, ankle, hip

You're caring for a patient with a sigmoid colostomy. The stool from this colostomy is ____.

formed

A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid?

grapefruit

It is halloween and a student nurse knows she needs to be ready for adults in the assisted living facility who have diabetes and eat all the candy with which of the following medications?

humalog What is humalog? a fast-acting mealtime insulin used to treat people with diabetes for the control of high blood sugar.

A patient has an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than one week. The nurse should assess the patient for which complication?

hypokalemia

Which electrolyte is essential for enzyme and neurochemical activities?

magnesium

Mary is admitted in the hospital due to having lower than normal potassium level. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase in her diet upon discharge?

orange juice and bananas.

A patient diagnosed with ulcerative colitis is admitted to the medical unit. When assessing the patient, which of these findings would be of most concern?

rebound tenderness What is Ulcerative Colitis (UC)? Widespread inflammation that begins in the rectum and proceeds in a continuous matter toward the cecum. Periodic flare-ups. Peak incidence ages are 15-25 and 55-65. Priority problems for patients with UC: -diarrhea due to inflammation of the bowel mucosa -Acute pain or chronic noncancer pain due to inflammation and ulceration of the bowel mucosa and skin irritation. -Potential for lower GI bleeding and resulting anemia due to UC What is borborygmi? Rumbling or gurgling noise made by the movement of fluid or gas in the intestines. High pitched bowel sounds

The patient had an elective below the knee amputation and reports pain in the part of his leg that was amputated. What is the nurse's best response?

"On a scale of 0-10, how would you rate your pain?" Define Phantom pain: pain that feels like it's coming from a body part that's no longer there.

A patient is prescribed a thiazide diuretic for the treatment of hypertension. When teaching the patient about the medication, which of the following will the healthcare provider include?

"Be sure to include a number of foods that are rich in potassium in your diet." What is a thiazide diuretic? Increases urine flow by acting directly on the kidneys. Ex. hydrochlorothiazide (HCTZ) and metolazone. Used specifically for older adults with mild volume overload. Action is self-limiting, so when there is no longer excess fluid, the action decreases.

The patient is prescribed 30 units of regular insulin and 70 units of insulin isophane suspension (NPH insulin) subcutaneously every morning. The nurse should provide which instruction to the patient for insulin administration?

"Draw up the regular insulin into the syringe first, following by the cloudy NPH insulin"

You're assessing a patient's health history for peripheral vascular disease. What signs and symptoms reported by the patient would indicate the patient may be experiencing peripheral arterial disease? Select all that apply:

"I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." "It hurts to elevate my legs." "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."

The nurse is educating a patient who must still instill multiple types of eye drops before cataract surgery. Which patient statement requires further teaching?

"If I cannot remember when to take which drops I will just use them all at once."

A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

"Most people with hypertension do not have symptoms." What are symptoms of hypertension? When a diagnosis of hypertension is made, most people have no symptoms. However, some pts experience headaches, facial flushing (redness), dizziness, or fainting as a result of the elevated BP. (P. 722 textbook).

An older patient with Peripheral Vascular Disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the patient may indicate a barrier to proper foot care?

"My hands shake when I try to do things requiring coordination."

A nurse is teaching a larger female patient about alcohol intake and how it affects hypertension. The patient asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best?

"No, women should only have one beer a day as a general rule."

Evaluation of patients for metabolic syndrome should include?

- Measurement of waist circumference - Measurement of vital signs - Height - Weight - BMI Metabolic syndrome: A collection of related health problems with insulin resistance as a main feature. Other features include obesity, low levels of physical activity, hypertension, high blood levels of cholesterol, and elevated triglyceride levels. Metabolic syndrome increases the risk for coronary heart disease. Also called syndrome X. Rationale: With metabolic syndrome there are usually no immediate physical symptoms or specific complaints. The medical problems tend to develop rather innocuously over time. Hx should include a thorough discussion of past medical conditions as well as current risk factors. With respect to lab tests, along with basic serum chemistry and complete blood count, there should be a measurement of fasting blood sugar and a lipid profile.

A patient is being discharged after surgery to correct a detached retina. Which symptoms will the nurse teach the patient to report immediately to the provider? Select all that apply.

- Pain in the eye - Fever of 102 - Purulent drainage in the post op eye Purulent: Consisting of, containing, or discharging pus.

A patient is asking about compartment syndrome. Select all the signs and symptoms you will discuss with the patient in compartment syndrome.

- Pallor - Feeling of tingling in the extremity - Affected extremity feels cooler to the touch than the unaffected extremity. Compartment Syndrome: A condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area, leading to hypoxia and pain. What is Pallor? having pale appearance

A patient is prescribed ibuprofen 800 mg every 4 hours for the treatment of rheumatoid arthritis (RA). Which of these clinical manifestations should the healthcare provider anticipate observing if the patient is developing an adverse effect from the medication? (Choose all answers that apply).

- Positive fecal occult blood test - Patient report of epigastric pain - Increased blood urea nitrogen (BUN) Rheumatoid Arthritis (RA): A chronic, progressive, systemic, inflammatory autoimmune disease process that primarily affects the synovial joints; one of the most common connective tissue diseases and the most destructive to the joints. What are symptoms of RA? Early: Joint inflammation, generalized weakness, fatigue, anorexia, weight loss, persistent low-grade fever, and joints that are reddened, warm, stiff, swollen, and tender or painful. Late: Progressively inflamed joints that are very painful. Morning stiffness, joints feel soft and look puffy, spindle-like fingers. What is a normal BUN? 10-20 mg/dL (slightly higher in older adults).

During a home visit you are helping a patient with gout identify foods in their pantry they should avoid eating. Select all the foods below the patient should avoid:

- Sardines - Sweetbreads - Craft Beer Gout: A systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation. What should the patient with gout eat? Patients with gout should limit their intake of purine-rich animal protein (e.g., organ meats, beef, lamb, pork, shellfish) and avoid alcohol (especially beer). Purine-rich vegetables do not increase the risk of gout. Consumption of vegetables and low-fat or nonfat dairy products should be encouraged.

Your patient has severe peripheral venous disease. During the head-to-toe nursing assessment, you would expect to find what skin characteristics of the lower extremities? Select all that apply:

- Thick - Tough - Brown pigmented

Your patient had a total knee 2 weeks ago. He comes to the ER with severe pain at the surgical site. Which questions from the nurse are most appropriate? (Select all that apply.)

- Which position makes the pain worse or better? - Could you describe the pain in your knee? - Please rate you pain 1-10 with 10 being the worst pain possible.

The nurse is preparing to measure the depth of a client's tunneled wound. Which of the following implements should the nurse use to measure the depth accurately?

A sterile, flexible applicator moistened with saline.

A patient with tented skin turgor, dry mucous membranes and decreased urinary output is under nurse Mark's care. Which nursing intervention should be included in the care plan of Mark for his patient?

Administering IV and oral fluids.

Which of these patients would be assessed immediately following the charge of shift report?

An older patient who is complaining of floaters in the visual field and an abrupt sensation of curtain over their eye. What are floaters associated with? Retinal detachment.

A patient tells the healthcare provider, "I stopped taking my medication because it kept me up at night with a dry cough." When reviewing the patient's medical record, which of these antihypertensive medications will the healthcare provider identify as the likely cause of this patient's report?

Angiotensin-converting enzyme (ACE) inhibitor What is an ACE inhibitor? Acts by relaxing veins and arteries to lower BP. Prevents the production of angiotensin II, which usually narrows blood vessels. May cause dry cough, hyperkalemia, fatigue, dizziness, etc. What is a calcium channel blocker? Disrupt the movement of calcium through calcium channels. Used to treat hypertension. May cause constipation, dizziness, fatigue, heart palpitations, flushing, etc. What is a Loop diuretic? The most effective drug in treating fluid volume overload. May cause dehydration. What are Beta Blockers (BB)? Used to reduce BP by temporarily stopping or reducing the body's natural "fight-or-flight responses." Side effects include cold feet and hands, fatigue, nausea, weakness, dizziness, and dry mouth, skin, and eyes, etc.

A 44 year old patient with diabetes asks how often a visit to the eye care provider is recommended? What is the appropriate nursing response?

Annually

A patient newly diagnosed with diabetes type 2 is being discharged and asks the nurse how often is an appointment recommended with an ophthalmologist. The most appropriate answer for the nurse is?

Annually

The nurse is caring for a male client postoperatively following the creation of a colostomy. Which nursing problem should the nurse include in the plan of care?

Body image, disturbed

The paraplegic patient is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?

Braden Scale: Scale used to predict the risk for a pressure ulcer to occur. Scoring system: 15-16 MILD RISK 12-14 MODERATE RISK <11 SEVERE RISK

Sitty, a 66 year old patient underwent a colostomy for a ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

Brownish-black stoma Stoma: The surgical creation of an opening; usually refers to an opening in the abdominal wall.

The RN is providing a list of recommended food to the family of a patient who recently had a total colectomy and colostomy. Which food item should the RN recommend including in the postoperative diet?

Chicken Noodle Soup

A nurse caring for a patient with non healing arterial lower leg ulcer. What action by the nurse is best?

Consult with the wound care nurse.

A patient has a severe exacerbation of ulcerative colitis. Long term medications will probably include:

Corticosteroids Glucocorticoids, such as prednisone and prednisolone, are corticosteroid therapies prescribed during exacerbations of the disease. Prednisone is typically prescribed, and the dose may be increased as acute flare-ups occur. Once clinical improvement occurs, the corticosteroids are tapered because of the adverse effects that commonly occur with long-term steroid therapy (e.g., hyperglycemia, osteoporosis, peptic ulcer disease, increased potential for infection, adrenal insufficiency). For patients with rectal inflammation, topical steroids in the form of small retention enemas or suppositories may be prescribed. Medications such as budesonide (Uceris or Entocort EC), steroids that are thought to work mostly in the bowel, produce less systemic side effects.

Your patient reports experiencing dull and achy sensations in the lower extremities. You note that the lower extremities have edema and brownish pigmentation. Pulses are present bilaterally and the extremities feel warm to the touch. To help alleviate the patient's symptoms, the nurse with position the lower extremities in the _____.

Elevated Position above heart level. Dependent position: simply means put the legs dangling because when you dangle legs you decrease the return of blood and reduce pulmonary congestion. Horizontal position: A position in which the patient lies supine with feet extended. It is used in palpation, in auscultation of fetal heart, and in operative procedures. Knee-flexed position: flexed at 90° angle.

Which of the following types of wound drainage should alert the nurse to the possibility of infection?

Foul smelling drainage that is grayish in color.

The nurse is caring for four hypertensive patients. Which drug-laboratory value combination would the nurse report immediately to the healthcare provider?

Furosemide (Lasix)/ Potassium: 2.1 mEq/L Furosemide: treats fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. Normal potassium range: 3.5-5.0 mEq/L

Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

Instituting seizure precaution to prevent injury Hypomagnesemia: is a serum magnesium (Mg2+) level below 1.8 mEq/L or 0.74 mmol/L. It is most often caused by decreased absorption of dietary magnesium or increased kidney magnesium excretion. Two major causes of hypomagnesemia are inadequate intake and the use of loop or thiazide diuretics. Table 11-11 lists additional causes of hypomagnesemia.

The nurse is caring for a patient who reports slow onset of a gradual loss of vision in the center of both eyes. The patient describes loss of vision in the center of both eyes. The patient describes their vision as "foggy" and reports ongoing headaches from trying to concentrate to see. What condition does the nurse anticipate?

Glaucoma Glaucoma: A group of ocular diseases resulting in increased intraocular pressure, causing reduced blood flow to the optic nerve and retina and followed by tissue damage. Progressively destroys the optic nerve. Types include primary/chronic open angle, primary/chronic closed angle, and acute closed angle. Detached Retina: Often develops in the eyes with retinas weakened by a hole or tear. Fluid seeps underneath, weakening the attachment and the retina detaches. When it is detached, the retina cannot compose a clear image from incoming light and vision is blurred and dim. Cataract: Lens opacity that distorts the image projected onto the retina. Clouding of the lens of the eye, light that passes through the lens to the retina is scattered. The scattered light causes images to be blurred and visual acuity is reduced. Conjunctivitis: Inflammation of the conjunctiva. Viral or bacterial. May be caused by an allergy.

A patient has an infection and reports not checking their blood glucose or regularly taking metformin. What condition is this patient MOST at risk for?

HHS (hyperglycemic hyperosmolar syndrome) HHS Hyperglycemic hyperosmolar syndrome: high blood sugar results in high osmolarity without significant ketoacidosis. Symptoms include signs of dehydration, weakness, leg cramps, vision problems, and an altered level of consciousness. Metabolic Acidosis: When the Ph is low causing the blood to become acidic. Too much acid build up in the body with an increase of HcO3 to decrease Metabolic Alkadosis: the pH of tissue is elevated beyond the normal range (7.35-7.45). This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate, or alternatively a direct result of increased bicarbonate concentrations. DKADiabetic ketoacidosis (DKA): is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones.

A nurse is counseling a patient who has hypertension and type 2 diabetes. During the initial assessment, the nurse notes that the patient has a blood pressure of 148/92 mmHg, a BMI of 28, and a blood glucose level of 161 mg.dL. Which of the following information about lifestyle changes would be most beneficial to help control this patient's state of health?

Help the patient understand how to lose weight to get her BMI less than 25. Hypertension- high blood pressure Diff BMI ranges: The least risk for malnutrition is associated with scores between 18.5 and 25. - Older adults should have a normal BMI of 23-27. - Underweight: Below 18.5 - Normal/Health: BMI of 18.5-24.9 - Overweight: BMI of 25-29.9. - Obese: BMI of 30+

In what type of electrolyte imbalance would the nurse observe tall, tented T waves, and a prolonged PR interval on the patient's EKG?

Hyperkalemia Hypercalcemia: A condition in which the calcium level in your blood is ABOVE normal. Too much calcium in your blood can weaken your bones, create kidney stones, and interfere with how your heart and brain work. A condition in which there are lower-than-average levels of calcium in the liquid part of the blood, or the plasma Hyperkalemia: Potassium level in your blood that's HIGHER than normal. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L). Under 2.5 is really dangerous and low. Hypokalemia: Blood's potassium levels are too LOW. Potassium is an important electrolyte for nerve and muscle cell functioning, especially for muscle cells in the heart.

A patient diagnosed with inflammatory bowel disease experiences an obstruction in the small bowel. When assessing the patient, which of the following should the student nurse anticipate?

Hypovolemia What is inflammatory bowel disease? an umbrella term used to describe disorders that involve chronic inflammation of your digestive tract. Scaphoid abdomen: caves in Hypovolemia: decrease in the volume of blood in your body, which can be due to blood loss or loss of body fluids. Could be due to internal bleeding Passage of melena: Melena is the passage of black, tarry stools What is increased flatus- gas? this is caused by swallowing air, eating high-fibre foods, lactose intolerance or some digestive disorders

Which statement, if made by the client or family member, would indicate the need for further teaching? related to pressure injuries

If a person cannot turn himself in bed, someone should help them change position q4h.

Jon has a potassium level of 6.6 mEq/L, which medication would nurse Wilma anticipate?

Kayexalate What is Kayexalate? This medication is used to treat a high level of potassium in your blood.

The patient has a bag of insulins and asks which of the insulins has no peak but a duration of 24 hours?

Lantus Review the following meds: Humalin R- short acting insulin & covers blood sugar from meals eaten within 30 minutes Humalin N- intermediate acting insulin that is slower to act and lasts longer than regular human insulin Lantus- Prescription Lantus is a long-acting insulin used to treat adults with type 2 diabetes and pediatric patients (children 6 years and older) with type 1 diabetes for the control of high blood sugar. Do not use Lantus to treat diabetic ketoacidosis. NPH insulin- an intermediate-acting insulin NOVOLOG- immediate acting insulin

Tim presents with an acute episode of gout. The student nurse expects the provider to prescribe:

NSAIDs and Colchicine Gout, or gouty arthritis, is a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation What are NSAIDs? Advil/Aspirin/Motrin (ibuprofen) and Tylenol (acetaminophen) What is Colchicine? decreasing swelling and lessening the build up of uric acid crystals that cause pain in the affected joint(s)

What is normal pain processing called?

Nociceptive pain Acute pain: Serves as a biological purpose in that it acts as a warning signal by activating the sympathetic nervous system and causing various physiologic responses. Neuropathic pain: Descriptive term used to refer to pain that is believed to be sustained by a set of mechanisms driven by damage to or dysfunction of the PNS and/or CNS. Neuropathic pain is sustained by abnormal processing of stimuli. Chronic pain AKA persistent pain: Often defined as pain that lasts or recurs for an indefinite period, usually for more than 3 months. The onset is gradual, and the character and quality of pain often change over time. Chronic pain serves no biologic purpose.

Which intervention by the emergency room nurse is critical in caring for the patient with a fractured tibia and fibula?

Palpation of the dorsalis pedis pulses. Rationale: Monitoring neurovascular (NV) status is ESSENTIAL in early recognition of NV deterioration or compromise. Delays in recognizing NV compromise can lead to permanent deficits, loss of limb or even death. Recognition of NV deterioration is therefore CRUCIAL NV deterioration can occur late after trauma, surgery, or cast application.

Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

Positive Trousseau's Sign Trousseau's sign: carpopedal spasm(are frequent and involuntary muscle contractions in the hands and feet) caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes -> sends pt into hypoxic state which triggers sign to occur if pt has hypocalcemia. Positive Chvostek's sign: the twitching of the facial muscles in response to tapping over the area of the facial nerve. Paresthesia: an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Tetany: Continuous contractions of muscle groups; hyper-excitability of nerves and muscles. Carpopedal spasm: frequent and involuntary contractions in the hands and feet.

Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?

Potassium Level What are normal levels for: Potassium- 3.50-5.00 mEq/L Magnesium- 1.60-2.60 mg/dL Calcium- 9.00-10.50 mg/dL Sodium- 135-145 mmol/L Phosphorus- 2.50-4.50 mg/dL furosemide: treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. digoxin: treat heart failure and heart rhythm problems.

After obtaining an EKG on a patient, you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding?

Potassium level of 2.2 Define normal potassium range: Blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L). Under 2.5 is really dangerous and low.

The results of an adult patient's blood pressure screening on three occasions are: 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the healthcare provider interpret this information?

Prehypertension Normal BP: Systolic less than 120, Diastolic less than 80 mmHg. Elevated BP: Systolic between 120-129, Diastolic less than 80 mmHg. HTN Stage 1: Systolic between 130-139, or Diastolic between 80-89 mmHg. HTN Stage 2: Systolic at least 140 mmHg, or Diastolic at least 90 mmHg.

The PCT tells the nurse that a patient with a PCA pump of IV morphine is very drowsy, cannot complete a sentence without falling asleep, their respirations are 10 per minute. What is the nurse's priority action?

Raise the head of the bed and wake the patient up. PRIORITY - first thing u do What is a PCA pump? (Patient-controlled analgesia) is an interactive method of management that allows patients to treat their pain by self administering doses of analgesics. It is used to manage all types of pain and given by multiple routes of administration, including IV, subcutaneous, epidural, and perineural. A PCA infusion device is used when PCA is delivered by invasive routes of administration and is programmed so the patient can press as button ("pendent") to self administer a set dose of analgesic (PCA dose) at a set time interval ("demand or "lockout") as needed.

A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency?

Retinopathy Retinopathy: Inflammation of the retina. Also used as a general term for vision problems.

A patient who has had rheumatic arthritis for several years is admitted to your unit. Upon physical examination of the patient the nurse should expect to find?

Small/limited joint involvement

Define the Stages of pressure ulcers:

Stage 1: INTACT skin with non-blanchable redness of localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a category/stage 3 pressure ulcer varies by anatomical location Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. May include undermining and tunneling. Category/stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur. Exposed bone/muscle is visible or directly palpable Deep tissue injury: Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed.

The graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first?

The newly admitted client with acute abdominal pain.

Your educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury?

The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue.

The nurse is providing dietary instructions to a patient who is immobile and experiencing frequent episodes of constipation. The patient complains that the constipation is uncomfortable. The nurse should tell the patient which food item would be most helpful to include in the diet?

Whole Grain Bread *Patient needs to include high fiber food in their diet.The only choice is whole grains. Cabbage is a gas forming food, could increase discomfort.

UNF student nurse Hannah is teaching a group of middle aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

alcohol abuse and smoking