HAN exam 3, Exam 4

Potential complications of HHS and how to recognize them

clotting- Clotting studies-prothrombin time (PT), partial thromboplastin time (PTT), and a D-Dimer detect increased potential of blood clots. The blood is more viscous dehydration: poor skin turgor, sunken appearance of the eyes, dry mouth and mucous membranes, tachycardia, orthostatic drop in blood pressures, and low urine output -cerebral edema

Potential complications of DKA and how to recognize them

ketosis- fruity breath, rapid respirations, metabolic acidosis, metabolic ketoacidosis cellular dehydration- impaired braing function hyperchloremic metabolic acidosis

Hyperchloremic metabolic acidosis

mainly a complication of DKA. It occurs as a result of several altered metabolic processes. Bicarbonate cannot be regenerated through the kidneys because of the lack of ketoanions. Bicarbonate that is regenerated moves rapidly to the intracellular space. Additionally, the chloride in IV solution contributes to hyperchloremic metabolic acidosis. This complication causes metabolic acidosis to continue longer than expected. However, with fluid therapy, insulin therapy, and correction of electrolytes, it is usually self-limiting, correcting itself within 24 to 48 hours.

If you see increased ICP what medication will you use?

mannitol

Where would you expect the anion gap to be for HHS

normal or slightly increased

How to recognize cerebral edema

- Irregular breathing, nausea, poor coordination, incontinence, seizures, changes in LOC Early signs of cerebral edema include headache, lethargy, confusion, and irritability. A CT scan can help to identify cerebral edema

DKA expected findings

- caused by insulin deficiency; mainly in type I diabetics (can also occur in type 2 diabetics who produce very little endogenous insulin). Insufficient insulin to facilitate the transport glucose from blood into cells. - Glucose usually > 300 mg/dL - fruity breath - pH typically < 7.3, bicarb < 10 to 15

HHS expected findings

- some insulin present, but often minimal, so cells don't starve and no or only mild ketosis and metabolic acidosis is also mild if it's even present. common in the patient with type 2 diabetes. - Hyperglycemia is often more severe. - Dont see severe metabolic acidosis. - Glucose >600 - Sodium; 135-145 - Potassium: Normal - Bicarbonate: normal/slightly reduced - Arterial pH: >7.3 - Anion gap: normal/slightly increased pCO2: Normal

What would you prioritize for a patient with HHS

-fluid replacement -treat underlying cause (lifestyle changes one at a time) -prevent clotting -Administer regular insulin IV until blood glucose returns close to normal limits The goal is to decrease serum glucose by 70-100 mg/dl/hr (assess hourly) -Identify and correct hypokalemia to prevent an unsafe serum potassium level. Goal potassium is 4 and 5 meq Dextrose may be added to to the iv fluid to help prevent hypoglycemia when the serum glucose drops below 250-300

Findings more common in DKA

-metabolic acidosis -gastrointestinal symptoms; loss of appetite, abdominal pain, N/V, inflamed abdomen -Kussamaul respirations -ketosis -serum osmolarity over 300mmol/l -low bicarbonate

Findings more common in HHS

-visual disturbances -weight loss -severe dehydration -usually present much sicker -usually very little if any acidosis -higher serum osmolarity than in DKA

what is the normal anion gap

12-20 Calculation: 16+- 4

Normal sodium levels

135-145 mEq/L

normal potassium levels

3.5-5.0 mEq/L

Normal glucose levels

70-110 In DKA: 250-600 in HHS: >600

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A. A positive Brudzinski's sign B. A negative Kernig's sign C. Absence of nuchal rigidity D. A Glascow Coma Scale score of 15

A. A positive Brudzinski's sign

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. An oral anticoagulant medication. B. A beta blocker medication. C. An anti-hyperuricemic medication. D. A thrombolytic medication

A. An oral anticoagulant medication.

Which of the following assessment data indicated nuchal rigidity? A. Positive Kernig's sign B. Negative Brudzinski's sign C. Positive homan's sign D. Negative Kernig's sign

A. Positive Kernig's sign

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases B. Pupils are 8 mm and nonreactive C. Systolic blood pressure remains at 150 mm Hg D. BUN and creatinine levels return to normal

A. Urine output increases

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose B. Cloudy CSF, elevated protein, and decreased glucose C. Clear CSF, elevated protein, and decreased glucose D. Clear CSF, decreased pressure, and elevated protein

B. Cloudy CSF, elevated protein, and decreased glucose

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A. Vomiting continues B. Intracranial pressure (ICP) is increased C. The client needs mechanical ventilation D. Blood is anticipated in the cerebralspinal fluid (CSF)

B. Intracranial pressure (ICP) is increased

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

B. Pupil size and pupillary response

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Raise the head of the bed C. Assess for any bladder distention D. Administer antihypertensive

B. Raise the head of the bed

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dL. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mm Hg. D. The presence of bronchogenic carcinoma

C. A blood pressure of 220/120 mm Hg.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A. A cerebral lesion B. A temporal lesion C. An intact brainstem D. Brain death

C. An intact brainstem

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

C. Blood pressure

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started B. Maintain enteric precautions C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics D. Maintain neutropenic precautions

C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C. Perform a lumbar puncture. D. Elevate the head of his bed.

C. Perform a lumbar puncture.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

C. Restlessness and confusion

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Flaccid paralysis of all extremities B. Adduction of the arms at the shoulders C. Rigid extension and pronation of the arms and legs D. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

C. Rigid extension and pronation of the arms and legs

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for a STAT computed tomography (CT) scan of head. D. Notify the speech pathologist for an emergency consult

C. Schedule for a STAT computed tomography (CT) scan of head.

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? A. Complete admission assessment B. Place a padded tongue blade at the bedside. C. Set up oxygen and suction equipment. D. Pad the side rails before the patient arrives.

C. Set up oxygen and suction equipment.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The UAP places the gait belt around the client's waist prior to ambulating. B. The UAP places the client on the abdomen with the client's head to the side. C. The UAP places her hand under the client's right axilla to help the client move up in bed. D. The UAP praises the client for performing activities of daily living independently.

C. The UAP places her hand under the client's right axilla to help the client move up in bed.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Current medications. B. Complete physical and history. C. Time of onset of current stroke. D. Upcoming surgical procedures.

C. Time of onset of current stroke.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure B. To prevent acute tubular necrosis C. To promote osmotic diuresis to decrease ICP D. To draw water into the vascular system to increase blood pressure

C. To promote osmotic diuresis to decrease ICP

What is the expected outcome of thrombolytic drug therapy? A. increased vascular permeability B. vasoconstriction C. dissolved emboli D. prevention of hemorrhage

C. dissolved emboli

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Squeezing the sternocleidomastoid muscle D. Nail bed pressure

D. Nail bed pressure

what would you see with an effective insulin drip

Decrease in K, blood sugar, and anion gap

Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat)

E. nitroglycerin (Nitrostat)

How often do you check labs and neuro status?

Electrolytes and arterial or venous blood gases are typically measured every hour or two initially. Neurological assessments, strength, orientation, and mentation should all be assessed hourly. If sodium levels are low, seizure precautions are appropriate. Frequent monitoring is essential because levels change rapidly as fluids and insulin are administered

What would you prioritize for a patient with DKA

Fluids (100 mL/kg of body weight to be replaced) Insulin!!! Normalize acidosis and electrolytes, treat underlying cause. Once stable, educate on prevention of complications and management of disease. Vitals, EKG, pulse oximetry

HHNS lab findings

Glucose >600 Sodium; 135-145 Potassium: Normal Bicarbonate: normal/slightly reduced Arterial pH: >7.3 Anion gap: normal/slightly increased pCO2: Normal

DKA lab findings

Glucose;250-600 sodium : 125-135 potassium : normal bicarb : 15meq/l Arterial pH: <7.3 Anion gap: increased pCO2: 20-30

what would cause you to stop the insulin drip?

Hypoglycemia or hypokalemia from rapid fluid shifts

Where would you expect the anion gap to be for DKA

Mild= Greater than 10 Severe= greater than 12

Bicarbonate therapy

ONLY for severe acidosis (those patients with DKA). Giving too much bicarbonate can cause rebound alkalosis, hypokalemia, hypernatremia, elevated lactate, paradoxical cellular acidosis, and slowed improvement of ketosis. treatment of acidosis only for pH < 7.0. It is recommended that bicarbonate be mixed in an IV solution of water or hypotonic saline (0.45% NS) so that it is isotonic. Bicarbonate is then administered slowly, over an hour

How do you recognize and prevent neuro complications?

Reduce blood sugar and serum osmolarity really slowly and watch for signs of ICP potential for cerebral edema is more common in HHS Early signs of cerebral edema include headache, lethargy, confusion, and irritability. A CT scan can help to identify cerebral edema. Prevention of rapid fluid shifts by decreasing serum glucose slowly and slow replacement of sodium are indicated to prevent cerebral edema.

Potassium in DKA and HHNS

Serum potassium may be high, normal, or low in the patient presenting with DKA or HHNS. High serum osmolarity pulls potassium into the vascular space, making serum potassium levels high. Once in the vascular space potassium is lost through the urine due to osmotic diuresis, making serum potassium levels normal or low. It is important to 5 remember that patients who present with normal or even slightly elevated serum potassium have intracellular potassium deficits. Goal potassium 4 and 5 mEq/L. It is common to give as much as 100 to 200 mEq of potassium over the first 24 hours to treat intracellular deficits. First ensure renal function adequate